Implementation of Coordinated Spontaneous Awakening and Breathing Trials Using Telehealth-Enabled, Real-Time Audit and Feedback for Clinician AdHerence: A Type II Hybrid Effectiveness-Implementation

项目摘要 虽然有创机械通气（IMV）是一种挽救生命的治疗约30万美国患者， 每年急性呼吸衰竭，它与重大的风险。自发觉醒， IMV期间的呼吸试验改善了患者的预后。自发觉醒和呼吸的协调 试验（C-SAT/SBT）是复杂的，在实施和遵守C-SAT/SBT方面存在重大障碍 在不同的机构中是高度可变的。尽管国家指南建议在以下情况下每日协调C-SAT/SBT IMV患者使用不足。 远程医疗支持的远程护理旨在改善C-SAT/SBT的使用。在Intermountain Healthcare，我们 拥有由重症监护医生、护士和呼吸科医生组成的全系统远程重症监护服务 使用实时视听通信远程监控和协助ICU患者的治疗师， 系统范围的电子医疗记录（EMR）、电子仪表板和临床决策支持。我们 最近研究了实施策略的影响，以改善肺部循证实践 保护性通气（LPV）在3个试点ICU，然后采用远程医疗启用，实时审计和 临床医生依从性反馈（“TEACH”），以向其他14个ICU传播LPV依从性策略， 达到90%以上的依从性（NCT 03984175）。这种成功的方法可以帮助确定候选人， C-SAT/SBT协议，提示床边提供者执行C-SAT/SBT，并指导执行。 本研究的具体目标是：（1）调整基线实施战略，并以C- （2）开展第二类集群- 随机混合有效性-实施试验，以比较通常的审计和反馈实施 一种通常的审计和反馈实施方法的方法，增强了远程医疗功能，真实的- 对临床医生adHerence（“TEACH”）进行时间审计和反馈，以促进C-SAT/SBT;以及（3）评估 在RCT结束后的最后一年持续坚持TEACH增强。 该项目的完成将促进关于C- SAT/SBT的具体实施和远程保健远程监测的一般有效性， 促进战略，以帮助最佳实践在ICU的实施。拟议的研究建立在这项研究的基础上， 团队的现有工作，并有潜力开发更知情和有效的护理的人呼吸道疾病 失败这种远程医疗支持的ICU护理关键方面的中央监测的传播和规模 考虑到ICU工作人员对COVID-19暴露的脆弱性，现在研究患者尤为重要。

PROJECT SUMMARY Although invasive mechanical ventilation (IMV) is a lifesaving treatment for about 300,000 U.S. patients with acute respiratory failure each year, it is associated with significant risks. Spontaneous awakening and breathing trials during IMV improve patient outcomes. Coordination of spontaneous awakening and breathing trials (C-SAT/SBT) is complex and significant barriers to implementation exist and adherence with C-SAT/SBT across institutions is highly variable. Although national guidelines recommend daily coordinated C-SAT/SBT in IMV patients they are underused. Telehealth-enabled remote care is positioned to improve C-SAT/SBT use. At Intermountain Healthcare, we have system-wide tele-critical care services staffed by critical care physicians, nurses, and respiratory therapists who remotely monitor and assist with patients in ICUs using real-time audiovisual communication, a systemwide electronic medical record (EMR), electronic dashboards, and clinical decision support. We recently studied the impact of implementation strategies to improve evidence-based practices for lung protective ventilation (LPV) in 3 pilot ICUs, and then adopted a Telehealth-Enabled, real-time Audit and feedback for Clinician adHerence (“TEACH”) to disseminate LPV adherence strategies to the other 14 ICUs, achieving over 90% adherence (NCT 03984175). This successful approach could help identify candidates for C-SAT/SBT protocols, prompt bedside providers to perform C-SAT/SBT, and guide execution. The specific aims of this research are to (1) adapt baseline implementation strategies and to target C- SAST/SBT using the Consolidated Framework for Implementation Research; (2) conduct a type II cluster- randomized hybrid effectiveness-implementation trial to compare a usual audit and feedback implementation approach to a usual audit and feedback implementation approach augmented with a Telehealth-Enabled, real- time Audit and feedback for Clinician adHerence (“TEACH”) to promote C-SAT/SBT; and (3) evaluate sustained adherence to the TEACH enhancement in the final year after the RCT has ended. Completion of this project will advance knowledge regarding the effective and sustainable strategies for C- SAT/SBT implementation specifically and the effectiveness generally of telehealth remote monitoring and prompting strategies to aid best practice implementation in ICUs. The proposed research builds on the study team’s existing work and has potential to develop more informed and effective care of persons with respiratory failure. Spread and scale of this telehealth-enabled, central monitoring of critical aspects of care for ICU patients is particularly important to study now, given the vulnerability of ICU staff to COVID-19 exposure.