The evolving application of implementation science in critical care*.
The evolving application of implementation science in critical care*.
复制标题
实施科学在重症监护中不断发展的应用*。
DOI：
10.1097/ccm.0000000000000084
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发表时间：
2014
影响因子：
8.8
通讯作者：
Baker,DavidW
中科院分区：
文献类型：
--
作者：
Weiss,CurtisH;Baker,DavidW
此外，床边提供者接受远程筛查提示的程度尚不清楚。作者没有提供关于提示导致患者管理变化的频率或提示床边护士与多学科团队其他成员沟通的频率的数据。在时间和空间上与患者首次有资格接受干预的时间点相分离的干预可能不太有效。这可能解释了某些护理过程、医院获得性感染和死亡率缺乏改善的原因。最后，改善的机制仍然不清楚，这是可能的，观察到的一些改善是由于霍桑效应的提供者知道他们的护理正在接受检查。实施研究不仅应试图了解干预措施是否有效，还应了解推动变革的机制。期望重症监护提供者记住在ICU这样复杂和不断发展的系统中使用所有循证实践是不合理和危险的。事实上，即使是强有力的循证护理，如急性呼吸窘迫综合征的肺保护性通气，仍然没有得到充分实施（2）。当这种情况发生时，我们无法最有效地实现这些疗法的临床试验所证明的承诺。实现科学渴望填补这一空白。Kahn等人的工作（9）是实施科学干预成熟的重要一步，从客观和遥远到更直接。他们利用远程医疗技术，并将这项技术与新的实施战略相结合，这些战略侧重于近实时的护理点干预措施，如提示。这种技术和策略的合并可能有助于在床边提示（实时直接干预）的优势和远程医疗（集中化和可扩展性）的优势之间实现有效的平衡。Kahn等人（9）的研究将帮助我们更多地了解哪些实施方法最有效地将循证治疗转化为临床实践。
In addition, the degree to which bedside providers accepted prompting from the remote screeners is unclear. The authors do not present data on the frequency with which prompting led to changes in patient management or how often the prompted bedside nurse communicated with the rest of the multidisciplinary team. Prompting that is removed in time and space from the point at which a patient is first eligible for an intervention may be less effective. This may explain the lack of improvement in some processes of care, hospital-acquired infections, and mortality. Ultimately, the mechanism of improvement remains unclear, and it is possible that some of the improvement observed resulted from a Hawthorne effect of providers knowing their care was being examined. Implementation studies should attempt to understand not only whether an intervention works but also the mechanisms driving change. It is unreasonable and dangerous to expect critical care providers to remember to use all evidence-based practices in a system as complex and evolving as the ICU. Indeed, even strongly evidence-based care, such as lung protective ventilation in acute respiratory distress syndrome, remains underimplemented (2). When this occurs, we fail to most effectively achieve the promise that clinical trials of these therapies demonstrate. Implementation science aspires to fill this void. The work by Kahn et al (9) is an important step in the maturation of implementation science interventions from the impersonal and distant to the more direct. They take advantage of telemedicine technology and couple this technology with newer implementation strategies focused on near real-time, point-of-care interventions, such as prompting. This merger of technology and strategy may help achieve an efficient balance between the advantages of bedside prompting (real-time direct intervention) and the advantages of telemedicine (centralization and scalability). Studies such as this one by Kahn et al (9) will help us learn more about which implementation methods most effectively translate evidence-based therapy into clinical practice.