The Coming of Age of Implementation Science and Research in Critical Care Medicine

Barr, Juliana; Paulson, Shirley; Ervin, Jennifer; Lane‐Fall, Meghan; Liu, Vincent; Kleinpell, Ruth M.

doi:10.1097/ccm.0000000000005131

Cited by 26 publications

(29 citation statements)

References 213 publications

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“…Proning practice has changed rapidly, whereas incorporating evidence-based therapy into practice typically takes more than a decade (9, 21). This rapid implementation may serve as a model for understanding how to further increase and sustain the use of proning and other evidence-based practices in critical care.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, use has varied with a range of 5–80% of patients proned in different settings (20). Understanding how proning practices have changed in patients with COVID-19 ARDS compared with historical ARDS could help to identify ongoing sources of practice variability and guide interventions to further expand and sustain use of this life-saving therapy (21, 22).…”

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confidence: 99%

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Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

Hochberg

Psoter

Sahetya

et al. 2022

Critical Care Explorations

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IMPORTANCE:Use of prone positioning in patients with acute respiratory distress syndrome (ARDS) from COVID-19 may be greater than in patients treated for ARDS before the pandemic. However, the magnitude of this increase, sources of practice variation, and the extent to which use adheres to guidelines is unknown. OBJECTIVES:To compare prone positioning practices in patients with COVID-19 ARDS versus ARDS treated before the pandemic. DESIGN, SETTING, AND PARTICIPANTS:We conducted a multicenter retrospective cohort study of mechanically ventilated patients with early moderateto-severe ARDS from COVID-19 (2020COVID-19 ( -2021 or ARDS from non-COVID-19 pneumonia (2018)(2019) across 19 ICUs at five hospitals in Maryland. MAIN OUTCOMES AND MEASURES:The primary outcome was initiation of prolonged prone positioning (≥ 16 hr) within 48 hours of meeting oxygenation criteria. Comparisons were made between cohorts and within subgroups including academic versus community hospitals, and medical versus nonmedical ICUs. Other outcomes of interest included time to proning initiation, duration of prone sessions and temporal trends in proning frequency. RESULTS:Proning was initiated within 48 hours in 227 of 389 patients (58.4%) with COVID-19 and 11 of 123 patients (8.9%) with historic ARDS (49.4% absolute increase [95% CI for % increase, 41.7-57.1%]). Comparing COVID-19 to historic ARDS, increases in proning were similar in academic and community settings but were larger in medical versus nonmedical ICUs. Proning was initiated earlier in COVID-19 versus historic ARDS (median hours (hr) from oxygenation criteria, 12.9 vs 30.6; p = 0.002) and proning sessions were longer (median hr, 43.0 vs 28.0; p = 0.01). Proning frequency increased rapidly at the beginning of the pandemic and was sustained. CONCLUSIONS AND RELEVANCE:We observed greater overall use of prone positioning, along with shorter time to initiation and longer proning sessions in ARDS from COVID-19 versus historic ARDS. This rapid practice change can serve as a model for implementing evidence-based practices in critical care.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

Hochberg

Psoter

Sahetya

et al. 2022

Critical Care Explorations

View full text Add to dashboard Cite

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“…Deliverables, such as the percentage of patients returning to the workforce, are not traditionally defined as metrics of success, nor listed as operational targets. Application of implementation frameworks and use of hybrid effectiveness-implementation trials ( 27 ) are needed to drive standardized ICU-RC and COVID-RC development, operation, and outcome measures. For example, pragmatic stepped-wedged cluster trials designed to evaluate long-term outcomes in the context of clinic delivery modes (e.g., telehealth) or clinical team composition could yield insights into intervention effectiveness via routine implementation.…”

Section: Discussionmentioning

confidence: 99%

Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems

Danesh

Boehm

Eaton

et al. 2022

Critical Care Explorations

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OBJECTIVES: The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.

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“…Further barriers in implementation include cultural context barriers, i.e., readiness of the local environment for change, as well as other practical limitations, such as resource requirements, staffing models, lack of PICU or institutional leadership investment, and lack of effective teamwork and collaboration skills ( 27 , 28 ). These context barriers are rarely assessed or discussed in research studies, yet present significant impediments to successful implementation.…”

Section: Challenges With Implementation Of Sedation and Analgesia Reg...mentioning

confidence: 99%

Implementation Science in Pediatric Critical Care – Sedation and Analgesia Practices as a Case Study

et al. 2022

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Sedation and analgesia (SA) management is essential practice in the pediatric intensive care unit (PICU). Over the past decade, there has been significant interest in optimal SA management strategy, due to reports of the adverse effects of SA medications and their relationship to ICU delirium. We reviewed 13 studies examining SA practices in the PICU over the past decade for the purposes of reporting the study design, outcomes of interest, SA protocols used, strategies for implementation, and the patient-centered outcomes. We highlighted the paucity of evidence-base for these practices and also described the existing gaps in the intersection of implementation science (IS) and SA protocols in the PICU. Future studies would benefit from a focus on effective implementation strategies to introduce and sustain evidence-based SA protocols, as well as novel quasi-experimental study designs that will help determine their impact on relevant clinical outcomes, such as the occurrence of ICU delirium. Adoption of the available evidence-based practices into routine care in the PICU remains challenging. Using SA practice as an example, we illustrated the need for a structured approach to the implementation science in pediatric critical care. Key components of the successful adoption of evidence-based best practice include the assessment of the local context, both resources and barriers, followed by a context-specific strategy for implementation and a focus on sustainability and integration of the practice into the permanent workflow.

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The Coming of Age of Implementation Science and Research in Critical Care Medicine

Abstract: The Institute of Medicine has long documented systemic deficiencies and significant gaps between the healthcare that critically ill patients should and actually receive. These gaps For information regarding this article,

Cited by 26 publications

References 213 publications

Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

Comparing Prone Positioning Use in COVID-19 Versus Historic Acute Respiratory Distress Syndrome

Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems

Implementation Science in Pediatric Critical Care – Sedation and Analgesia Practices as a Case Study

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