Handoffs and Transitions in Critical Care - Understanding Scalability

项目总结： 《重症监护中的移交和过渡-了解可扩展性》(HATRICC-US) 需要重症监护支持的急性心肺衰竭患者的现代护理的特点是 未充分采用和使用经证实有效的干预措施。我们迫切需要确定 适用于快节奏、高风险的重症监护环境的实施战略；这样做 将通过缩小证据与实践的绩效差距来产生重大的公共卫生影响 这些高度敏锐的患者。其中一个差距是由于手术后标准化的采用不一致造成的 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方案将病人护理从手术室(OR)移交给 以重症监护病房(ICU)为模型研究急性呼吸窘迫综合征患者对复杂社会技术干预的吸收和使用 关心。在之前的工作中，我们的团队展示了采用、保真度和流程结果的改进 手术室到ICU移交标准化的试点2现场研究。我们在这一领域发表的工作建立在更多 超过65项已发表的研究证明了移交协议对一系列相关结果的有效性 对心肺衰竭患者的护理，包括过程、提供者和患者结果。这个 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 年在12个成人和儿科ICU中研究标准化移交方案的实施情况 五个卫生系统的八家医院。这项语用研究是一种混合型第二类有效性-实施 双重关注证明短期患者预后改善的研究(综合衡量 新发器官衰竭[共同原发]；术后不良事件)和实施结果(保真度[共同- 主要]；可行性；可接受性；适当性；实施成本；以及两年以上的维持)。这个 Study将实现框架、理论和模型与工作流的工程方法相结合 评估、干预适应和评估。我们的具体目标是：(1)阐明切换协议 使用混合方法现场上下文调查的实施决定因素，(2)使用工程方法 称为参与式设计，使切换协议适应每个ICU并使用基于理论的实施 映射以选择定制的、多方面的、多层次的实施策略，(3)在 在现场团队的领导下随机推出的阶梯式楔形时尚，以及(4)使用人- 以设计为中心创建实施工具包，以促进将研究结果传播和使用到 广大观众。这项工作的近期目标是确定有效的实施方法 急性护理环境中的复杂社会技术干预。更长期的目标是使用这种方法来 促进采用和持续使用经证实有效的干预措施护理急性呼吸窘迫综合征患者 心肺衰竭。这项工作直接解决了NHLBI翻译中心声明的兴趣 混合方法研究和实用试验设计中的研究和实施科学。

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.