Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic: A Qualitative Study.
Factors Influencing the Implementation of Prone Positioning during the COVID-19 Pandemic: A Qualitative Study.
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DOI：
10.1513/annalsats.202204-349oc
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发表时间：
2023-01
影响因子：
8.3
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中科院分区：
文献类型：
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对急性呼吸窘迫综合征(ARDS)患者采用俯卧位的做法历来很差。然而，在机械通气的冠状病毒病(新冠肺炎)ARDS患者中，拔牙增加。了解影响这一变化的因素对于进一步扩大和维持俯卧位在适当的临床环境中的使用是重要的。探讨新冠肺炎急性呼吸窘迫综合征机械通气患者实施俯卧位的影响因素。我们对在两家学术医院工作的40名重症监护病房(ICU)团队成员(医生、护士、高级实践提供者、呼吸治疗师和物理治疗师)进行了半结构化访谈，进行了定性研究。我们使用了执行研究综合框架，这是一个广泛使用的执行科学框架，概述了执行的重要特点，用来构建访谈指南和访谈专题分析。ICU临床医生报告说，在新冠肺炎大流行期间，剪枝被视为新冠肺炎急性呼吸窘迫综合征的标准早期治疗，而不是难治性低氧血症的抢救治疗。通过护理大量的修剪患者，临床医生获得了更多的修剪舒适度，现在认为修剪是一种低风险、高收益的干预措施。在ICU内，足够数量的训练有素的工作人员，围绕剪裁的团队协议增加，以及特定设备的可获得性(例如，限制压力伤害)促进了更多的剪裁使用。医院层面的支持包括剪裁团队、针对新冠肺炎管理的集中式教育资源(包括俯卧位的建议)和电子病历剪裁订单。重要的实施过程包括在常规床边护理期间通过在职学习和团队互动非正式地传播最佳做法。新冠肺炎急性呼吸窘迫综合征俯卧定位的实施是在不断发展的临床医生观点和重症监护病房团队文化的背景下进行的。Proning得到了医院的支持和床边临床医生的支持和领导。在新冠肺炎大流行期间成功实施俯卧位可作为在危重护理中实施其他循证治疗的典范。
The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with coronavirus disease (COVID-19) ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings. To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS. We conducted a qualitative study using semistructured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews. ICU clinicians reported that during the COVID-19 pandemic, proning was viewed as standard early therapy for COVID-19 ARDS rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk, high-benefit intervention. Within ICUs, adequate numbers of trained staff members, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure injuries) facilitated greater proning use. Hospital-level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care. The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.