Handoffs and Transitions in Critical Care - Understanding Scalability

项目概要： “重症监护中的交接和过渡-了解可扩展性（HATRICC-US）” 需要重症监护支持的急性心肺功能衰竭患者的现代护理的特点是 没有充分采纳和使用已证明有效的干预措施。迫切需要确定 适用于快节奏、高风险重症监护环境的实施策略;这样做 将通过缩小证据与实践的绩效差距， 这些高敏感度的病人。一个这样的差距是由于不一致的采用标准化的手术后 美国心脏协会认为这是一项高度优先的干预措施。在这个项目中， 我们使用基于证据的标准化协议，用于从手术室（OR）到 重症监护病房（ICU）作为一个模型，研究急性重症患者复杂的社会技术干预措施的吸收和使用， 在乎在以前的工作中，我们的团队展示了采用，保真度和过程结果的改进， 对手术室到重症监护室的交接标准化进行了试点2研究。我们在这一领域的出版工作建立在更多 超过65项已发表的研究证明了ECOFFFF协议在一系列相关结果上的有效性 心肺衰竭患者的护理，包括过程，提供者和患者结局。的 拟议的研究是我们工作的延伸，将解决有关实施的关键知识差距， 通过研究12个成人和儿科ICU中标准化交接协议的实施， 五个卫生系统的八家医院。本研究是一个混合型的有效性-实施研究 一项双重关注的研究，旨在证明短期患者结局的改善（ 新发器官衰竭[共同主要];术后不良事件）和实施结局（保真度[共同主要] 主要];可行性;可接受性;适当性;执行费用;两年以上的维持）。的 本研究将工作流的实施框架、理论和模型与工程方法相结合 评估、干预适应和评估。本文的具体目标是：（1）阐明切换协议 实施的决定因素，使用混合方法现场情境调查，（2）使用工程方法 称为参与式设计，以使切换协议适应每个ICU并使用基于理论的实现 映射以选择定制的、多方面的、多级的实现策略，（3）实现切换协议， 在研究中心团队的领导下，采用阶梯楔形方式随机推出，以及（4）使用人类- 中心设计，以创建一个实施工具包，以促进研究结果的传播和使用， 广大观众。这项工作的近期目标是确定有效的执行办法， 急症护理环境中复杂的社会技术干预。长期目标是使用这种方法， 促进在急性呼吸道疾病患者的护理中采用和持续使用经证明有效的干预措施， 心肺衰竭这项工作直接解决了NHLBI的翻译中心的声明利益 研究和实施科学在混合方法研究和那些使用务实的试验设计。

PROJECT SUMMARY: “Handoffs and Transitions in Critical Care – Understanding Scalability (HATRICC-US)” Modern care of the patient with acute cardiopulmonary failure requiring critical care support is marked by the inadequate adoption and use of interventions with proven effectiveness. There is an urgent need to characterize implementation strategies suitable for use in the fast-paced, high stakes environment of critical care; doing so would generate a substantial public health impact by narrowing the evidence-to-practice performance gap for these high-acuity patients. One such gap is caused by inconsistent adoption of standardized post-surgical handoffs in U.S. hospitals, an intervention deemed high priority by the American Heart Association. In this project, we use an evidence-based standardized protocol for patient care handoffs from the operating room (OR) to the intensive care unit (ICU) as a model to study the uptake and use of complex sociotechnical interventions in acute care. In previous work, our group demonstrated adoption, fidelity, and improvement in process outcomes in a pilot 2-site study of OR-to-ICU handoff standardization. Our published work in this area builds on a base of more than 65 published studies demonstrating the effectiveness of handoffs protocols on a range of outcomes relevant to the care of patients with cardiopulmonary failure, including process, provider, and patient outcomes. The proposed study is an extension of our work that will address critical knowledge gaps about implementation in acute care by studying the implementation of a standardized handoff protocol in 12 adult and pediatric ICUs in eight hospitals in five health systems. This pragmatic study is a Hybrid Type 2 effectiveness-implementation study with a dual focus on demonstrating improvements in short-term patient outcomes (composite measure of new-onset organ failure [co-primary]; adverse postoperative events) and implementation outcomes (fidelity [co- primary]; feasibility; acceptability; appropriateness; implementation cost; and sustainment over two years). The study integrates implementation frameworks, theories, and models with engineering approaches to workflow evaluation, intervention adaptation, and evaluation. Our specific aims are to: (1) elucidate handoff protocol implementation determinants using mixed-methods on-site contextual inquiry, (2) use an engineering approach known as participatory design to adapt the handoff protocol to each ICU and use theory-based implementation mapping to select tailored, multifaceted, multilevel implementation strategies, (3) implement handoff protocols in stepped wedge fashion with randomized roll-out under the leadership of site based teams, and (4) use human- centered design to create an implementation toolkit to facilitate the dissemination and use of study findings to a broad audience. The proximate goal of this work is to determine effective approaches to implementation for complex sociotechnical interventions in acute care settings. The longer-term goal is to use this approach to promote the uptake and sustained use of proven-effective interventions in the care of patients with acute cardiopulmonary failure. This work directly addresses the stated interest of NHLBI's Center for Translation Research and Implementation Science in mixed methods studies and those using pragmatic trial designs.