Table 4 Understanding the complexities of research implementation: analyzing the translation pathways in the Heartstart Scotland case study

There was a regular flow of audit and research data from this evaluation of all attempts at defibrillation made by Scottish ambulance crews. The AEDs had originally been introduced through the Heartstart Scotland initiative led by the BHF and that raised funds from members of the public. The evaluation data made an impact on the management decisions of the Heartstart Scotland program in a formative way, and probably had some influence on the decision to renew the AEDs in Scotland from Scottish Office (ie Government) funds. While the main credit for the increased survival following out-of-hospital cardiac arrest should be allocated to Heartstart Scotland program itself, the various decisions that were informed by the evaluation also made an important contribution.

The research was translated through the close involvement of key figures from the Scottish Ambulance Service in all aspects of the research project. Also, the project PI, Prof Stuart Cobbe, chaired the evaluation sub-committee for the Heartstart Scotland program and from 1992 chaired the Professional Advisory Group to the Scottish Ambulance Service. (Cobbe had also played a role in encouraging the adoption of AEDs in the Scottish Ambulance Service in the first place). Furthermore, members of the research team regularly consulted with ambulance crews who had to provide the data for the evaluation.

This case provides a strong example of the benefits of the collaborative approach between health researchers and potential users: such analysis was developed in the 1970s and 80s by Kogan and Henkel [27] and increasingly confirmed in later reviews and analyses [28–32]. This example goes further than just standard collaborative approaches and provides a rarer example of how ‘Linkage and Exchange’ [33] can successfully work in practice. The Linkage and Exchange concept goes beyond collaboration on research agendas, and suggests there should be a continuing involvement by potential users in the research project, which was the case in this example. Within Scotland, Cobbe could be considered a ‘product champion,’ but the wider application of this term is discussed below in relation to adoption outside Scotland.

The evaluation continued with further funding from the Scottish Office and, especially, the BHF. The evaluation demonstrated that benefits from the intervention (ie introduction of defibrillators at a system level) were maintained. Such maintenance of a high level of benefits compares favourably with other examples of the introduction of comparable initiatives that were not accompanied by continuing evaluation research [34]. It was suggested in the case study that the continuing evaluation contributed to the continuing high levels of benefit from the introduction of AEDs.

Several aspects of this case, while not common, provide an interesting example of how the sustained research funding could be linked to the sustainability of the impact of an intervention. A key reason why the same project continued for so long, and established possibly the most significant database on out-of-hospital defibrillation in any country, was the incorporation of the funding for the project into the long-term funding provided for Cobbe through his BHF Chair funding. The continuing links between the research team and the users in the Scottish Ambulance Service, would probably have contributed to the continued benefits from the introduction of AEDs.

In setting an agenda for Implementation research Eccles et al. (2009) set out the importance of sustainability: ‘Within research itself it is important to examine attributes of sustainability (within individuals, teams, and organizations) and to develop methods to examine whether the effects of interventions are sustained over time.’ ([35]: p.5) Sustainability continues to be included in taxonomies of implementation outcomes [36]. The chair funding was very important in this case, and this form of long-term funding is increasingly being shown to assist with the ability to pursue ideas in a way that can contribute either to sustainability of initiatives, or promotion of ideas that might take a long period before they come to fruition [16].

The research almost certainly contributed to the decisions of some ambulance services in the UK and elsewhere to introduce AEDs.

This was probably caused by several factors, including the role of Dr Douglas Chamberlain, a leading national and international figure in the field of resuscitation, who was a pioneer in the use of defibrillators. In his active promotion of AEDs, he frequently drew on the Heartstart Scotland study; Chamberlain believed the study to be a very careful evaluation. The quality and credibility of the study might therefore have been important in the willingness of Chamberlain to draw on it so heavily. Cobbe’s research ranged from basic research, including on the electrophysiology of the heart, through to health services research such as this evaluation. The case study noted other examples where researchers who conducted a wide spectrum of research could sometimes transfer understandings [23].

Various theories of implementation identify the role that can be played by ‘product champions’ in promoting an innovation [37]. This can be seen as going even further than the role of opinion leaders first demonstrated in the healthcare field by Coleman et al. (1966) [38] and elaborated in the description of ‘expert’ opinion leaders by Locock et al. (2001) [39]. While in this case the innovation Chamberlain was promoting was the actual introduction of a system of defibrillators, his activities contributed considerably to the impact made by the Heartstart Scotland evaluation project, because he frequently quoted this evidence when making the case for defibrillators. His willingness to do so seems to have been influenced by the nature of the evaluation research.

The research made a considerable impact on guidelines of many leading and local organizations in the resuscitation field from 1992 onwards. In relation to a range of issues, and in a number of resuscitation-related guidelines and educational and training programmes, papers from the Heartstart Scotland evaluation project were used as the main evidence, or as one of a small number of supporting papers.

The publications and conference presentations from the PI and other team members played a major role in transferring the findings to potential users beyond those directly involved in the project. The team’s dissemination activities were picked up very widely by many organizations. These included ones with whom the research team had links, eg the European Resuscitation Committee, and others with whom the research team appeared to have no direct links. Much of the impact occurred prior to the findings being incorporated into a meta-analysis in 1999 [40], and the specific papers from the research team continued to be cited on guidelines after 1999.

Dissemination of work is increasingly viewed as a major responsibility of researchers: Wilson et al. (2010) reviewed conceptual frameworks designed for use by researchers to guide dissemination and concluded that most applied health research funding agencies expect some effort on the part of researchers to disseminate their findings [7]. The direct impact of this single study raises key issues in the implementation field. Grimshaw et al. 2012 suggest ‘the basic unit of knowledge translation should usually be up-to-date systematic reviews or other syntheses of research findings.’ [6]: p.1 In this case, however, the impact achieved before the publication of a systematic review was an important contribution.

The research made a considerable impact on the meta- analysis published in 1999 on the effectiveness of defibrillator-capable emergency medical services for victims of out-of-hospital cardiac arrest [40].

The Heartstart Scotland database made the biggest contribution to the review: out of 37 papers, Heartstart contributed one third of the patients, more than double next highest [40]. This again illustrates the impact made by the follow-on funding that allowed the project to continue.

This case study demonstrates the complexity of ways in which even a single stream of research might be translated, and that making a major impact on a meta-analysis might be important, but might just be one part of a much broader picture.