Adapting and testing a deimplementation program in the Intensive Care Unit

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PROJECT SUMMARY/ ABSTRACT The goal of the K-award is to position the candidate on the pathway to independent research study. Although the applicant has some training in dissemination and implementation science, which provided preliminary data for her current proposal, the applicant needs to acquire higher level implementation methodology training to propel her towards career independence. The applicant’s goal is to optimize care for critically ill patients through implementation and deimplementation approaches that achieve systematic absorption of evidence-based innovations. There are several areas of critical care medicine in need of implementation principles to close the evidence-to-practice gap that exist. For example, there are millions of critically ill patients annually who require imaging confirmation after central venous catheter insertion. Emerging literature demonstrates that ultrasound is a faster alternative to historical chest xray, thus serving as the ideal confirmation for catheter use. When able to confirm catheter position, ultrasound decreases the number of unnecessary chest radiographs, cumulative resources (technologist, radiologist, equipment), and patient care delays. However, providers are not adopting this practice. During the candidates previous 2-year K award, she developed and initiated a successful evidence- based deimplementation program for ultrasound in lieu of chest xray called DRAUP in the Emergency Department. We hypothesize that this deimplementation program, developed from a theory-driven model and guided by the Behavioral Change Wheel framework addresses the foundational constructs of behavior thus should be successful in any environment. In this K01 proposal, the applicant seeks to demonstrate the generalizability of the theory-driven constructs of DRAUP by refining, testing, and determining the mechanism of impact in a new environment. Thus, the applicant proposes a research agenda that aligns with the NHLBI’s strategic vision objection #6 for studies that “optimize clinical and implementation research to improve health and reduce disease.” In Aim 1, the applicant will employ a systematic approach to DRAUP component refinement dosed to the unique context of the Intensive Care Unit. In Aim 2, the applicant seeks to examine effectiveness outcomes and importantly for de-implementation – cost effectiveness of the program. In Aim 3, the applicant seeks to use mixed methods to evaluate the mechanism of impact of the refined program in the new environment. These aims support the applicant’s training plan in which she will receive expert mentorship and training in Intervention Mapping (Training Goal 1); cost effectiveness analysis (Training Goal 2); and mix methods for mechanistic exploration (Training Goal 3) from Drs. Elvin Geng, Richard Griffey, Aimee James, and Derek Brown. Expertise of the mentorship team, along with the academic and training environment of Washington University, will ensure the applicant’s success. Results of this study will be used to support the scientific premise of the deimplementation program, which can be tested in a subsequent multicenter larger trial and transferrable to other critical care medicine evidence-to-practice gaps.