Strengthening implementation science in Acute Respiratory Failure using multilevel analysis of existing data

项目总结 多达100万美国人患有急性呼吸衰竭(ARF)，需要在 每年都有重症监护病房。研究一再表明，已证实有效的、 有时为这些患者提供挽救生命的循证实践(EBP)，但尚不清楚如何选择 能够弥合证据和实践之间差距的最佳实施战略。普普通通 选择的方法有其固有的局限性。例如，概念映射和实现映射 严重依赖利益相关者的观点，是劳动密集型的，可能会关注利益相关者的偏好 而不是潜在影响最大的战略。量化方法也具有挑战性，因为 实践的重要决定因素--如个人动机和组织文化--很难 按比例进行测量。 实施的一个重要目标是减少可归因于以下原因的EBPS吸收的可变性 临床医生和环境设置。虽然临床实践应该根据患者的因素和 偏好、实施方案试图克服临床医生和环境因素(例如不足 知识或资源)，限制了EBP的吸收。应用综合框架进行实施 研究(CFIR)到这个概念模型，个体的领域和内部环境应该有最小 成功实施危重病护理计划后对循证计划依从性的影响。我们假设 在患者中，可归因于个体和内部环境的CFIR结构域的变异性较低 治疗得到了高质量证据的支持，而患者的现有证据表明 治疗力度较弱。我们的总体目标是演示1)已建立的多层建模技术 可用于估计可归因于CFIR结构域的EBPS使用的变化比例 个人的内部环境和特征，以及2)所产生的信息如何为选择提供信息 执行战略，并评估其有效性。作为概念的证明，我们将研究两个有效的证明 干预措施-低潮气量呼吸机治疗急性呼吸窘迫综合征和袋式面罩 插管时的通风。我们将使用Low Tate Volume Universal的现有多中心数据集 支持：招募介入试验(莲花-水果)队列研究的可行性，来自3个随机的 收集使用袋式口罩通风的数据的试验。

PROJECT SUMMARY Up to 1 million Americans experience acute respiratory failure (ARF) and require mechanical ventilation in an intensive care unit annually. Studies repeatedly revealed incomplete penetration of proven-effective, sometimes life-saving, evidence-based practices (EBP) for these patients, and it is unclear how to select optimal implementation strategies that can bridge the gap between evidence and practice. Common approaches to selection have inherent limitations. For example, concept mapping and implementation mapping rely heavily on stakeholder perspectives, are labor-intensive, and may focus on stakeholder preferences instead of strategies with the greatest potential impact. Quantitative approaches are also challenging because important determinants of practice - such as individual motivation and organizational culture - are difficult to measure at scale. One important goal of implementation is to reduce variability in the uptake of EBPs attributable to clinicians and the environmental setting. While clinical practice should vary in response to patient factors and preferences, implementation programs try to overcome clinician and environmental factors (e.g. insufficient knowledge or resources) that limit EBP uptake. Applying the Consolidated Framework for Implementation Research (CFIR) to this conceptual model, the domains of Individuals and Inner Setting should have minimal influence on adherence to EBPs after a successful critical care implementation program. We hypothesize that variability attributable to the CFIR domains of Individuals and Inner Setting is lower among patients when a treatment is supported by high-quality evidence compared to patients for whom the existing evidence for a treatment is weaker. Our overall objective is to demonstrate 1) how established multilevel modeling techniques can be used to estimate the proportion of variation in the use of EBPs that is attributable to the CFIR domains of Inner Setting and Characteristics of Individuals, and 2) how the resulting information can inform selection of implementation strategies and evaluate their effectiveness. As a proof of concept, we will study two proveneffective interventions - low tidal volume ventilation for acute respiratory distress syndrome and bag mask ventilation during intubation. We will use existing multicenter datasets from the Low Tidal Volume Universal Support: Feasibility of Recruitment for lnterventional Trial (LOTUS-FRUIT) cohort study and from 3 randomized trials that collected data on the use of bag-mask ventilation.