Determinants of Implementation Success Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts in the ICU (DISCOVER-ICU) study

在发现被证明有效的重症监护病房(ICU)镇静剂之间存在着根本的差距， 可以装备ICU的机械通风、移动性和症状管理策略和方法 具有在日常实践中可靠地采用这些干预措施所需技能的提供者。直到这个缺口 每年入住ICU的数百万心、肺和血液疾病患者仍将处于危险之中。 对于可避免的身体、精神和认知健康损害，这些损害可能会持续几个月到几年 出院。在拟议的研究中，我们将继续与重症护理学会建立伙伴关系 医学(SCCM‘s)ICU解放协作；一个由68个人组成的全国质量改进网络 学术、社区和联邦重症监护室。在执行研究综合框架的指导下， 实施成功的决定因素的总体目标协调呼吸机、早期活动 ICU(DISCOVER-ICU)研究中的康复努力是制定多层次的实施战略 促进在常规ICU实践中可持续地采用ABCDEF捆绑包。ABCDEF捆绑包是一个 以证据为基础的多组件ICU管理战略，结合了SCCM的许多临床 ICU成人患者的疼痛、躁动和妄想的处理实践指南。使用 多阶段、序贯、混合方法设计，本研究有三个具体目的：1)评估 ABCDEF捆绑使用的患者水平特征；2)检查ABCDEF捆绑的单位水平变异 采用以及相关的提供商和组织级别的特征；以及3)确定哪种实施 战略带来了对ABCDEF捆绑包的最大采用。我们将使用已获得的已确认身份的现有数据 来自15,000名患者，5,000名跨专业ICU团队成员，以及68家参与ICU的医院 解放协作以实现具体目标1和2。对于具体目标3，我们将扩展数据收集，使用 跨专业ICU团队调查，修改后的德尔福流程和概念图，以实现更大的 了解对ABCDEF捆绑应用最有效的实施策略。我们的重点是 在高ABCDEF捆绑包和低ABCDEF捆绑包上，我们将允许我们选择和定制潜在的ABCDEF捆绑包 实施战略，以满足特定的当地背景需求。这种方法具有创新性，因为它： 利用来自具有全国代表性的大型ICU网络的现有数据；包括已拥有 已知且高度可变的ABCDEF捆绑包性能比率和实施策略；并允许 检查实际和感知的ABCDEF捆绑包性能。这项工作的结果将直接导致 制定可适应、响应社区需求的实施战略，并考虑 关于增加ABCDEF捆绑应用所需的文化和组织因素。这些 实施战略随后将在未来的集群随机混合II实施中进行测试- 有效性试验。

There is a fundamental gap between the discovery of proven-effective intensive care unit (ICU) sedation, mechanical ventilation, mobility, and symptom management strategies and approaches that can equip ICU providers with the skills necessary to reliably adopt these interventions in everyday practice. Until this gap is filled, the millions of patients with heart, lung, and blood disorders admitted to ICUs annually will remain at risk for avoidable physical, mental, and cognitive health impairments that may persist for months to years after hospital discharge. In the proposed study, we will continue our partnership with the Society of Critical Care Medicine's (SCCM's) ICU Liberation Collaborative; a national quality improvement network comprised of 68 academic, community, and federal ICUs. Guided by the Consolidated Framework for Implementation Research, the overall objective of the Determinants of Implementation Success Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts in the ICU (DISCOVER-ICU) study is to develop multilevel implementation strategies to enhance sustainable adoption of the ABCDEF bundle in routine ICU practice. The ABCDEF bundle is an evidence-based, multicomponent ICU management strategy that incorporates many of the SCCM's Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. Using a multiphase, sequential, mixed-methods design, this study has three specific aims: 1) estimate the effects of patient-level characteristics on ABCDEF bundle adoption; 2) examine unit-level variation in ABCDEF bundle adoption and associated provider- and organization-level characteristics; and 3) determine which implementation strategies result in the greatest adoption of the ABCDEF bundle. We will use existing deidentified data obtained from >15,000 patients, >5,000 interprofessional ICU team members, and 68 hospitals participating in the ICU Liberation Collaborative to achieve specific aims 1 and 2. For specific aim 3, we will extend data collection using interprofessional ICU team surveys, a modified Delphi process, and concept mapping to achieve greater understanding of implementation strategies that prove most effective for ABCDEF bundle adoption. Our focus on high- and low-ABCDEF bundle-performing units will allow us to select and tailor potential ABCDEF bundle implementation strategies to meet specific local contextual needs. This approach in innovative because it: capitalizes on existing data from a large, nationally representative network of ICUs; includes units with already known and highly variable ABCDEF bundle performance rates and implementation strategies; and allows for the examination of actual versus perceived ABCDEF Bundle performance. Results of this work will directly lead to the development of implementation strategies that are adaptable, responsive to community needs, and account for the cultural and organizational factors necessary to increase ABCDEF bundle adoption. These implementation strategies will then be tested in a future cluster randomized hybrid II implementation- effectiveness trial.