Explanation & Elaboration

3. Background Knowledge

• Provides a brief, non-selective summary of current knowledge of the care problem being addressed, and characteristics of organizations in which it occurs

Example

"Several studies document that patients frequently show signs and symptoms of clinical instability before actual cardiac arrest. Schein et al. found that 70% of patients showed evidence of respiratory deterioration within 8 hours of cardiac arrest. Other warning signs include hypotension, hypertension, tachycardia, tachypnea, and altered mental status. Despite documentation of the patient's clinical deterioration and physician notification, interventions are frequently inappropriate or absent. The rapid response team concept has evolved as a means of extending critical care outside of the intensive care unit to intervene early and to prevent deterioration to cardiac arrest. We recently implemented a rapid response team at our hospital and this study evaluates our early experience with this approach..."

"Saint Anthony Central Hospital is a busy community-based urban Level I trauma center in Denver, CO. There are over 2,500 trauma admissions annually and just over 600 of the admissions have an Injury Severity Score > 16. Moreover, St. Anthony Central Hospital functions as a tertiary referral center for multiple other facilities within the Centura health hospital Network. Experienced, board certified trauma surgeons are available inhouse 24 hours a day, 7 days a week (24/7). Similarly, critical care physicians are also inhouse and available at all times."

"Before March, 2005, patient clinical deterioration was managed by the inhouse physicians, both trauma and critical care, after notification by the nurse caring for the patient. During the year before March 2005, we developed a rapid response team to react to patient clinical deterioration outside of the intensive care unit; in effect, bringing critical care to the patient's bedside." [17]

Elaboration

To understand a quality improvement intervention clearly, readers need to understand how the intervention relates to general knowledge of the care problem. This requires the authors to place their work within the context of issues that are known to impact the quality of care. Context means "to weave together." [18]  The interweaving of the issues that stimulated the improvement idea and a variety of spatial, social, temporal, and cultural factors within the local setting form the canvas upon which improvement is painted. The explanation of context should go beyond a description of physical setting. A general description of the organization (types of patients served, staff providing care, and care processes prior to introducing the intervention) will help readers to determine if findings from the study are likely to be transferable to their own care setting. In studies with multiple sites, a table can be a convenient way to summarize differences in context across sites. The table can specify the structures, processes, people, and patterns of care that are unique to each site and assist the reader in interpreting results.

The above example places the improvement work within the context of a recognized need to provide earlier intervention to patients who are experiencing clinical deterioration; however, the authors also provide substantial details about their facility as a Level I trauma center that is highly invested in critical care delivery. This description will capture the attention of readers from similar facilities, as the results may have implications for their own institutions. Conversely, this also allows readers whose context is very different to interpret the results appropriately.

Whereas controlled trials attempt to control the context to avoid selection bias, quality improvement studies often seek to describe and understand the context in which the delivery of care occurs. Pawson et al. propose using form of inquiry known as "realist evaluation" to explore complex, multi-component programs that are designed to change performance. The relevant questions in realist evaluation are: "WHAT is it about this kind of intervention that works, for WHOM, in what CIRCUMSTANCES, in what RESPECTS and WHY?" [19]  Answering these questions within a quality improvement report requires a thoughtful and thorough description of the background circumstances into which the change was introduced.

The description of the background knowledge and local context of care will be blended between checklist item 3. Background Knowledge and item 4. Local Problem. Placing information into the exact category is less important than ensuring the background knowledge, local context, and local problem are fully described.

References

17. Offner PJ, Heit J, Roberts R. Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. The Journal of trauma. 2007;62(5):1223-1227; discussion 1227-1228.

18. Harper D. The Online Etymology Dictionary; 2001.

19. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review--a new method of systematic review designed for complex policy interventions. Journal of health services research & policy. 2005;10 Suppl 1:21-34.

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