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BMC Health Services Research

, 14:648

Quality, performance, safety and outcomes


BackgroundClinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals – but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation TDFI approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes.

MethodsThe TDFI approach was used in a pre-post study in three NHS hospitals with a fourth acting as a control with usual care and no TDFI. The target behavior identified for change was to increase the use of pH testing as the first line method for checking the position of a nasogastric tube. Repeat audits were undertaken in each hospital following intervention implementation. We used Zou’s modified Poisson regression approach with robust standard errors to estimate risk ratios for the use of pH testing. The projected return on investment ROI was also calculated.

ResultsFollowing intervention implementation, the use of pH first line increased significantly across intervention hospitals risk ratio 95% CI ranged from 3.1 1.14 to8.43 p < .05, to 8.14 3.06 to21.67 p < .001 compared to the control hospital, which remained unchanged risk ratio CI = .77 .47-1.26 p = .296. The estimated savings and costs in the first year were £2.56 million and £1.41 respectively, giving an ROI of 82%, and this was projected to increase to 270% over five years.

ConclusionThe TDFI approach improved the uptake of a patient safety guideline across three hospitals. The TDFI approach is clinically and cost effective in comparison to the usual practice.

KeywordsTheoretical domains framework Patient safety Hospitals Barriers Interventions AbbreviationsTDFTheoretical Domains Framework

TDFI approachTheoretical domains framework implementation approach

ROIReturn on investment

NHSNational Health Service

NPSANational Patient Safety Agency


IPSBQInfluences on Patient Safety Behaviours Questionnaire

H1H2, H3, H4: Hospital 1, Hospital 2, Hospital 3, Hospital 4

Electronic supplementary materialThe online version of this article doi:10.1186-s12913-014-0648-4 contains supplementary material, which is available to authorized users.

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Author: Natalie Taylor - Rebecca Lawton - Sally Moore - Joyce Craig - Beverley Slater - Alison Cracknell - John Wright - Mohammed 


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