Toward understanding evidence uptake: Semirecumbency for pneumonia prevention
Toward understanding evidence uptake: Semirecumbency for pneumonia prevention
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DOI：
10.1097/00003246-200207000-00012
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发表时间：
2002-07-01
影响因子：
8.8
通讯作者：
McMullin, JP
中科院分区：
文献类型：
--
作者：
Cook, DJ;Meade, MO;McMullin, JP
目的：随机试验表明，与仰卧位相比，半卧位可减少机械通气患者胃食道吸入和肺炎的发生。然而，在实践中，半卧位的使用并不一致。本研究的目的是了解重症监护室临床医生对半卧位的决定因素和后果的看法。设计：采用半结构化访谈和焦点小组的定性研究。设置：三所大学附属的重症监护病房。参与者：共93名重症监护病房临床医生，包括床边护士、呼吸治疗师、物理治疗师、营养师、住院医师、研究员和重症监护室患者。方法：我们引出关于半卧位的益处和危害、促进和阻止使用的因素以及鼓励半卧位的卫生系统变化的认识。访谈和焦点小组笔记被归纳分析，以确定新出现的主题。验证方法包括对通过多种方法收集的几个数据源进行多学科分析的三角测量和成员检查。测量和主要结果：强化医学家和营养学家熟悉半卧位作为潜在的肺炎预防策略，而其他临床医生不熟悉。当得知证据后，所有参与者都赞成半卧位。护士认为半卧位的主要决定因素是医生的命令，而集约主义者认为主要决定因素是护理偏好。参与者确定了与有用的替代体位(例如侧卧位)、禁忌症(例如血液动力学不稳定)、伤害风险(例如卧位溃疡)、安全性(例如滑出床外)和资源(例如促进半卧位的床位不足)有关的半卧位障碍。教育、指南、提醒、审计和反馈、图表和质量改进倡议被倡导以促进半卧位。结论：半卧位预防肺炎的影响因素是对其益处的认识不足，实际和感知的威慑力，对实施责任的不一致，以及缺乏支持和加强策略。在复杂、动态的重症监护病房环境中，可能需要认知、行为和管理方法来增强证据的获取。
Objective: Randomized trials show that the semirecumbent position compared with the supine position is associated with less gastroesophageal aspiration and pneumonia in patients receiving mechanical ventilation. However, semirecumbency is inconsistently used in practice. The objective of this study was to understand the perspectives of intensive care unit clinicians regarding the determinants and consequences of semirecumbency.Design: Qualitative study using semistructured interviews and focus groups.Setting: Three university-affiliated intensive care units.Participants: A total of 93 intensive care unit clinicians, including bedside nurses, respiratory therapists, physiotherapists, nutritionists, residents, fellows, and intensivists.Methods: We elicited perceptions about benefits and harms of semirecumbency, factors promoting and deterring use, and health systems changes to encourage semirecumbency. Interview and focus group notes were analyzed inductively to identify emerging themes. Validation methods involved triangulation by multidisciplinary analysis of several data sources collected through multiple methods and member checking.Measurements and Main Results: Intensivists and nutritionists were familiar with semirecumbency as a potential pneumonia prevention strategy, whereas other clinicians were not. When made aware of the evidence, all participants endorsed semirecumbency. Nurses perceived that the main determinant of semirecumbency was physicians' orders, whereas intensivists perceived that the main determinant was nursing preference. Participants identified barriers to semirecumbency related to useful alternative positions (e.g., lateral position), contraindications (e.g., hemodynamic instability), risk of harm (e.g., decubitus ulcers), safety (e.g., sliding out of the bed), and resources (e.g., insufficient beds facilitating semi recumbency). Education, guidelines, reminders, audit and feedback, charting, and quality improvement initiatives were advocated to promote semirecumbency.Conclusions: Under-utilization of semirecumbency for pneumonia prevention is influenced by insufficient awareness of its benefit, real and perceived deterrents, poor agreement about implementation responsibility, and lack of enabling and reinforcing strategies. Cognitive, behavioral, and administrative approaches to enhancing evidence uptake may be needed in the complex, dynamic intensive care unit setting.