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

摘要

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.