Intervention Protocol

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Interventions to improve adherence to guidelines on 'Standard Precautions' for the control of healthcare-associated infections

  1. Ione Corrêa1,
  2. Donna Moralejo2,
  3. Pasqual Barretti3,
  4. Regina P El Dib4,*

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 9 OCT 2013

Assessed as up-to-date: 2 OCT 2013

DOI: 10.1002/14651858.CD010768


How to Cite

Corrêa I, Moralejo D, Barretti P, El Dib RP. Interventions to improve adherence to guidelines on 'Standard Precautions' for the control of healthcare-associated infections (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD010768. DOI: 10.1002/14651858.CD010768.

Author Information

  1. 1

    Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Nursing, Botucatu, São Paulo, Brazil

  2. 2

    Memorial University, School of Nursing, St. John's, Newfoundland, Canada

  3. 3

    Botucatu Medical School, UNESP - Univ Estadual Paulista, Clinical Medicine, Botucatu, São Paulo, Brazil

  4. 4

    Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Anaesthesiology, Botucatu, São Paulo, Brazil

*Regina P El Dib, Department of Anaesthesiology, Botucatu Medical School, UNESP - Univ Estadual Paulista, Distrito de Rubião Júnior, s/n, Botucatu, São Paulo, 18603-970, Brazil. eldib@fmb.unesp.br. re.lucci@terra.com.br.

Publication History

  1. Publication Status: New
  2. Published Online: 9 OCT 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
 

Description of the condition

While infections in both community and healthcare settings have been a concern of healthcare providers, organisations and governments for centuries, there has been an increased focus on the prevention and control of healthcare-associated infections (HAIs) in the past few decades. Global estimates of the prevalence of HAIs are not available, but it has been estimated that over four million patients in Europe and 1.7 million in the US develop an infection each year, with higher prevalence in developing countries (Allegranzi 2011; WHO 2011). HAIs are associated with increased length of stay, excess mortality, billions of dollars in associated hospital costs, as well as psychosocial and economic impacts on the people involved, their families and their communities (Andersson 2010; WHO 2011).

HAIs can occur when susceptible patients are exposed to infectious microorganisms during their stay in the healthcare setting. Patients in hospitals and long-term care facilities are frequently more susceptible to infections than those in the community because of their illness, use of immunosuppressive therapy, exposure to invasive procedures, or contact with others who have infections. Infectious agents are most frequently spread by direct contact with contaminated hands, or indirect contact via contaminated objects, such as patient care equipment, healthcare workers' uniforms, or environmental surfaces.

In 1996, the Centers for Disease Control and Prevention in the US introduced guidelines, called 'Standard Precautions', which summarise strategies to be used to prevent transmission of microorganisms in healthcare settings. Standard Precautions replaced previously used guidelines such as 'Universal Precautions' (introduced in 1985) and 'Body Substance Isolation' (introduced in 1987). These previously used guidelines had varied in terms of strategies used and the conditions to which they applied, whereas Standard Precautions recommends strategies to be used on all patients at all times in all settings. Standard Precautions are based on the assumption that all patients carry transmissible microorganisms although the patients may be asymptomatic.

Strategies included in Standard Precautions include: 1) Appropriate hand hygiene (handwashing with soap and water or use of an alcohol-based hand rub) and appropriate use of gloves to disrupt the spread of microorganisms from one patient to another by healthcare workers' contaminated hands (Armstrong-Evans 1999; Johnson 1990; Tenorio 2001); 2) use of gowns to disrupt transmission of microorganisms carried on healthcare workers' uniforms; 3) appropriate cleaning and disinfection of patient care equipment and environment surfaces to reduce transmission by the indirect contact route; 4) use of appropriate facial protection (e.g. masks (Health Canada 1999; Siegel 2007; Wong 2004) and goggles (Siegel 2007; Wong 2004)) or an N95 respirator to reduce exposure of healthcare workers to infectious agents spread by the droplet or airborne route; 5) management of used needles and other sharp objects to prevent exposure from percutaneous injury; 6) management of clinical waste and used linen to reduce environmental contamination; and 7) cough etiquette to reduce droplet transmission and contamination of the environment.  All of these strategies protect patients in the setting or healthcare workers from exposure to infectious agents, or both. 

Standard Precautions guidelines also include specific transmission-based precautions to be taken when patients are known or suspected to have an infection. There are three categories of transmission-based precautions: airborne, contact and droplet. They involve additional strategies to those of Standard Precautions that are based on the route of transmission of the known or presumed causative microorganism.

Standard Precautions have been adopted worldwide, with periodic updates since they were first released. In Canada, a similar system, called 'Routine Practices and Additional Precautions', has been in place since 1999 (Public Health Agency of Canada 2012). While multiple guidelines have been published for the control of specific microorganisms, such as Clostridium difficile or norovirus, they build on, rather than replace, Standard Precautions.

In spite of widespread adoption of Standard Precautions by organisations, there are gaps in their implementation by healthcare workers (Clock 2010; Gammon 2008). The barriers reported by the healthcare professionals include inadequate infrastructure such as lack of handwashing facilities; lack of information about transmission and insufficient personal protective equipment (Oliveira 2010). Interventions have, therefore, been used to promote implementation of Standard Precautions as the basis for infection prevention and control.

 

Description of the intervention

Interventions can be categorised into three approaches: educational, behavioural, or technical. While these categories differ from the Cochrane Effective Practice and Organisation of Care (EPOC)'s usual taxonomy of professional, financial, organisational and structural interventions (EPOC 2012), they are more reflective of the actual interventions implemented with respect to promoting Standard Precautions. Educational approaches, one aspect of professional interventions, include educational campaigns, instruction and training, use of pamphlets and posters, and audits with feedback. Education may be provided to individuals or directed to groups. Behavioural interventions, also reflective of professional interventions, include raising risk awareness, or providing penalties or rewards for the desired behaviours. Financial interventions may also be used to influence behaviour. Technical interventions illustrate both organisational and structural interventions; examples include provision and placement of materials required to implement Standard Precautions and eliminating barriers to their use.

 

How the intervention might work

Educational interventions can increase healthcare workers' knowledge of what strategies to use to reduce transmission of microorganisms, when to use these strategies, and how to implement them correctly. Behavioural interventions might increase awareness of specific individual behaviours and their consequences, and provide motivation for change, such as inducing shame if not adhering to guidelines or pride if adherence is appropriate. Technical interventions, such as ensuring availability of personal protective equipment or adequate housekeeping staff, may reduce barriers that prevent optimal adherence to Standard Precautions. By promoting knowledge of, and belief in, the value of Standard Precautions guidelines or enabling their application, or both, adherence can be improved.

We have not identified a systematic review of interventions to improve adherence to Standard Precautions although there is a review of interventions to improve hand hygiene (Gould 2010).

 

Why it is important to do this review

The results will be useful to provide healthcare professionals involved in healthcare settings with evidence of the best approach (educational, behavioural, technical, or a combination of these) to improve adherence to Standard Precautions in the provision of care.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

To evaluate the effectiveness of interventions to improve adherence to Standard Precautions in patient care.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
 

Criteria for considering studies for this review

 

Types of studies

We will include the following types of studies:

  • randomised controlled trials (RCTs) of individuals and cluster-randomised controlled trials;
  • non-randomised controlled trials (non-RCTs) (studies in which investigators allocated participants to the different groups that are being compared using a method that is not random, but at least two groups with different interventions are followed);
  • controlled before-and after-studies (CBAs) (with at least two intervention sites and two control sites);
  • interrupted time-series (ITS) (with at least three observations available before the intervention and further three available after the intervention).

See the EPOC checklist for definition of designs (EPOC).

 

Types of participants

Any healthcare professional (e.g. doctors, nurses, or pharmacists) with responsibility for patient care in any hospital, long-term care or community setting, or artificial setting, such as a classroom or learning laboratory.

 

Types of interventions

We will consider any intervention intended to improve adherence to Standard Precautions or transmission-based precautions, or both:

  • educational interventions, including professional interventions (such as distribution of educational materials, educational meetings, patient-mediated interventions, reminders);
  • behavioural interventions (such as audit and feedback, social marketing) including financial interventions (such as rewards or benefits or loss thereof tied to specific actions);
  • technical interventions including organisational interventions (such as administrative support or policies) and structural interventions (such as changes to the setting/site of service delivery; changes in physical structure, facilities, and equipment; presence and organisation of quality monitoring mechanisms).

We will include studies if they relate to Standard Precautions or transmission-based precautions in general, or both, or to a particular type of transmission-based precautions, such as contact precautions. We will also include studies that only evaluate one component of Standard Precautions or transmission-based precautions, or both, such as use of gowns or gloves.  

Older studies will have examined existing systems of precautions, rather than Standard Precautions. We will, therefore, also consider studies of interventions to improve adherence to universal precautions, category-specific precautions, body substance isolation precautions, and routine practices and additional precautions. These systems are all sufficiently similar in goals and issues that it is reasonable to assume that interventions for increasing adherence to one system will be relevant to another system.

We will exclude studies that evaluate only hand hygiene as this was already covered by another review (Gould 2010).

We will compare interventions against each other or no intervention.

 

Types of outcome measures

We will only include studies if they address the primary outcome.

 

Primary outcomes

  1. Rates of observed Standard Precautions or transmission-based precautions (SP*) adherence or a proxy indicator of SP adherence (e.g. increased use of SP guidelines as policy; volume of glove use; number of patients put on contact precautions), or a combination of these. The definition of adherence may vary across studies and adherence may be assessed using observational methods.

 

Secondary outcomes

  1. Rates of healthcare-associated infection.

 

Search methods for identification of studies

Search strategies will be written by M. Fiander, EPOC Trials Search Co-ordinator (TSC), in consultation with the authors. The TSC will search the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE) for related systematic reviews and the following databases for primary studies.

•Cochrane Central Register of Controlled Trials (CENTRAL), Wiley

•Health Technology Assessment Database, Cochrane Library, Wiley

•NHS Economic Evaluation Database, Cochrane Library, Wiley

•MEDLINE, 1950-, In-Process and other non-indexed citations, OvidSP

•EMBASE, 1947 - , OvidSP

•The Joanna Briggs Institute EBP Database, OVID SP

•PubMed http://www.ncbi.nlm.nih.gov/pubmed/

•PubMed Central http://www.ncbi.nlm.nih.gov/pmc/

•EPOC Group, Specialised Register

•ProQuest Dissertations & Theses Full Text

•ProQuest Dissertations & Theses: UK & Ireland

•Dissertations and Theses Database, 1861-, ProQuest

•Latin American and Caribbean Health Sciences database (LILACS), Virtual Health Library (VHL)

•Science Citation Index Expanded (SCI-EXPANDED) --1900-present (Web of Science)

•Conference Proceedings Citation Index- Science (CPCI-S) --1990-present (Web of Science)

•World Health Organization Library Information System (WHOLIS/IRIS), Virtual Health Library (VHL)

A draft search strategy for MEDLINE is provided in Appendix 1. This strategy will be tested by screening selected citations for relevance and validated using a selection of exemplar papers on the topic of this review. The finalized strategy will be presented in the review. The Medline strategy will be translated for other databases using appropriate syntax and vocabulary for those databases. Results will be limited by two methodological filters: the Cochrane Highly Sensitive Search Strategy (sensitivity- and precision-maximizing version - 2008 revision) to identify randomized trials, and an EPOC methodology filter to identify non-RCT designs. Neither date nor language limits will be used.

 

Searching other resources

Gray Literature
We will conduct a grey literature search to identify studies not indexed in the databases listed above. Sources will include the sites listed below. Additional sources, if any, will be documented in the review.

Open Grey http://www.opengrey.eu/
Grey Literature Report (New York Academy of Medicine) http://greylit.org/
Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov/
National Institute for Health and Clinical Excellence (NICE) www.nice.org.uk/

Trial Registries

We will search the following registries for ongoing and completed trials:

•International Clinical Trials Registry Platform (ICTRP), Word Health Organization (WHO) http://www.who.int/ictrp/en/
•ClinicalTrials.gov, US National Institutes of Health (NIH) http://clinicaltrials.gov/

We will also:

• Screen individual journals and conference proceedings (e.g. hand search).
• Review reference lists of all included studies, relevant systematic reviews and primary studies.
• Contact the authors of relevant studies or reviews to clarify reported published information or to seek unpublished results/data.
• Contact researchers with expertise relevant to the review topic or EPOC interventions.
• Conduct cited reference searches for all included studies in citations indexes.

We will handsearch the available conference proceedings from the UK Hospital Infection Society and the Infection Prevention Society, the American Association of Professionals in Infection Control, and the Canadian Community and Hospital Infection Control Association.

 

Data collection and analysis

 

Selection of studies

Two review authors (IC and DM) will independently assess the titles and abstracts of all reports. We will obtain full-text hard copies for studies that appear to meet the selection criteria and for studies where there is some doubt whether they fulfil the selection criteria. We will resolve any discrepancies with a third review author (RED). If consensus is still not reached, we will not include data from the trial in question unless and until the authors of the trial are able to resolve the contentious issues.

 

Data extraction and management

Two review authors (IC and DM) will independently extract data. We will resolve any discrepancies with a third review author (RED). We will use a standard data extraction form to extract the following information: characteristics of the study (design, methods of randomisation); participants; interventions; and outcomes (types of outcome measures, adverse events). We will then check for errors before entering the data into Review Manager 5 software (RevMan 2011).

 

Assessment of risk of bias in included studies

For the assessment of study quality, we will use the 'Risk of bias' approach for Cochrane reviews (Higgins 2011).

Both review authors (IC and DM) will independently assess each included study's risk of bias using a form with the standard criteria described by the EPOC Group (EPOC 2009). We will use the EPOC nine-point criteria for RCTs, non-RCTs, CBA studies and the seven-point criteria for ITS studies to determine the quality of all eligible studies. When information in the studies is not sufficient, we will attempt to contact the study authors to provide further details. We will report risk of bias for each study in the 'Characteristics of included studies' section. Studies will be categorised as 'low' risk if all risk of bias criteria are judged to be adequate. Studies will be categorised as 'moderate' risk of bias if one or two criteria are judged to be inadequate, and as 'high' risk of bias if more than two criteria are judged to be inadequate. We will record this information for each included trial in 'Risk of bias' tables in Review Manager 5 (RevMan 2011), and summarise the risk of bias for each study in a summary 'Risk of bias' figure and graph.

 

Measures of treatment effect

 

(a) Binary outcomes

For dichotomous data, we will use the risk ratio (RR) as the effect measure with 95% confidence intervals (CI).

 

(b) Continuous outcomes

For continuous data, we will present the results as mean differences (MD) with 95% CI). When pooling data across studies, we will estimate the MD if the outcomes are measured in the same way between studies. We will use the standardised mean difference (SMD) to combine studies that measure the same outcome but use different methods.

 

(c) Change scores versus final values

We will also report both pre- and post-intervention values for studies where change has not been reported. The difference-in-scores may be compared using a t-test (if assuming scores are continuous).

We will present results from CBAs and ITS that were not analysed using appropriate methods in a separate table.

 

Unit of analysis issues

We will assess whether appropriate analysis was conducted to adjust for clustering in estimating precision of intervention effects in cluster RCTs and CBAs. Where clustering has not been accounted for, we will contact study authors, and, if possible, work with them to adjust the results using (standard) approaches incorporating measures of intracluster correlation coefficients (ICCs) (Higgins 2011). If adjustment is not possible (e.g. due to lack of estimates of ICCs), we will report effect sizes without measures of precision.

Where relevant data can be obtained, inappropriately analysed ITS will be re-analysed using time-series regression to account for secular trends and potential autocorrelation (in time) of data; the best fit pre-intervention and post-intervention line will be estimated using linear regression or autoregressive integrated moving average (ARIMA) techniques (Lagarde 2012; Ramsay 2003).

 

Dealing with missing data

We will attempt to contact authors of the primary studies to obtain relevant missing data.

An intention-to-treat analysis (ITT) is one in which all the participants in a trial are analysed according to the intervention to which they were allocated, whether they received the intervention or not. We will assume that participants who dropped out are non-respondents. For each trial, we will report whether or not the investigators stated if the analysis was performed according to the ITT principle. If participants were excluded after allocation, we will report any details provided in full. As we will consider the dropouts as non-respondents, we will treat the participants who are not included in the analysis as if they have presented a negative outcome (for dichotomous data) or no change in the rates of healthcare-associated infection for continuous data. Where trials report results for participants who complete the trial without specifying the numbers initially randomised per group, we will present only complete case data. For other outcomes, we will present data for all patients randomised where reported; otherwise we will base estimates on complete cases only.

 

Assessment of heterogeneity

We will look for clinical heterogeneity (e.g. community versus artificial setting; healthcare professional versus students; educational versus behavioural interventions), by examination of the study details then test for statistical heterogeneity between trial results using the Chi2 test and the I2 value. We will consider I2 values of 40% to indicate a low level of heterogeneity and 75% to represent very high heterogeneity with a P value statistically significant (Deeks 2011).

 

Assessment of reporting biases

Apart from assessing the risk of selective outcome reporting considered under assessment of risk of bias in included studies, we will assess the likelihood of potential publication bias using funnel plots provided that there are at least eight trials. When small studies in a meta-analysis tend to show larger treatment effects, we will consider other causes including; selection biases, poor methodological quality, heterogeneity, artefactual, and chance.

 

Data synthesis

Given the substantial heterogeneity of interventions and methods across studies, it will be not sensible to use meta-analyses to pool results if these differences are deemed statistically and clinically significant. Instead, we will present the results of studies in tabular form and make a qualitative assessment of the effects of studies, based on quality. However, we will consider combining the results of subsets of studies using meta-analysis (random-effects method) where between-study differences are considered unlikely to explain variability in treatment effects. For studies that are sufficiently homogenous in terms of setting, design and intervention, we will use a fixed-effect model.

 

Subgroup analysis and investigation of heterogeneity

In this review, we will perform subgroup analyses considering the different subtypes of:

  1. staff specialities (such as physicians versus nurses);
  2. professionals from intensive care units (ICUs) versus others units;
  3. different settings such as hospital versus primary care;
  4. low- versus middle- versus high-income countries.

We will perform subgroup analyses in Review Manager 5 (RevMan 2011).

 

Sensitivity analysis

We will perform a sensitivity analysis to examine the effects of different trials as follows:.

  1. excluding trials with high risk of bias;
  2. excluding trials with rates of withdrawal of 20% or greater.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

We would also like to thank Alain D. Mayhew, Julia Worswick and Pierre Durieux (Cochrane Effective Practice and Organisation of Care Group) for their help during the preparation of this protocol.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
 

Appendix 1. DRAFT Medline Strategy


#Searches [Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to Present]Results

1((standard or universal or transmission-based or isolation) and precaution?).ti.479

2((standard or universal or transmission-based or isolation) adj4 precaution?).ab.1799

3((airborn$ or bacteria$ or barrier? or blood$ or body substanc$ or body fluid? or contact or droplet$ or HAI or infection? or infectious or nosocomial) and precaution?).ti.341

4((airborn$ or bacteria$ or barrier? or blood$ or body substanc$ or body fluid? or contact or droplet$ or HAI or infection? or infectious or noscomial or transmission-based) adj5 precaution?).ab.1567

5(isolation and precaution?).ti. or (isolation adj5 precaution?).ab.465

6(Routine Practices and Additional Precaution?).ti,ab.3

7((mask? or glove? or gown?) and precaution?).ti. or ((mask? or glove? or gown?) adj5 precaution?).ab.94

8body substance? isolation?.ti,ab.34

9((ICU or intensive care unit?) and precaution?).ti.16

10((aseptic or sterile) and precaution?).ti. or ((aseptic or sterile) adj5 precaution?).ab.182

11(precaution? adj4 (communication? or sign? or signage or notif$)).ti,ab.33

12or/1-11 [Keyword Search Standard Precautions]3353

13Cross Infection/ or Pneumonia, ventilator-associated/47105

14catheter-related infections/ or prosthesis-related infections/ or exp sepsis/102145

15Surgical Wound Infection/28028

16exp Catheterization/ae, co, mo [Adverse Effects, Complications, Mortality]41867

17exp Catheterization/ and (infection? or infectious).ti,hw.9863

18Surgical Wound Infection/28028

19(cross infection? or HAI or Hospital Acquired infection? or (catheter$ adj3 infection?) or (ventilator$ adj3 (infection? or pneumonia))).ti,ab.14850

20(sepsis or septic shock or blood$ infection? or blood poisoning or Bacter?emia$ or endotox?emia$).ti.37500

21(sepsis or septic shock or blood$ infection? or blood poisoning or Bacter?emia$ or endotox?emia$).ab.88831

22((surgery or surgical or postop$ or post-operat$) adj4 infection?).ti,ab.21957

23((antibiotic? or methicill$ or vancomyc$) adj2 (resistant? or resistance)).ti,ab. and (exp hospitals/ or exp hospitalization/ or hospital$.ti.)4949

24or/13-23 [Hospital Infections]277860

25Cross Infection/pc or Pneumonia, ventilator-associated/pc or catheter-related infections/pc or prosthesis-related infections/pc or exp sepsis/pc or Surgical Wound Infection/pc [Prevention & control]36656

26precaution?.ti,ab.13179

27infection control/ or antisepsis/ or asepsis/ or blood safety/ or infection control, dental/ or patient isolation/ or quarantine/ or sterilization/ or disinfection/50083

28((infection? adj2 control$) or blood safety or (antisepsis or asepsis or sterili?ation or disinfect$)).ti.23281

29((antisepsis or asepsis or sterili?ation or disinfect$) adj7 (procedur$ or process or processes or strategy or strategies or strategi? or guideline? or protocol? or pathway? or policy or policies or checklist? or check-list?)).ab.3706

30protective devices/ or eye protective devices/ or masks/ or protective clothing/ or gloves, protective/ or gloves, surgical/ or respiratory protective devices/19587

31infection control.jn.672

32(scrubs or mask or masks or gown or gowns or glove or gloves or gloved or goggles or ((eye or eyes or clothing or uniform? or respiratory) adj2 protective)).ti,ab.33988

33isolation room?.ti,ab.305

34((Reduce? or reducing or disrupt$) adj2 (transmission? or spread or spreading)).ti,ab.5746

35or/26-34 [Infection Control/Precautions]124719

3624 and 3517420

3725 not 3625047

3825 and (precaution? or guideline? or standard? or guidance or protocol? or pathway?).ti,ab.5447

3938 not 372625

40or/12,36,38 [Results before filters]22363

41(randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti.924266

42exp animals/ not humans.sh.4033798

4341 not 42 [Cochrane RCT Filter 6.4.d Sens/Precision Maximizing]854621

4440 and 431598

45intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi-component or multidisciplin$ or multi-disciplin$ or multifacet$ or multi-facet$ or multimodal$ or multi-modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab.164789

46(pre-intervention? or preintervention? or "pre intervention?" or post-intervention? or postintervention? or "post intervention?").ti,ab. [added 2.4]10129

47(hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw.718557

48demonstration project?.ti,ab.1976

49(pre-post or "pre test$" or pretest$ or posttest$ or "post test$" or (pre adj5 post)).ti,ab.65153

50(pre-workshop or post-workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab.600

51trial.ti. or ((study adj3 aim?) or "our study").ab.627775

52(before adj10 (after or during)).ti,ab.358993

53("quasi-experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab,hw.103858

54("time series" adj2 interrupt$).ti,ab,hw.1176

55(time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or "more than")).ab.9302

56pilot.ti.39630

57Pilot projects/83610

58(clinical trial or controlled clinical trial or multicenter study).pt.646015

59(multicentre or multicenter or multi-centre or multi-center).ti.29580

60random$.ti,ab. or controlled.ti.773841

61(control adj3 (area or cohort? or compare? or condition or design or group? or intervention? or participant? or study)).ab. not (controlled clinical trial or randomized controlled trial).pt.409016

62(control year? or experimental year? or (control period? or experimental period?)).ti,ab. [Added May 30-2013]13347

63evaluation studies as topic/ or prospective studies/ or retrospective studies/ [Added Jan 2013]956325

64(utili?ation or programme or programmes).ti. [Added Jan 2013]55054

65(during adj5 period).ti,ab. [Added Jan 2013]299404

66((strategy or strategies) adj2 (improv$ or education$)).ti,ab. [Added Jan 2013]18632

67(purpose adj3 study).ab.225352

68"comment on".cm. or review.pt. or (review not "peer review$").ti. or randomized controlled trial.pt. [Changed Jan 2013]2942022

69(rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti,hw. or veterinar$.ti,ab,hw. [Edited May 2013]5605705

70exp animals/ not humans.sh.4033798

71(or/45-67) not (or/68-70) [EPOC Methods Filter 2.5-added Evaluation Studies line forward--Jan 20130 Medline]2825498

7240 and 43 [RCT Results]1598

73(and/40,71) not 72 [EPOC FIlter Results]6873

74Guideline Adherence/ or Guideline/ or Practice Guideline/45403

75Critical Pathways/4518

76(protocol? or guideline? or guidance or standard? or pathway?).ti,ab,hw.2046217

77guidelines as topic/ or practice guidelines as topic/110783

78or/74-77 [Terms to focus EPOC Filter results]2046217

7973 and 78 [EPOC Filter Results]2575

80(12 and 71) not (or/72,79) [Keywords & EPOC Filter]778

81or/72,79-80 [Results of Draft Strategy]4951



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

Conceiving the protocol: Ione Corrêa (IC) and Regina El Dib (RED).

Co-ordinating the protocol: RED.

Writing the protocol: IC, Donna Moralejo (DM), Pasqual Barretti (PB) and RED

Guarantor for the protocol (one author): RED.

Reading and checking protocol before submission: IC, DM, PB and RED.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support
 

Internal sources

  • No source, Brazil.

 

External sources

  • No sources of support supplied

References

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Acknowledgements
  7. Appendices
  8. Contributions of authors
  9. Declarations of interest
  10. Sources of support
  11. Additional references
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