Implementation of Coordinated Spontaneous Awakening and Breathing Trials Using Telehealth-Enabled, Real-Time Audit and Feedback for Clinician AdHerence: A Type II Hybrid Effectiveness-Implementation

项目总结 尽管有创机械通气(IMV)是一种挽救生命的治疗方法，但美国约有30万名 每年的急性呼吸衰竭，都与重大风险有关。自发觉醒和 IMV期间的呼吸试验改善了患者的预后。自然觉醒与呼吸的协调 试验(C-SAT/SBT)是复杂和重大的实施障碍，并遵守C-SAT/SBT 不同机构之间的差异很大。尽管国家指南建议每天协调C-SAT/SBT IMV患者，他们没有得到充分利用。 支持远程医疗的远程医疗定位于提高C-SAT/SBT的使用率。在山间医疗集团，我们 有系统范围的远程危重护理服务，由危重病护理医生、护士和呼吸系统人员配备 使用实时视听通信远程监控和协助ICU患者的治疗师，a 全系统电子病历(EMR)、电子仪表板和临床决策支持。我们 最近研究了改善肺病循证实践的实施战略的影响 在3个试点ICU中实施保护性通风(LPV)，然后采用支持远程医疗的实时审计和 向其他14个ICU传播LPV依从性策略的临床医生依从性反馈， 达到90%以上的遵从率(NCT 03984175)。这一成功的方法可以帮助确定候选人 C-SAT/SBT方案，提示床边提供者执行C-SAT/SBT，并指导执行。 这项研究的具体目标是：(1)调整基线实施战略，并针对C- 使用执行研究综合框架的SAST/SBT；(2)开展第二类分组-- 随机混合有效性-实施试验以比较通常的审计和反馈实施 采用通常的审计和反馈实施方法，并使用支持远程医疗的实时 为促进C-SAT/SBT而对临床医生依从性的时间审核和反馈(“教学”)；以及(3)评估 在随机对照试验结束后的最后一年，继续坚持加强教学。 该项目的完成将促进人们对可持续发展战略的了解。 SAT/SBT的具体实施和远程医疗远程监测的一般有效性 促进战略，以帮助在重症监护病房实施最佳做法。拟议的研究建立在这项研究的基础上 团队现有的工作，并有潜力开发更知情和更有效的护理呼吸系统患者 失败了。这种支持远程医疗的、集中监控ICU关键护理方面的服务的传播和扩展 鉴于ICU工作人员对新冠肺炎的脆弱性，现在对患者进行研究尤为重要。

PROJECT SUMMARY Although invasive mechanical ventilation (IMV) is a lifesaving treatment for about 300,000 U.S. patients with acute respiratory failure each year, it is associated with significant risks. Spontaneous awakening and breathing trials during IMV improve patient outcomes. Coordination of spontaneous awakening and breathing trials (C-SAT/SBT) is complex and significant barriers to implementation exist and adherence with C-SAT/SBT across institutions is highly variable. Although national guidelines recommend daily coordinated C-SAT/SBT in IMV patients they are underused. Telehealth-enabled remote care is positioned to improve C-SAT/SBT use. At Intermountain Healthcare, we have system-wide tele-critical care services staffed by critical care physicians, nurses, and respiratory therapists who remotely monitor and assist with patients in ICUs using real-time audiovisual communication, a systemwide electronic medical record (EMR), electronic dashboards, and clinical decision support. We recently studied the impact of implementation strategies to improve evidence-based practices for lung protective ventilation (LPV) in 3 pilot ICUs, and then adopted a Telehealth-Enabled, real-time Audit and feedback for Clinician adHerence (“TEACH”) to disseminate LPV adherence strategies to the other 14 ICUs, achieving over 90% adherence (NCT 03984175). This successful approach could help identify candidates for C-SAT/SBT protocols, prompt bedside providers to perform C-SAT/SBT, and guide execution. The specific aims of this research are to (1) adapt baseline implementation strategies and to target C- SAST/SBT using the Consolidated Framework for Implementation Research; (2) conduct a type II cluster- randomized hybrid effectiveness-implementation trial to compare a usual audit and feedback implementation approach to a usual audit and feedback implementation approach augmented with a Telehealth-Enabled, real- time Audit and feedback for Clinician adHerence (“TEACH”) to promote C-SAT/SBT; and (3) evaluate sustained adherence to the TEACH enhancement in the final year after the RCT has ended. Completion of this project will advance knowledge regarding the effective and sustainable strategies for C- SAT/SBT implementation specifically and the effectiveness generally of telehealth remote monitoring and prompting strategies to aid best practice implementation in ICUs. The proposed research builds on the study team’s existing work and has potential to develop more informed and effective care of persons with respiratory failure. Spread and scale of this telehealth-enabled, central monitoring of critical aspects of care for ICU patients is particularly important to study now, given the vulnerability of ICU staff to COVID-19 exposure.