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

摘要 复杂组织环境中的复杂干预措施，如重症监护病房(ICU)， 与门诊或社区环境相比，在传播和实施研究方面研究不足。 虽然大多数D&I研究的目标是在患者病程的某个时间点进行干预，但快速的 急性器官衰竭的演变使我们能够研究循证最佳实践(EBPS)的实施 在一个快速的时间范围内病人病程的连续体。医院中的危重护理实践 代表关键的知识差距和传播和实施的理想机会(D&I) 研究沿着疾病表现和演变的连续体检查多项干预措施，并 评估电子健康记录工具在促进这些干预措施方面的有效性。 急性呼吸衰竭(ARF)是ICU中最常见的器官功能障碍。 死亡率为28%。约四分之一的ARF患者出现或升级为急性呼吸窘迫 综合征(ARDS)，使死亡率增加到40%。无论ARF的严重程度如何，最初的ARF升级 CARE，在启动各种机械通风策略的地方，将过渡到降低 减少医源性并发症和促进从机械通气中解放出来的干预措施。EBPS 存在于ARF从最初的升级/复苏阶段到降级的整个范围内 相位。在急性呼吸衰竭患者的整个护理过程中坚持循证医学 机械通风是获得最佳结果的关键。 我们的长期目标是设计和实施一种阶梯式楔形、集群随机控制的混合 有效性--实施试验，以确定统一实施循证政策的有效性 持续护理ARF和ARDS以减少死亡率和机械通气时间。整体而言 这项规划拨款的目标是评估包括整个连续体的可行性，重点是 有机会提取电子健康记录数据，并将基于电子健康记录和非电子健康记录的实施干预提供给 在急性呼吸窘迫综合征和急性呼吸窘迫综合征的整个过程中推广使用循证药物。 我们的具体目标包括：在ARF和ARDS的连续统一体中确定可能的EBPS，并关注纳入 在计划的整群随机试验中；组建一个具有基于电子病历的能力的医院网络 拟议试验的数据提取、电子病历警报和临床决策支持系统(CDSS)；设计 基于评估的障碍、促进者和临床医生意见的电子健康记录和非电子健康记录实施干预 关于EHR警报和CDSS；利用上面的发现来改进拟议试验的设计，以改进 ARF和ARDS在使用和不使用基于EHR的工具的情况下的结果。

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.