Educational strategies to promote post-extubation non-invasive ventilation in patients with acute respiratory failure

项目总结 美国近80万名急性呼吸衰竭患者需要有创机械通气 每年都有。在那些恢复到拔管的人中，相当大的比例保持在 拔管失败的高风险，即反复发生的呼吸衰竭需要在48小时内重新插管 拔管。对于这些脆弱的患者，直接拔管到无创呼吸机可以降低风险。 反复呼吸衰竭，重新插管，和死亡。基于来自多个随机调查的证据 对照试验：高危患者拔管后无创呼吸机 在最近的临床实践指南中推荐使用。然而，尽管有这些建议，使用这一点 循证做法仍然有限，导致可预防的发病率和死亡率。我们的长期合作 目标是进行一项多中心、混合有效性实施试验，以确定最佳 在高危患者中推广拔管后无创呼吸机使用的策略 正在从急性呼吸衰竭中恢复。在本申请中，我们提出了一系列研究，将 最终使我们有能力成功地进行这场审判。具体地说，我们计划实现以下目标 目标：(1)定性评估拔管后无创插管的障碍和促进者 通风和评估教育干预措施在促进采用方面的作用；(2)制定和试点 测试三种旨在加快实施拔管后无创通气的策略：一 控制策略(传统在线继续医学教育)和两种新策略 (3)完成四臂培训的筹备工作， 多中心、混合有效性--在UPMC卫生系统内进行的实施试验 确定最佳促进拔管后无创呼吸机使用的实施策略； 将控制与跨专业教育、适时教育以及两者进行比较。这项工作是 这很重要，因为它将直接导致一项主要的临床试验，有可能改善对 数十万患有急性呼吸衰竭的高危患者，它将为 了解跨专业教育和适时教育在实施过程中的作用 医院环境中的策略。这项工作具有创新性，因为它基于 导致重症监护跨专业性质的组织学习和行为改变 以及成人学习者的独特需求。这项工作在我们手中是可行的，因为它建立在 现有的研究基础设施由一支经验丰富的成熟研究团队开发 在危重病人中进行实施研究和多中心临床试验。

PROJECT SUMMARY Nearly 800,000 patients require invasive mechanical ventilation for acute respiratory failure in the United States each year. Among those who recover to the point of extubation, a substantial proportion remain at high risk for extubation failure, i.e., recurrent respiratory failure requiring reintubation within 48 hours of extubation. For these vulnerable patients, extubation directly to noninvasive ventilation reduces the risk of recurrent respiratory failure, reintubation, and death. Based on evidence from multiple randomized controlled trials, post- extubation noninvasive ventilation among high-risk patients is strongly recommended in recent clinical practice guidelines. Yet, despite these recommendations, the use of this evidence-based practice remains limited, leading to preventable morbidity and mortality. Our long-term objective is to conduct a multicenter, hybrid effectiveness-implementation trial to identify the optimal strategy for promoting the use of post-extubation noninvasive ventilation among high-risk patients recovering from acute respiratory failure. In this application, we propose a series of studies that will culminate in our ability to successfully conduct this trial. Specifically, we plan to achieve the following aims: (1) qualitatively assess barriers and facilitators to the adoption of post- extubation noninvasive ventilation and evaluate the role of educational interventions in improving adoption; (2) develop and pilot test three strategies designed to speed implementation of post-extubation noninvasive ventilation: one control strategy (traditional online continuing medical education) and two novel strategies (interprofessional education and just-in-time education); and (3) finalize preparations for a four-arm, multicenter, hybrid effectiveness-implementation trial conducted within the UPMC Health System to identify the implementation strategy that best promotes use of post-extubation noninvasive ventilation, comparing control with interprofessional education, just-in-time education, and both. This work is important because it will lead directly to a major clinical trial with the potential to improve outcomes for hundreds of thousands of high-risk patients with acute respiratory failure, and it will provide foundational knowledge about the roles of interprofessional education and just-in-time education as implementation strategies in the hospital setting. This work is innovative because it is based on novel theories for organizational learning and behavior change that account for the interprofessional nature of critical care and the unique needs of the adult learner. This work is feasible in our hands because it builds off an existing research infrastructure developed by an accomplished study team with extensive experience conducting both implementation research and multicenter clinical trials in critically ill patients.