Implementation science: relevance to the NHS and global anaesthesia

Evidence-based practices developed through clinical research have the potential to enhance the quality of peri-operative care. However, it is often not known whether a negative or inconclusive impact of scale-up is because the intervention was ineffective, or just wasn’t used. Only half of all evidence-based practices ever reach widespread clinical use, taking up to 17 years for changes to be widely adopted. This has been termed the ‘research-to-reality’ or ‘implementation’ gap. Reducing this gap will maximise the benefits of evidence-based practices and is the focus of implementation science, defined as ‘The scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services’ [1]. Using a scientific approach to implementation can improve effectiveness from 15% to 83% and reduce the ‘research to reality gap’ from 17 to three years.

Quality improvement and implementation science share the goal of improving care quality, but there are important differences (Table 1). Quality improvement focuses on specific problems in a specific setting and may generate new evidence-based practices. In contrast, implementation science typically starts with an evidence-based practice that is under-utilised, seeks to understand why this is, and creates strategies for widespread sustainable uptake.

Relevance to the NHS

There are several high-profile examples of implementation failures in the NHS: Matching Michigan, the Surgical Safety Checklist, and the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. Matching Michigan was an NHS study aiming to ‘match’ Michigan in reducing central venous catheter (CVC)-associated infections. Work at Johns Hopkins University demonstrated reduced CVC infection rates using a bundle of infection prevention interventions. These interventions were then successfully applied at scale across the state of Michigan. In the NHS study, although CVC infections rates fell, few of the multiple implementation strategies used in Michigan were applied in the NHS. The ‘negative’ result was considered a failure of implementation, rather than failure of the intervention [3]. In 2010, around the same time as Matching Michigan, all UK hospitals were mandated to implement the Surgical Safety Checklist. Like Matching Michigan, the Surgical Safety Checklist also faced significant challenges during implementation, especially integrating it into existing practices [4]. Despite being mandatory, wide variation in use was reported, being as low as 40% in some cases. Even today implementation challenges remain, and CQC inspections continue to identify considerable variation in checklist use.

A decade on, the EPOCH trial also failed to demonstrate success at a national level [5]. Subsequent analysis again acknowledged problems with implementation as the cause for the ‘negative’ result. It seems that while the NHS continues to design many good evidence-based practices, knowledge of how to apply them at scale is lacking.

Relevance to global anaesthesia

Worldwide, five billion people lack access to safe affordable surgical care, with more deaths due to poor quality healthcare rather than lack of access. In Low- and Middle-Income Countries (LMICs) resources are limited, surgical quality and safety is often poor, and outcomes are significantly worse than in high income countries. Scale-up of evidence-based practices is therefore even more important. In 2019, the WHO declared that health systems must urgently focus on implementation science if the momentum of patient safety is to be maintained, especially in LMICs.

Table 1: Similarities and differences between implementation science and quality improvement science [2].

A huge number of evidence-based practices exist that would improve care in LMICs, but implementing these at scale is a monumental challenge. A recent analysis of Surgical Safety Checklist use in 94 countries reported a 75% rate of use overall, but < 30% in LMICs. Failure to scale up evidencebased practices around the world has been described as ‘a major failure in global health’, and a ‘form of waste that donors, researchers, clinicians, and … communities in developing nations cannot afford’ [6].

Conclusions

Anaesthetists have long been at the forefront of driving improvements in peri-operative care, especially at the individual and local level. We now need to raise our sights to the population level and learn how to apply evidence-based practices at scale. The current emphasis on clinical effectiveness over implementation risks leaving researchers wondering why interventions work in some contexts and not others, keeps potential solutions hidden in pockets but never reaching those in greatest need, and deprives many patients of high quality care. We must embrace this emerging discipline and understand its value for designing, planning and evaluating scale-up of evidence-based practices in the NHS and worldwide.

Susanna Ritchie McLean
Consultant Paediatric Anaesthetist
Birmingham Children’s Hospital

Dina Hadi
Consultant Anaesthetist
Whittington Health NHS Trust, London

Michelle White
Consultant Paediatric Anaesthetist
Great Ormond Street Hospital, London

Twitter: @Ritchiebiscuit; @mcwdoc

References 

1. Eccles MP, Mittman BS. Welcome to Implementation Science. Implementation Science 2006; 1: 1. 
2. White MC. Informing the knowledge gap of implementation of the World Health Organisation Surgical Safety Checklist in sub-Saharan Africa. PhD Thesis, King’s College London, London, UK. 2021 in press. 
3. Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implementation Science 2013; 8: 70. 
4. Russ SJ, Sevdalis N, Moorthy K, et al. A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project" Annals of Surgery 2015; 261: 81-91. 
5. Stephens TJ, Peden CJ, Pearse RM, et al. Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial). Implementation Science 2018; 13: 142. 
6. McCannon CJ, Berwick DM, Massoud MR. The science of large-scale change in global health. JAMA 2007; 298: 1937-9.

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