Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice.

Objective: To determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease.

Design: A 6-year follow-up of a cluster randomised controlled trial, which found after 18 months that both total and cardiovascular hospital admissions were significantly reduced in intervention practices (8% absolute reduction).

Setting: 48 general practices in the Republic of Ireland and Northern Ireland.

Participants: 903 patients with established coronary heart disease at baseline in the original trial.

Intervention: The original intervention consisted of tailored practice and patient plans; training sessions for practitioners in medication prescribing and behavioural change; and regular patient recall system. Control practices provided usual care. Following the intervention period, all supports from the research team to intervention practices ceased.

Outcome measures: Primary outcome: hospital admissions, all cause and cardiovascular; secondary outcomes: mortality; blood pressure and cholesterol control.

Results: At 6-year follow-up, data were collected from practice records of 696 patients (77%). For those who had died, we censored their data at the point of death and cause of death was established. There were no significant differences between the intervention and control practices in either total (OR 0.83 (95% CI 0.54 to 1.28)) or cardiovascular hospital admissions (OR 0.91 (95% CI 0.49 to 1.65)). We confirmed mortality status of 886 of the original 903 patients (98%). There were no significant differences in mortality (15% in intervention and 16% in control) or in the proportions of patients above target control for systolic blood pressure or total cholesterol.

Conclusions: Initial significant differences in the numbers of total and cardiovascular hospital admissions were not maintained at 6 years and no differences were found in mortality or blood pressure and cholesterol control. Policymakers need to continue to assess the effectiveness of previously efficacious programmes.

Trial registration number: Current Controlled Trials ISRCTN24081411.

Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries

Importance Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS).

Objectives To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation management, and use of adjuncts—for example prone positioning—in routine clinical practice for patients fulfilling the ARDS Berlin Definition.

Design, Setting, and Participants The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents.

Exposures Acute respiratory distress syndrome.

Main Outcomes and Measures The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS.

Results Of 29 144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical ventilation. The period prevalence of mild ARDS was 30.0% (95% CI, 28.2%-31.9%); of moderate ARDS, 46.6% (95% CI, 44.5%-48.6%); and of severe ARDS, 23.4% (95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4% (95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5% (95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1% (95% CI, 38.2-42.1), whereas 82.6% (95% CI, 81.0%-84.1%) received a positive end-expository pressure (PEEP) of less than 12 cm H2O. Prone positioning was used in 16.3% (95% CI, 13.7%-19.2%) of patients with severe ARDS. Clinician recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was 34.9% (95% CI, 31.4%-38.5%) for those with mild, 40.3% (95% CI, 37.4%-43.3%) for those with moderate, and 46.1% (95% CI, 41.9%-50.4%) for those with severe ARDS.

Conclusions and Relevance Among ICUs in 50 countries, the period prevalence of ARDS was 10.4% of ICU admissions. This syndrome appeared to be underrecognized and undertreated and associated with a high mortality rate. These findings indicate the potential for improvement in the management of patients with ARDS.

The challenges and successful strategies of secondary school administrators /

This study presents information gathered during personal interviews in the area of challenges that administrators have faced in their careers, and the strategies they have found to be successful in meeting those challenges. This research is a qualitative study, using an inductive approach. Five participants were chosen, based on convenience sampling, with semi-structured interviews that were audio recorded. The theoretical research found that school violence and stafS'school morale were key challenges facing administrators, with a variety of approaches suggested to foster success in meeting those challenges. Some of these approaches included knowledge, team work, an ethic of care, and having a school vision. From the interviews it became clear that the challenges administrators faced included those posed by students, including disciplinary issues, those posed by adults and those posed by government changes in education. In regards to strategies for success, the interviews revealed three key concepts that were emphasized as vital. These were the assets of craft knowledge (experience), collegiality, and the use of other professional resources and educators.

Evaluating three self-help smoking cessation interventions for post-secondary smokers : a randomized controlled trial on six Ontario campuses

Objective. Smoking prevalence is highest among the young adult cohort. Postsecondary students are no exception. Although many students intend to quit smoking, no research has established what methods best promote reductions in, or complete abstinence from smoking. This randomized controlled trial examined the effectiveness of three self-help smoking cessation interventions. Method. On six post-secondary campuses, 483 smokers who voluntarily accessed Leave The Pack Behind (a tobacco control initiative) were randomly assigned to one of three smoking cessation interventions: One Step At A Time (a 2-booklet, *gold standard' program for adults); Smoke|Quit (a newly-developed 2-booklet program for young adult students); and usual care (a 'Quit Kit' containing a booklet on stress management, information about pharmacological quitting aides and novelty items). All participants also received one proactive telephone support call from a peer counsellor. During the study, 85 participants withdrew. The final sample of 216 students who completed baseline questionnaires and 12-week follow-up telephone interviews was representative of the initial sample in terms of demographic characteristics, and smokingquitting- related variables. Results. Whether participants quit smoking depended upon treatment condition, ^(2, N=2\6) = 6.34, p = .04, with Smoke|Quit producing more successfijl quitters (18.4%) than One Step At A Time (4.5%) or the Quit Kit (1 1.4%). On average, participants had quit 53.46 days, with no significant difference across treatments. Selfefficacy also increased. Use of the intervention or other quitting aides was not associated with treatment condition. Among the 191 participants who did not quit smoking, treatment condition did not influence outcomes. Overall, 46.2% had made a quit attempt. Significant decreases in weekly tobacco consumption and increases in self-efficacy to resist smoking were observed from baseline to follow-up. Conclusion. Post-secondary institutions represent a potentially final opportunity for age-targeted interventions. Self-help resources tailored to students' social and contextual characteristics will have considerable more impact than stage-only tailored interventions. Both reduction and abstinence outcomes should be emphasized to positively support students to stop smoking.

Athletic injury care training in high school coaches

The purpose of this qualitative study was to understand the client and occupational therapist experiences of a mental health group. A secondary aim was to explore the extent to which this group seemed to have reflected a client-centred approach. The topic emerged from personal and professional issues related to the therapist as teacher and to inconsistencies in practice with the profession's client-centred philosophy. This philosophy, the study's frame of reference, was established in terms of themes related to the client-therapist relationship and to client values. Typical practice was illustrated through an extensive literature review. Structured didacticexperiential methods aiming toward skill development were predominant. The interpretive sciences and, to a lesser extent, the critical sciences directed the methodology. An ongoing support group at a community mental health clinic was selected as the focus of the study; the occupational therapist leader and three members became the key participants. A series of conversational interviews, the . core method of data collection, was supplemented by observation, document review, further interviews, and fieldnotes. Transcriptions of conversations were returned to participants for verification and for further reflection Analysis primarily consisted of coding and organizing data according to emerging themes. The participants' experiences of group, presented as narrative stories within a group session vignette, were also returned to participants. There was a common understanding of the group's structure and the importance of having "air time" within the group; however, differences in perceptions of such things as the importance of the group in members' lives were noted. All members valued the therapeutic aspects of group, the role of group as weekly activity and, to a lesser extent, the learning that came from group. The researcher's perspective provided a critique of the group experience from a client-centred perspective. Some areas of consistency with client-centred practice were noted (e.g., therapist attitudes); however the group seemed to function far from a client-centred ideal. Members held little authority in a -relationship dominated by the leaders, and leader agendas rather than member values controlled the session. Possible reasons for this discrepancy ranging from past health care encounters through to co-leader discord emerged. The actual and potential significance of this study was discussed according to many areas of implications: to OT practice, especially client-centred group practice, to theory development, to further areas of research and methodology considerations, to people involved in the group and to my personal growth and development.

Foraging ecology and parental care of common terns (Sterna hirundo) nesting in Windermere Basin, Lake Ontario

The relationships among chick feeding, size and type of prey item, and foraging time away from the brood have not been well studied in seabirds. This study investigated spatial and temporal patterns of foraging and chick-provisioning among 23 radio-tagged male common terns nesting at Hamilton Harbour, Lake Ontario during 1991 and 1992. Telemetry data were collected concurrently with behavioural observations from an elevated blind. Terns fitted with transmitters did not differ from controls with respect to either brood attendance, patterns of chick mortality, species and size distributions of prey delivered to offspring, or chick-provisioning rates. There was a clear separation of parental roles: males were primarily responsible for feeding chicks while females allocated more time to brood attendance. The prey species most commonly delivered to chicks by adults were rainbow smelt (Osmerus mordax) and alewife (A/osa pseudoharengus), followed in importance by larval fish, emerald shiner (Notropis antherinoides), salmonids, and fathead minnows (Pimepha/es prome/as). The relative proportions of various fish speCies delivered to chicks by males differed over the course of each breeding season, and there was also much variability in species composition of prey between years. Sizes of prey delivered to chicks also differed between sampling periods. The modal size of fish brought to chicks during Peak 1991 was 1.5 bill lengths, while the majority of prey in Late 1991 were small larval fish. The reverse trend occurred in 1992 when small fish were delivered to chicks predominantly during the Peak nesting period. During periods when predominantly small fish were delivered to chicks, the foraging activity of radio-tagged males was concentrated within a two kilometer radius of the colony. The observed variation in prey composition and foraging locations during the study likely reflects temporal variation in the availability of prey in the vicinity of the colony. Males delivered fish to chicks at a constant rate, while females 4 increased their feeding frequency over the first six to ten brood days. The mean length of fish delivered to chicks by adults increased significantly with increasing chick age. As a group, within each nesting period, transmittered males either foraged predominantly in the same directional bearing (north during Peak 1991, south during Late 1992), or concentrated foraging activity in the immediate vicinity of the colony (Late 1991, Peak 1992). However, individual radio-tagged males exhibited unique and predictable foraging patterns, often favouring specific locations within these areas and differing in their secondary foraging patterns. Overall, the Lake Ontario shoreline between NCB Bay" (3.5 km south of colony) and the lift bridge canal (4 km north of colony) was the foraging area used most frequently by radiotagged males during the chick-rearing period. Foraging patterns of transmittered males at Windermere Basin are similar to patterns of peak-nesting common terns, but differ from those of late-nesters, at a nearby colony (Port Colborne, Lake Erie). Differences between the foraging patterns of late-nesting terns at these colonies likely reflect differences in annual patterns of fish availability between the two locations. No relationship was found between foraging proficiency of adults and survival of offspring. Stochastic factors, such as predation by black-crowned nightherons (Nycticorax nycticorax) and adverse weather conditions during the early stages of chick rearing, may be more important determinants of common tern breeding success than parental quality or fish availability.

La reconnaissance des aidants informels : care, justice et vulnérabilité dans la famille

Doctorat réalisé en cotutelle avec l’Université Paris I- Panthéon Sorbonne.

Horizontal Inequity in Access to Health Care in Four South American Cities

The objective of this paper is compare socioeconomic inequalities in the use of healthcare services in four South-American cities: Buenos Aires, Santiago, Montevideo, and San Pablo. We use secondary data from SABE, a survey on Health, Well-being and Aging administered in 2000 underthe sponsorship of the Panamerican Health Organization, and representative of the elderly population in each of the analyzed cities. We construct concentration indices of access to and quality of healthcare services, and decompose them in socioeconomic, need, and non-need contributors. Weassess the weight of each contributor to the overall index and compare indices across cities. Our results show high levels of pro-rich socioeconomic inequities in the use of preventive services in all cities, inequities in medical visits in Santiago and Montevideo, and inequities in quality of access to care in all cities but Montevideo. Socioeconomic inequality within private or public health systems explains a higher portion of inequalities in access to care than the fragmented nature of health systems. Our results are informative given recent policies aimed at enforcing minimum packages of services and given policies exclusively focused on defragmenting health systems.

Self-assembly of palmitoyl lipopeptides used in skin care products

The self-assembly of three cosmetically active peptide amphiphiles C16-GHK, C16-KT, and C16-KTTKS (C16 denotes a hexadecyl, palmitoyl chain) used in commercial skin care products is examined. A range of spectroscopic, microscopic, and X-ray scattering methods is used to probe the secondary structure, aggregate morphology, and the nanostructure. Peptide amphiphile (PA) C16-KTTKS forms flat tapes and extended fibrillar structures with high β-sheet content. In contrast, C16-KT and C16-GHK exhibit crystal-like aggregates with, in the case of the latter PA, lower β-sheet content. All three PA samples show spacings from bilayer structures in small-angle X-ray scattering profiles, and all three have similar critical aggregation concentrations, this being governed by the lipid chain length. However, only C16-KTTKS is stained by Congo red, a diagnostic dye used to detect amyloid formation, and this PA also shows a highly aligned cross-β X-ray diffraction pattern consistent with the high β-sheet content in the self-assembled aggregates. These findings may provide important insights relevant to the role of self-assembled aggregates on the reported collagen-stimulating properties of these PAs.

Existential issues in surgical care : Nurses’ experiences and attitudes in caring for patients with cancer

The overall aim of this thesis was to explore surgical nurses’ experiences of being confronted with patients’ existential issues when caring for patients with cancer, and to examine whether an educational intervention may support nurses in addressing existential needs when caring for patients with cancer. Previously recorded discussions from supervision sessions with eight healthcare professionals were analysed (I), written descriptions of critical incidents were collected from 10 nurses, and interviews with open questions were conducted (II). An educational intervention on existential issues was pilot tested and is presented in Studies III and IV. The intervention was the basis of a pilot study with the purpose of testing whether the whole design of the educational intervention, including measurements instruments, is appropriate. In Study III and IV interviews with 11 nurses were conducted and 42 nurses were included in the quantitative measurements of four questionnaires, which were distributed and collected. Data was analysed using qualitative secondary analysis (I), hermeneutical analysis (II), and mixed methods using qualitative content analysis and statistical analyses (III-IV). Results in all studies show that existential issues are part of caring at surgical wards. However, although the nurses were aware of them, they found it difficult to acknowledge these issues owing to for example insecurity (I-III), a strict medical focus (II) and/or lacking strategies (I-III) for communicating on these issues. Modest results from the pilot study are reported and suggest beneficial influences of a support in communication on existential issues (III). The results indicate that the educational intervention may enhance nurses’ understanding for the patient’s situation (IV), help them deal with own insecurity and powerlessness in communication (III), and increase the value of caring for severely ill and dying patients (III) in addition to reducing work-related stress (IV). An outcome of all the studies in this thesis was that surgical nurses consider it crucial to have time and opportunity to reflect on caring situations together with colleagues. In addition, descriptions in Studies III and IV show the value of relating reflection to a theory or philosophy in order for attitudes to be brought to awareness and for new strategies to be developed.

How initial vocational education and training (IVET) teachers in Sweden perceive their prospects of being able to prepare upper secondary school pupils for a future occupation

Vocational teachers in Swedish upper secondary schools are a heterogeneous category of teachers, connected to different types of trade. These teachers represent a broad set of trade skills varying in content and character. In their teacher role, they continue to wear the clothes, speak the language, share the culture and remain mentally in their former professions. Still, it is central that they keep up this contact to be able to school the pupils into the environment of the trade in question, but also to help them to understand what skills a profession demands. However, the individual teacher also has to distance himself from the negative elements in the culture of the profession: patterns and habits that, for various reasons, have to be broken or changed. This paper draws attention to the ways in which a group of vocational teachers, who were participants in a project that aimed to train unauthorized vocational teachers, expressed their ambitions to prepare the pupils for a future professional career. When collecting information, we used the degree dissertations they produced and discussed in seminars, and informal dialogues. The result shows that it is important that the instruction location resembles a real working site as far as possible. These places are more or less realistic copies of a garage, a restaurant kitchen, a hairdressing salon, and so on, in order to give the pupils a realistic setting for instruction. However, the fact that these simulated workplaces lack the necessary support functions that exist in a company creates problems, problems which make a lot of extra work for the teachers. Vocational teachers also have to instruct the pupil in the experienced practitioner’s professional skills and working situation, but the pupil herself/himself must learn the job by doing it in practice. Some vocational upper secondary programs lack relevant course literature and the businesses give little support. This also makes extra work for the teachers. Moreover, the distance between the vocational programs and the trainee jobs was experienced as being difficult to overcome. One reason seems to be differences between businesses and differing preconditions between small and big companies’ abilities to take care of these pupils. The upper secondary school vocational programs also play a role in cementing existing gender roles, as well as perpetuating class-related patterns on the labour market.

How initial vocational education and training (IVET) teachers in Sweden perceive their prospects of being able to prepare upper secondary school pupils for a future occupation

Vocational teachers in Swedish upper secondary schools are a heterogeneous category of teachers, connected to different types of trade. These teachers represent a broad set of trade skills varying in content and character. In their teacher role, they continue to wear the clothes, speak the language, share the culture and remain mentally in their former professions. Still, it is central that they keep up this contact to be able to school the pupils into the environment of the trade in question, but also to help them to understand what skills a profession demands. However, the individual teacher also has to distance himself from the negative elements in the culture of the profession: patterns and habits that, for various reasons, have to be broken or changed. This paper draws attention to the ways in which a group of vocational teachers, who were participants in a project that aimed to train unauthorized vocational teachers, expressed their ambitions to prepare the pupils for a future professional career. When collecting information, we used the degree dissertations they produced and discussed in seminars, and informal dialogues. The result shows that it is important that the instruction location resembles a real working site as far as possible. These places are more or less realistic copies of a garage, a restaurant kitchen, a hairdressing salon, and so on, in order to give the pupils a realistic setting for instruction. However, the fact that these simulated workplaces lack the necessary support functions that exist in a company creates problems, problems which make a lot of extra work for the teachers. Vocational teachers also have to instruct the pupil in the experienced practitioner’s professional skills and working situation, but the pupil herself/himself must learn the job by doing it in practice. Some vocational upper secondary programs lack relevant course literature and the businesses give little support. This also makes extra work for the teachers. Moreover, the distance between the vocational programs and the trainee jobs was experienced as being difficult to overcome. One reason seems to be differences between businesses and differing preconditions between small and big companies’ abilities to take care of these pupils. The upper secondary school vocational programs also play a role in cementing existing gender roles, as well as perpetuating class-related patterns on the labour market.

Women's acceptability of misoprostol treatment for incomplete abortion by midwives and physicians : secondary outcome analysis from a randomized controlled equivalence trial at district level in Uganda

OBJECTIVE: This study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians. METHODS: This was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14-28 days following treatment. Analysis of women's overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024. RESULTS: From April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded. CONCLUSIONS: Treatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women. TRIAL REGISTRATION: ClinicalTrials.gov NCT01844024.

Acceptability of home-assessment post medical abortion and medical abortion in a low-resource setting in Rajasthan, India : Secondary outcome analysis of a non-inferiority randomized controlled trial

Background: Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education. Objective: To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India. Design: Secondary outcome of a randomised, controlled, non-inferiority trial. Setting Outpatient primary health care clinics in rural and urban Rajasthan, India. Population: Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85mg/l and were below 18 years. Methods: Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1: 1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible. Main outcome measures: Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups. Results: 731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001). Conclusion: Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.

Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care : a cluster randomised study

BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention. METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention. RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal. CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.