Designing and implementing a CAP intervention

6.3. Designing and implementing a CAP intervention

A multidisciplinary team should oversee the design and implementation of the intervention. The team will need to include representation from local opin- ion leaders and all the major stakeholders (including patients), and may need to include persons with specific expertise, such as in behavioural psychology and statistics. Prior to deciding on which interventions are to be used and how they are to be implemented, the potential impact and costs of each component of any complex intervention and how these components interrelate should be under- stood. This can be achieved by review of the literature, modelling (e.g., of the economic costs), and small qualitative and/or quantitative studies, as described above. Ideally, components that appear likely to succeed at reasonable cost should then be tested in small intervention studies to establish, for example, the incremental effectiveness of each component, actual costs, and appropriate con- trol groups (MRC framework for the development and evaluation of RCTs for complex interventions to improve health; www.mrc.ac.uk). The latter is unlikely to be feasible, however, for routine QI or small research projects.

In TAYCAPP, the results of the described quantitative and qualitative studies suggested that multiple and complex barriers to any new intervention were

Pneumonia Guidelines in Practice

57 likely to exist and that a multifaceted intervention would be most likely to

succeed. For example, we recognised that an educational programme targeting the link between severity assessment and antibiotic therapy may well improve clinicians’ knowledge. However, the qualitative interviews identified the pres- ence of a potentially negative attitude towards CAP, in that it is considered less important than some other acute medical problems. For example:

I guess the same for myocardial infarction, we can do a lot for it and minutes mean muscle to coin a phrase, whereas in pneumonia it’s just pneumonia … It’s the attitude to it that I see. (Verbatim text from an in-depth interview)

We recognised that potentially this attitudinal barrier could prevent a change in physician behaviour and thereby process of care, even if knowledge did improve. We therefore attempted to upgrade the importance of CAP by empha- sising the high mortality and morbidity and marketing a “door to needle time” ethos in all aspects of the programme. The use of a multifaceted approach was supported by a previously published systematic review that found that multi- faceted interventions (i.e., two or more of audit and feedback, reminders, a local consensus process, and marketing) and interactive educational meetings ( participation of healthcare providers in workshops that include discussion or practice) were more consistently effective in promoting behaviour change in healthcare professionals than, for example, single interventions, such as paper-based educational materials (Bero et al., 1998). In light of the literature review and emerging local evidence, interventions, and implementation strate- gies subsequently included: (1) strategically sited management pathways based on the BTS recommendations and adapted to local practice, (2) posters marketing the BTS severity assessment criteria and a “door to needle time” ethos, (3) dissemination of implementation packs, which contained an expla- nation of the programme, a pocket-sized laminated management algorithm and an interactive educational workbook focusing on the link between severity assessment and appropriate therapy, (4) interactive educational meetings emphasising the severity assessment–appropriate antibiotic therapy link, and (5) continuous audit and monthly feedback.