NUR 8050 Module 6 Evaluation Paper: RE-AIM, Implementation Outcomes and Sustainability Example

Lower Rates, Missed Patients and a Plan to Outlast the Project: An RE-AIM Evaluation of a Toothbrushing Protocol on a Medical-Surgical Unit

Student Name

Doctor of Nursing Practice, Thomas Edison State University

NUR-8050: Scholarly Inquiry: The Basis for Evidence-Based Practice

Mentor Name

Month Day, Year

Lower Rates, Missed Patients and a Plan to Outlast the Project: An RE-AIM Evaluation of a Toothbrushing Protocol on a Medical-Surgical Unit

Introduction

The analysis in Module 5 found that pneumonia fell after the oral care protocol began, with process data showing reliable delivery and several analytic methods pointing the same way. That result answers one question. A practice change can lower a rate during a project and fade within a year, or work for some patients and miss others. This paper evaluates the project with two frameworks that look beyond the outcome and sets out what is needed for the change to continue.

The RE-AIM Framework

Glasgow et al. (1999) built RE-AIM so that health programs would be judged on five fronts: how many people they touch, whether they work, who adopts them, how they are carried out and whether they endure. They argued that a program helps a population only to the extent that it reaches people and is delivered well, however strong it looks in a trial. The framework suits a unit-level project because each dimension can be measured with data already collected.

Reach: The Patients the Protocol Missed

Reach was high overall but lower among patients who needed full assistance with brushing, at 79 percent of patient-days, compared with over 90 percent among those who could brush with setup. These are the patients at greatest risk of aspiration and pneumonia. The gap appeared mainly on night shift for bedtime brushing and on days when the unit was short of assistants. This is the most important finding of the evaluation, because it locates the remaining risk precisely and suggests the next change: moving the second brushing for dependent patients to early evening, when staffing is stronger.

Patient characteristics mattered too. Patients with advanced dementia sometimes refused brushing or bit down on the brush, and staff were unsure how often to try again. A short teaching module on mouth care for people with dementia, using gentle approaches and a second attempt later in the shift, is planned. Patients admitted for less than 24 hours were also less likely to receive two brushings, which matters less because their risk of pneumonia is low.

Implementation Outcomes

Proctor et al. (2011) separate how well a change is put in place from how patients fare, and list eight measures of the first: whether staff find it acceptable, take it up, see it as fitting, can manage it, deliver it as designed, at what cost, how widely, and whether it lasts. Their point is that a failed outcome can reflect a failed implementation rather than an ineffective intervention, and the only way to tell the difference is to measure implementation directly.

On this unit, acceptability was assessed with a short staff survey at six months: most staff agreed the protocol was worth the time, though several assistants noted that brushing dependent patients takes about five minutes each. Appropriateness was supported by the dysphagia pathway, which addressed the main safety concern. Feasibility was demonstrated by sustained compliance without added staff, though overtime rose slightly in the first two months before returning to baseline. Fidelity was measured by bedside audits. Penetration, the share of eligible patients reached, is reported above as reach. Sustainability is addressed below.

Patients' views were gathered as well. A two-question survey given at discharge to patients able to answer found that most noticed the change and described it as part of feeling cared for, and several said they had not had their teeth brushed in previous hospital stays. These comments helped persuade the nursing quality council, since patient experience is a measure the hospital already reports.

Cost

Supplies, including toothbrushes, toothpaste, suction toothbrushes for patients with dysphagia and denture supplies, cost about $9,800 a year for 34 beds. Staff time for education was about 15 hours of paid time in total. Each avoided case of pneumonia is likely to cost the hospital far more than this, through longer stays, intensive care transfers and antibiotics. Quinn et al. (2014) estimated large cost savings in their initiative, but those were modeled estimates, and this project reports only its measured costs alongside the change in cases. A conservative business case notes that preventing even one or two cases a year would be expected to exceed the supply cost.

Sustainability

Projects often end when their leader moves on. To prevent that, the protocol was written into unit policy, oral care supplies were added to the standard admission cart, and the documentation fields became permanent. The unit practice council took ownership of the monthly measures, with the infection preventionist continuing to report pneumonia cases. A unit champion on each shift reviews compliance weekly. Maintenance will be judged by counting again two and four quarters after the handover.

Orientation now teaches the protocol to every new hire, and each Monday the unit secretary restocks the brush cart, so nothing rests on one person remembering. Two months in a row under 80 percent brushing will send the question back to the practice council for a fix.

Dissemination

The nursing quality council will hear the results first, with a proposal to roll the protocol out on two sister units and keep counting there. A manuscript shaped by SQUIRE 2.0, from setting and intervention through measures, results and limits, will go to a nursing quality journal.

Conclusion

The oral care protocol was effective on the measures available and reached most patients, though fewer of those who most needed help. Staff adopted it, delivered it faithfully and found it acceptable at a modest cost. The evaluation identified a specific gap for dependent patients and a plan to close it, and the protocol has been built into policy, supplies and the unit council's routine so it can outlast the project.

References

Glasgow, R. E., Vogt, T. M., & Boles, S. M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89(9), 1322-1327. https://doi.org/10.2105/AJPH.89.9.1322

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7

Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic nursing care to prevent nonventilator hospital-acquired pneumonia. Journal of Nursing Scholarship, 46(1), 11-19. https://doi.org/10.1111/jnu.12050