Table 1

The Sick Day Guidance Project TIDieR39

TIDieR Item	Brief description
Name	Salford Kidney Implementation Project
(1) Why	The SPARC was established to ensure a shared strategy and optimise kidney care across the city. The ambition of sick day guidance is to reduce the risk of avoidable harm to patients taking certain medications. Salford CCG in collaboration with SPARC defined the original implementation design of the sick day guidance intervention. NIHR CLAHRC Greater Manchester works in partnership with Salford CCG to support implementation and evaluation of projects. NIHR CLAHRC Greater Manchester evaluated this CCG priority and supported the implementation of sick day guidance.
(2) What	Medicines sick day guidance was delivered in two phases of work.
(3) Materials	Sick day guidance cards that suggested the temporary cessation of medicines during bouts of sickness were produced, and the text was replicated from the NHS Highland sick day rules card. Two, one and a half hour, educational events were run for healthcare professionals, organised and delivered by the Steering Group. This included why AKI is important from a local and national context. Information leaflet outlining the sick day guidance project and guidance on how to use the sick day guidance cards and poster summarising this information for use in practice. Poster for patients promoting the sick day guidance card intervention to be used in waiting areas.
(4) Procedures	Training was offered to all GPs, practice nurses and the wider practice team and to community pharmacists for the sick day guidance card implementation. During Phase One, the cards were distributed to all community pharmacies and general practices accompanied by an information leaflet and poster with patient engagement instructions. Distribution was carried out by project facilitators face to face, to explain and address any questions arising. Two further face to face visits were made to each general practice and pharmacy by the NIHR CLAHRC Greater Manchester (GM) project team to reinforce the project/provide additional materials/support. The cards were to be provided to patients receiving the drugs listed on the card by general practices and community pharmacies. Posters were displayed in practice waiting areas promoting the intervention to patients. GPs and other practice staff were advised to record the intervention in Salford Integrated Records using Read code 80AG. During Phase Two, the practice-based pharmacists accessed patient health records from Salford Royal NHS Foundation Trust to identify those at risk of AKI and constructed a database to record relevant data. The practice-based pharmacists were to contact and educate patients on the sick day guidance and to issue a card. They were also expected to complete a medications review. Approval was sought to ensure the project was in keeping with national Think Kidneys guidance.
(5) Who	The NIHR CLAHRC GM project team (facilitation, project management and research staff). The Steering Group (clinical, pharmacist and managerial staff at Salford CCG and Salford Royal NHS Foundation Trust plus the NIHR CLAHRC GM project team). Salford CCG general practices and community pharmacies.
(6) How	The initial recruitment of GPs onto the project was implemented via email, and then three face to face visits were delivered per practice/pharmacy by NIHR CLAHRC GM project team to ensure full understanding of the sick day guidance project. Support was also gained from the local pharmaceutical committee.
(7) Where	General practices (48) and community pharmacies (60) in Salford. 106 000 cards were provided to general practices and community pharmacies for administration to patients. In England, there were structural changes to the health service in 2013 and CCGs were formed. Each CCG covers the population of a defined area (ie, patients registered at general practices within the area) and is responsible for planning and commissioning the majority of health services in that area. Primary healthcare services are provided by GPs, community pharmacies, dentists and opticians. Patients register with a GP practice and attend that practice for appointments with a GP(s). Community pharmacies, also known as local chemist shops, are found on most local high streets, in shopping centres and also in many large supermarkets. Community pharmacies dispense prescription medicines, sell other (non-prescription) medicines and various other goods (typically health-related, baby and cosmetic products) and also provide other services, such as medicines use reviews. Patients do not register with a community pharmacy and may use any pharmacy (for dispensing or other services), although many patients become regular users of their local pharmacy. Pharmacists also work in general practices; such ‘practice-based’ pharmacists review medicines prescribing and take part in projects, such as the ‘sick day guidance’ intervention described here.
(8) When and how much	Cards were to be provided to a patient, when they attended a general practice appointment or visited a pharmacy between March 2015 and January 2016. Practice pharmacists contacted patients who fit within their criteria for being at risk of AKI.
(9) Tailoring	While guidance on the explanation to give patients (described above) was provided, professionals were expected to use their professional judgement in deciding how to deliver the intervention.
(10) Modifications	Opportunistic observations were conducted during facilitation visits. Cards were noticed on pharmacy counters, which were available for anyone visiting the pharmacy to pick up and take. Practice pharmacists encountered difficulties around the process of completing the record searches and communicating with patients in that there was not enough time to do this, consequently, no face to face appointments took place and pharmacists tried to contact patients by telephone. One practice pharmacist developed their own information sheet on patient with AKI that was posted out with cards.
(11) How well (planned)	Adherence and fidelity were not formally assessed; however, the facilitation visits were designed to provide flexible, ongoing support and advice on delivering the intervention and an understanding of how well the intervention was operating in practice was gained through these visits.
(12) How well (actual)	Practice pharmacists encountered barriers to obtaining the information they needed. CLAHRC facilitators gained understanding through their visits and the qualitative evaluation formally researched experiences of implementation—both these are documented in the CCG report. Sustained efforts had to be made to recruit health professionals and patients via medical practices.

AKI, acute kidney injury; CCG, Clinical Commissioning Group; CLAHRC, Collaboration for Leadership in Applied Health Research and Care; NIHR, National Insitute for Health Research; GP, general practitioner; SPARC, Salford Partnership for Advancing Renal Care.