Implementation Science

Definition of IS:

“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]

Aim of IS:

To research approaches and methods for closing the gap between what 'we think we know' from evidence, and what is routinely practiced ^[2]

Why is implementation important?

Successful translation of evidence into practice is important:

• Improve quality of care to patients
• Maximize benefits or minimize harm to patients
• Minimize waste of healthcare and research resources

Key concepts and components of implementation science:

1. Logic pathway on how the implementation strategy is expected to work and the mechanism by which the intervention is expected to improve healthcare.

   Implementation strategy is how the intervention was implemented such as training or changing the computer system

   Intervention is the healthcare intervention that is being implemented.

   Implementation strategy is how the intervention was implemented.

   To find out more about Logic models:
   www.wkkf.org/resource-directory/resource/2006/02/wk-kellogg-foundationlogic-model-development-guide
   

2. Balance between fidelity to and adaptation of the implementation strategy and intervention.

   Fidelity is the degree of adherence to described implementation strategy and intervention.

   Adaptation refers to modification of strategy and intervention to suit the local context.

3. Implementation success requires understanding of the various domains (individuals, process, context and intervention) to guide and promote evidence-informed practice (Figure below)^[3,4].

   Use of a framework such as Consolidated Framework For Implementation Research (CFIR)can provide a practical guide for systematically assessing potential barriers and facilitators across the various domains that affect implementation.
   

   
   

Figure. Major Domains of the CFIR

Reporting of implementation studies

Implementation studies are an extension of clinical studies and use of a standard guideline in reporting of implementation studies can improve the reporting of implementation studies to facilitate the translation of research into practice. The Standards for Reporting Implementation Studies(StaRI)comprise of 27 items to help researchers describe both the implementation strategy and the effectiveness of the intervention that was implemented ^[5].

(RE-AIM) Implementation framework

Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM)

RE-AIM is a framework used to improve the sustainable adoption and implementation of evidence-based interventions. It emphasizes five essential steps in translating research ^[6]. A prospective single-cohort study, KKH reported using RE-AIM for evaluation ^[7].

Projects in KKH

1. Adapting the US-based clinic-community model of child obesity treatment into an online intervention model in Singapore during COVID-19
2. Integrating community LITE programme into a school-clinic-community partnership as an online family-based intervention to combat childhood obesity
3. Family characteristics and challenges in navigation of health,social and education service in the lower and middle-income households with young children in NorthEast Singapore
4. Healthy Early Life Moments in Singapore (HELMS)!

Concussion awareness and follow-up

Our systematic review and meta-analysis emphasize on the need for close neuro-monitoring even with mild and moderate traumatic brain injuries ^[8,9].

Following our qualitative work in the community on the lack of concussion awareness and management, the paediatric emergency department collaborated with the neurosurgery and paediatric neurorehabilitation departments to derive a concussion workflow. In this cross-discipline workflow, children aged 7 years old and above with sports related injuries, or head injuries from other causes but with persistent giddiness or headaches undergo a modified Sport Concussion Assessment Tool (SCAT5 and child-SCAT5) in the ED and are referred for assessment by the neurorehabilitation team.

Trauma related Head Injuries in Children

Children with traumatic brain injuries due to abuse are at risk for poor neurocognitive outcomes and result in greater financial burden, compared to other mechanisms of TBI ^[10,11].

This has been highlighted to colleagues working with children involved in non-accidental injuries, for collaborations with MSF and other agencies. This collaborative work is ongoing.

Computed Tomography rules for radiation-sensitive children with head injuries

When validating international Computed Tomography rules for young children derived in North America, we found that widespread implementation of these rules would result in an increase in radiation to our children presenting with head injuries. The guidelines in KKH Children's Emergency provides guidance for watchful waiting and close monitoring, resulting in lower CT rates and adopting a ALARA (as low as reasonably achievable posture) ^[12,13].

Other pediatric health services epidemiology studies have helped us to understand how KKH CE and other mixed EDs in the country attend to the needs for the nation's children.

Childhood Injuries: Moving Upstream

The injury related research work has expanded proximally into PRIMARY PREVENTION - there is now an active Childhood Injury Prevention Workgroup in KKH Children's Emergency that seeks to work with multiple agencies (including the Traffic Police, Singapore Road Safety Council, etc) ^[14,15]. (There are also other agencies involved including water safety bodies) A large injury prevention stakeholder meeting has been organised annually since July 2022.