Behavioral Economic and Staffing Strategies To Increase Adoption of the ABCDEF Bundle in the ICU (BEST-ICU)

项目摘要 危重疾病的幸存者经常经历严重的身体、心理和认知健康损害 由已知的种族和社会经济健康差距和过时的 重症监护病房(ICU)机械通风和症状管理实践。这种发病率是 通过应用ABCDEF捆绑包可能可以预防；一个多组件的、基于证据的 采取干预措施，改善基于团队的护理。虽然一直被证明是安全有效的，但国家ABCDEF捆绑包 由于临床医生继续与捆绑交付的多重障碍作斗争，绩效仍然低得令人无法接受。 拟议工作的长期目标是制定务实和可持续的战略，以增加 提供循证实践，从而改善各种不同领域的危重成年人的护理 医疗保健系统，特别是那些为已知健康差距人群提供服务的系统(安全网 医院)。我们的总体目标是评估两种基于行为经济学理论和 实施科学，以增加ABCDEF捆绑应用。正在评估的战略目标是a ICU团队成员的多样性和捆绑性能的已知行为决定因素。建议数 该项目包括两个阶段和四个目标。在第一阶段(UG3)，我们将与NIH的医疗系统合作 研究合作实验室协调中心和我们的社区合作伙伴实现旨在 加强和最终确定用于促进和评价的执行战略和研究方法 ABCDEF捆绑采用的有效性(UG3目标1)。在第二阶段(UH3)，我们将进行务实的， 阶梯-楔形、群组随机杂交III型有效性--实施试验。在创建6个 来自3家医院的12个ICU的配对(N=8100名接受机械通气的患者)，我们将随机 在每个匹配对中分配ICU以接收实时审核和反馈(策略A)或 注册护士(RN)实施促进者(战略B)和每一对到六个楔子中的一个。目标 试验的目的是比较实时审计和反馈的有效性以及RN实施的促进者 关于ABCDEF捆绑采用(UH3目标1；主要结果)和临床结果(即 机械通气；ICU、住院和30天死亡率；ICU和住院时间；急性 脑功能障碍；出院倾向、精神活性药物和理疗利用；以及30- 日间再次住院)(UH3目标2)。最后，我们将确定并描述关键利益相关者的经验 关于实施战略的可接受性和对工作量的影响的观点(UH3 目标3)。我们预计研究结果将通过开发简单而有效的加速方法来影响该领域 可靠地采用各种基于证据的ICU干预措施，以解决已知的健康差距 并最终改善每年数以百万计的危重成年人的护理和预后。

Project Summary Survivors of critical illness frequently experience profound physical, mental, and cognitive health impairments that are initiated and/or exacerbated by known racial and socioeconomic health disparities and outdated intensive care unit (ICU) mechanical ventilation and symptom management practices. This morbidity is potentially preventable through the application of the ABCDEF bundle; a multicomponent, evidence-based intervention to improve team-based care. While consistently proven safe and effective, national ABCDEF bundle performance remains unacceptably low as clinicians continue to struggle with multiple barriers to bundle delivery. The long-term goal of the proposed work is to develop pragmatic and sustainable strategies to increase the delivery of evidence-based practices that lead to improved care for critically ill adults across a variety of healthcare systems, particularly those serving populations with known health disparities (safety net hospitals). Our overall objective is to evaluate two strategies grounded in behavioral economic theory and implementation science to increase ABCDEF bundle adoption. The strategies being evaluated target a variety of ICU team members and known behavioral determinants of bundle performance. The proposed project includes two phases and four aims. In Phase 1 (UG3), we will work with the NIH’s Healthcare System Research Collaboratory Coordinating Center and our community partners to meet key milestones aimed at enhancing and finalizing the implementation strategies and research methods used to facilitate and evaluate the effectiveness of ABCDEF bundle adoption (UG3 Aim 1). In Phase 2 (UH3), we will conduct a pragmatic, stepped-wedge, cluster randomized hybrid type III effectiveness-implementation trial. After creating 6 matched pairs of 12 ICUs from 3 hospitals (N=8,100 patients on mechanical ventilation), we will randomly assign ICUs within each matched pair to receive either real-time audit and feedback (strategy A) or a Registered Nurse (RN) implementation facilitator (strategy B) and each pair to one of six wedges. The aims of the trial are to compare the effectiveness of real-time audit and feedback and RN implementation facilitator on ABCDEF bundle adoption (UH3 Aim 1; primary outcome) and clinical outcomes (i.e., duration of mechanical ventilation; ICU, hospital, and 30-day mortality; ICU and hospital length of stay; days with acute brain dysfunction; discharge disposition, psychoactive medication, and physical therapy utilization; and 30- day hospital readmission) (UH3 Aim 2). Finally, we will identify and describe key stakeholders’ experiences with, and perspectives on, the acceptability and impact on workload of the implementation strategies (UH3 Aim 3). We expect study results will impact the field by developing simple, yet effective, ways of accelerating the reliable uptake of a variety of evidence-based ICU interventions that will address known health disparities in the ICU and ultimately improve the care and outcomes of millions of critically ill adults annually.