Digital Implementation Intervention Trials in Acute Lung Care (DIGITAL-C) Network Planning

摘要 在复杂的组织环境中进行复杂的干预，如重症监护室（ICU）， 与门诊或社区环境相比，在传播和实施研究方面研究不足。 虽然大多数D&I研究的目标是在患者疾病过程中的一个时间点进行干预，但 急性器官衰竭的发展使我们能够沿着循证最佳实践（EBP）的实施 患者在快速时间范围内的疾病过程的连续性。医院的重症监护实践 这是一个关键的知识差距，也是传播和实施的理想机会 研究检查沿着疾病表现和演变的连续体的多种干预措施， 评估EHR工具在促进这些干预措施方面的有效性。 急性呼吸衰竭（ARF）是ICU中最常见的器官功能障碍， 死亡率为28%。大约四分之一的ARF患者出现或升级为急性呼吸窘迫 急性呼吸窘迫综合征（ARDS），死亡率高达40%。无论ARF的严重程度如何， 护理，在机械通气的各种策略开始，将过渡到降级， 最大限度地减少医源性并发症并促进从机械通气中解脱的干预措施。EBPs 存在于ARF从初始升级/复苏阶段到降级的整个频谱中，沿着 相位在急性呼吸衰竭患者的整个护理过程中坚持EBP， 机械通气对于获得最佳结果至关重要。 我们的长期目标是设计和进行一个阶梯楔形，集群随机对照杂交 有效性-实施试验，以确定在 ARF和ARDS的连续护理，以降低死亡率和机械通气时间。整体 这项规划补助金的目标是评估包括整个连续体的可行性，重点是 有机会提取EHR数据，并提供基于EHR和非EHR的实施干预措施， 在ARF和ARDS的整个过程中促进EBP的使用。 我们的具体目标包括：在ARF和ARDS护理的连续性中识别可能的EBP， 在计划中的随机分组试验中;组建一个具有EHR能力的医院网络 数据提取和EHR警报和临床决策支持系统（CDSS）的拟议试验;设计 基于评估的障碍和促进者以及临床医生输入的EHR和非EHR实施干预措施 电子健康记录警报和CDSS;利用上述研究结果改进拟议试验的设计， 使用和不使用EHR工具的ARF和ARDS结局。

Abstract Complex interventions in complex organizational settings, such as intensive care units (ICU), are understudied in dissemination and implementation research compared to outpatient or community settings. While most D&I research targets interventions at one time point in a patient's disease course, the rapid evolution of acute organ failure allows us to study implementing Evidence-based Best Practices (EBPs) along the continuum of a patient's course of disease in a rapid timeframe. Critical care practices in the hospital represent a critical knowledge gap and an ideal opportunity in dissemination and implementation (D&I) research to examine multiple interventions along the continuum of disease presentation and evolution and to evaluate the effectiveness of EHR tools in promoting these interventions. Acute respiratory failure (ARF) is the most common organ dysfunction managed in the ICU with high mortality at 28%. About a quarter of ARF patients present with or escalate to Acute Respiratory Distress Syndrome (ARDS) which increases mortality to 40%. Regardless of the severity of ARF, the initial escalation of care, where various strategies in mechanical ventilation are initiated, will transition to de-escalation of interventions to minimize iatrogenic complications and to facilitate liberation from mechanical ventilation. EBPs exist along the entire spectrum of ARF from the initial escalation/resuscitation phase to the de-escalation phase. Adhering to EBPs throughout the entire continuum of care for patients with acute respiratory failure on mechanical ventilation is essential to obtaining optimal outcomes. Our long-term aim is to design and conduct a stepped-wedged, cluster randomized controlled hybrid effectiveness-implementation trial to determine the effectiveness of unified implementation of EBPs within the continuum of care in ARF and ARDS to decrease mortality and duration of mechanical ventilation. The overall goal of this planning grant is to assess the feasibility of including the entire continuum, focusing on opportunities to extract EHR data and to deliver EHR and non-EHR based implementation interventions to promote use of EBPs throughout the continuum of ARF and ARDS. Our specific aims include: to identify possible EBPs in the continuum of ARF and ARDS care for inclusion in the planned cluster randomized trial; to assemble a network of hospitals with the capacity for EHR-based data extraction and EHR alerts and clinical decision support system (CDSS) for the proposed trial; to design EHR and non-EHR implementation interventions based on assessed barriers and facilitators and clinician input on EHR alerts and CDSS; to use the findings from above to refine the design of the proposed trial to improve outcomes in ARF and ARDS with and without EHR-based tools.