A Mixed Methods Evaluation of the Implementation of Prone Positioning in COVID-19 ARDS

项目总结/摘要 尽管经过几十年的研究，急性呼吸窘迫综合征（ARDS）的死亡率仍然很低， 高最近，在冠状病毒病19（COVID-19）期间，ARDS受到越来越多的关注。 大流行，因为大多数需要重症监护病房（ICU）的COVID-19患者 ARDS。由此导致的这种综合征患者的增加突出了确保广泛和 持续实施现有的ARDS循证干预措施（EBI）。一个这样的救生ARDS 干预是俯卧位。虽然俯卧位得到了随机对照试验的支持， 在ARDS指南中推荐，历史上它一直未得到充分利用。随着医疗保健服务的变化， 在2019冠状病毒病期间，俯卧位的重症监护实践也得到了迅速和显著的发展。之前 在大流行期间，10-15%的适当患者采用俯卧位，现在在大流行期间， 在40-80%的患者中使用，具体取决于环境。了解这种快速增长背后的机制 实践的改变是更广泛地实施俯卧位和其他EBI的关键， 2019冠状病毒病疫情及以后。 该项目的主要目标是评估影响增加使用倾向性药物的因素。 COVID-19期间的定位。我们假设与组织变革相关的因素（例如，俯卧 团队、Proning协议和人员配备水平），提供者特征（例如，对疗效的信念，对 ARDS）和患者因素（例如，更高的疾病严重程度）导致俯卧位的使用显著增加 2019冠状病毒大流行期间。我们将使用包括综合框架在内的执行科学工具 用于实施研究（CFIR），以提供一个全面的混合方法评估倾向定位 在大流行期间。使用COVID-19机械通气患者的回顾性队列研究 ARDS，我们将定义在我们的卫生系统内不同环境中俯卧位的频率， 评估预测俯卧使用的患者和ICU因素。使用定性方法，我们将进行半- 与ICU团队成员进行结构化访谈，以探索俯卧位的促进因素和障碍， 2019冠状病毒病。最后，我们将调查整个卫生系统的ICU团队成员，以评估CFIR 与可接受性，适当性， 俯卧位的保真度和可持续性。这项工作有可能为更广泛和持续的 实施俯卧位，以及增加我们对如何快速转换治疗 先进到危重病人的床边。 这项研究将为申请人提供必要的培训，以发展所需的技能， 职业生涯作为一个独立资助的研究人员在实施科学和重症监护领域的工作。

Project Summary/Abstract Despite decades of research, mortality from the acute respiratory distress syndrome (ARDS) remains high. Recently, ARDS has received increased attention during the coronavirus disease 19 (COVID-19) pandemic, as the majority of patients with COVID-19 requiring intensive care unit (ICU) admission develop ARDS. The resulting increases in patients with this syndrome has highlighted the need to ensure broad and sustained implementation of existing evidence-based interventions (EBIs) for ARDS. One such lifesaving ARDS intervention is prone positioning. While prone position is supported by randomized controlled trials and recommended in ARDS guidelines, historically it has been underutilized. As healthcare delivery has changed rapidly and dramatically during COVID-19, the critical care practice of prone positioning has also evolved. Prior to the pandemic, prone positioning was utilized in 10-15% of appropriate patients, and now during the pandemic is being used in 40-80% of patients depending on the setting. Understanding the mechanisms behind this rapid practice change is key to more broadly implementing prone positioning and other EBIs for ARDS care during the COVID-19 pandemic and beyond. The main objective of this project is to evaluate the factors influencing the increased use of prone positioning during COVID-19. We hypothesize that factors related to organizational changes (e.g., proning teams, proning protocols and staffing levels), provider characteristics (e.g., belief in efficacy, recognition of ARDS) and patient factors (e.g., higher disease severity) led to the marked increases in use of prone positioning during the COVID-19 pandemic. We will use implementation science tools including the Consolidated Framework for Implementation Research (CFIR) to provide a comprehensive mixed methods evaluation of prone positioning during the pandemic. Using a retrospective cohort study of mechanically ventilated patients with COVID-19 ARDS, we will define the frequency of prone positioning in different settings within our health system and evaluate the patient and ICU factors that predict proning use. Using qualitative methods, we will conduct semi- structured interviews with ICU team members to explore the facilitators of and barriers to prone positioning in COVID-19. Finally, we will survey ICU team members across our health system to evaluate the CFIR implementation determinants associated with the implementation outcomes of acceptability, appropriateness, fidelity and sustainability of prone positioning. This work has the potential to inform a broader and sustained implementation of prone positioning as well as increase our understanding of how to rapidly translate therapeutic advances to the bedside of critically ill patients. This research will provide the applicant with the necessary training to develop the skills needed to pursue a career as an independently funded researcher working in the field of implementation science and critical care.