Andrew J. Knighton

Despite high post-implementation adherence, clinicians may have unresolved questions or concerns regarding use of a protocol to standardize routine daily coordination of the spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) on ventilated patients. Unresolved questions or concerns may unwittingly curtail practice normalization, impacting practice sustainment when implementation support is withdrawn. The objective of this study was to identify unresolved questions or concerns that may persist following successful implementation of a coordinated SAT/SBT (C-SAT/SBT) protocol. We used an attributed, cross-sectional survey of physicians, advanced practice providers, nurses and respiratory therapists likely to have participated in a C-SAT/SBT in 12 hospitals (15 intensive care units) in Utah and Idaho. We evaluated clinician perceptions of acceptability, including ease of use, usefulness and confidence, along with perceived practice normalization, six months post implementation of a protocol to routinize C-SAT/SBT use. C-SAT/SBT adherence was 83.1% at the 6th month post implementation. 606 clinicians completed the survey (response rate: 50.0%). Perceived individual usefulness, ease of use, and confidence using the C-SAT/SBT protocol were high [range: 72.1%-88.1% agree/strongly agree], though individuals not performing an SAT or SBT in more than six months and respiratory therapists scored lower. Perceived practice normalization was similar with 82.0% aggregate agreement [agree/strongly agree]. However, when stratifying respondents into four categories based upon respondent percentage agreement with all statements, 71% did not agree with at least one practice normalization statement and 27% agreed with less than 80% of statements, varying by role and site. Sets of observable characteristics or phenotypes regarding the degree of practice normalization begin to emerge by subgroup. Unresolved questions or concerns may persist regarding implementation of a C-SAT/SBT protocol among certain population subgroups despite current high practice adherence and high levels of perceived acceptability, including ease of use, usefulness and confidence. It is not clear what impact these unresolved questions or concerns may have on practice normalization and multi-year practice sustainment systemwide, including whether targeted late post-implementation strategies are needed to mitigate concerns and promote sustainment when implementation support is withdrawn.

BACKGROUND: Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system. METHODS: Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers. RESULTS: A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56–79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40–2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58–80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47–7.78]; stroke centers (77.4%–90.0%); nonstroke centers [59.3%–72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, −9.68 [95% CI, −17.17 to −2.20]; stroke centers [41–35 minutes]; nonstroke centers [55–52 minutes]). No differences were observed in clinical effectiveness outcomes. CONCLUSIONS: A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.

Rationale: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. Objectives: We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. Methods: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. Results: The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5–11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9–68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. Conclusions: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.

Background: Effective communication in transitions between healthcare team members is associated with improved patient safety and experience through a clinically meaningful reduction in serious safety events. Family-centered rounds (FCR) can serve a critical role in interprofessional and patient-family communication. Despite widespread support, FCRs are not utilized consistently in many institutions. Structured FCR approaches may prove beneficial in increasing FCR use but should address organizational challenges. The purpose of this study was to identify intervention, individual, and contextual determinants of high adherence to common elements of structured FCR in pediatric inpatient units during the implementation phase of a large multi-site study implementing a structured FCR approach. Methods: We performed an explanatory sequential mixed methods study from September 2019 to October 2020 to evaluate the variation in structured FCR adherence across 21 pediatric inpatient units. We analyzed 24 key informant interviews of supervising physician faculty, physician learners, nurses, site administrators, and project leaders at 3 sites using a qualitative content analysis paradigm to investigate site variation in FCR use. We classified implementation determinants based on the Consolidated Framework for Implementation Research. Results: Provisional measurements of adherence demonstrated considerable variation in structured FCR use across sites at a median time of 5 months into the implementation. Consistent findings across all three sites included generally positive clinician beliefs regarding the use of FCR and structured rounding approaches, benefits to learner self-efficacy, and potential efficiency gains derived through greater rounds standardization, as well as persistent challenges with nurse engagement and interaction on rounds and coordination and use of resources for families with limited English proficiency. Conclusions: Studies during implementation to identify determinants to high adherence can provide generalizable knowledge regarding implementation determinants that may be difficult to predict prior to implementation, guide adaptation during the implementation, and inform sustainment strategies.

Objective: Computer-aided decision tools may speed recognition of acute respiratory distress syndrome (ARDS) and promote consistent, timely treatment using lung-protective ventilation (LPV). This study evaluated implementation and service (process) outcomes with deployment and use of a clinical decision support (CDS) synchronous alert tool associated with existing computerized ventilator protocols and targeted patients with possible ARDS not receiving LPV. Materials and Methods: We performed an explanatory mixed methods study from December 2019 to November 2020 to evaluate CDS alert implementation outcomes across 13 intensive care units (ICU) in an integrated healthcare system with >4000 mechanically ventilated patients annually. We utilized quantitative methods to measure service outcomes including CDS alert tool utilization, accuracy, and implementation effectiveness. Attitudes regarding the appropriateness and acceptability of the CDS tool were assessed via an electronic field survey of physicians and advanced practice providers. Results: Thirty-eight percent of study encounters had at least one episode of LPV nonadherence. Addition of LPV treatment detection logic prevented an estimated 1812 alert messages (41%) over use of disease detection logic alone. Forty-eight percent of alert recommendations were implemented within 2 h. Alert accuracy was estimated at 63% when compared to gold standard ARDS adjudication, with sensitivity of 85% and positive predictive value of 62%. Fifty-seven percent of survey respondents observed one or more benefits associated with the alert. Conclusion: Introduction of a CDS alert tool based upon ARDS risk factors and integrated with computerized ventilator protocol instructions increased visibility to gaps in LPV use and promoted increased adherence to LPV.

The risk of serious intracranial injury in pediatric patients with minor head trauma (MHT) is less than 5%; most computerized tomography (CT) scans in MHT are normal or contribute little to management, yet expose children to unnecessary radiation. Despite evidence‐based risk classification criteria from the Pediatric Emergency Care Applied Research Network (PECARN) for assessing appropriate CT use during emergency department (ED) visits, barriers persist to replacing unnecessary scans with structured observation. Field readiness assessments at Intermountain Healthcare suggest that physicians often believe they know the risk factors for traumatic brain injury (TBI) but sometimes misremember elements. Information retrieval when delivering ED care can be cumbersome. Many physicians also perceive ordering CT scans is the safest course of action despite a lack of significant symptoms. We theorized that targeting evidence‐based education at the individual scan decision point, coupled with timely performance feedback, would increase cognitive support for assessing risk of clinically‐important TBI (ciTBI), reducing potentially unnecessary scans. We conducted a prospective pre‐post comparison implementation study. The primary implementation strategies were two‐fold. First, we embedded an alert containing an easy‐to‐understand, information‐rich graphic providing current PECARN risk stratification criteria and supporting evidence for classifying ciTBI, along with a risk assessment prompt linked to a CT order. Second, we provided timely feedback on performance and local prompting to educate physicians. Uptake and effectiveness measures included % adherence change in PECARN guidelines and the CT scan rate. Safety was evaluated by counting 48‐hour readmissions with clinical evidence of ciTBI confirmed via chart review. Acceptability, fidelity and feasibility were assessed using qualitative analysis. Statistical analysis was conducted using tests of proportions. Approximately 14,000 pediatric patients presenting with MHT at 22 EDs from January 2019–December 2020 within a single, integrated delivery system including urban, rural and frontier locations and a children's hospital. Year 1 adherence to PECARN guidelines was 98.7% with a 14% reduction in the CT scan rate for pediatric MHT patients across geographies with no readmissions for ciTBI (Table). Results were sustained in Year 2 despite increased patient acuity in 2020 due to the novel coronavirus pandemic. Subsequent field discussions found good acceptance by physicians noting the alert was relevant, timely and easy to understand. Implementation fidelity was high given routinization of the alert into clinical workflow. Combining local performance feedback with use of an information‐rich text alert was associated with significant improvements in adherence to PECARN guidelines and a reduction in the CT scan order rate for diagnosis of clinically‐important TBI in MHT patients without impacting safety. The routinized nature of the alert was associated with good practice sustainment over multiple years across geographies. Simple, information‐rich text alerts may prove useful as an implementation strategy for updating physicians on changes in evidence‐based triage and risk classification criteria often associated with de‐implementation of legacy clinical practices. Measure Baseline‐Dec2018 Rolling‐6mo Uptake‐Dec2019 Rolling‐12mo Sustainment‐Dec2020 Rolling‐12mo z‐score/p‐value % adherence to PECARN guidelines 95.66% 98.74% 99.32% z = −10.3; p < 0.001 CT scan rate 33% 29% 29% z = 6.0; p < 0.001 48‐hour readmission for ciTBI 0 0 0

CONTEXT: The American Academy of Pediatrics and Institute for Patient and Family-Centered Care issued a joint policy statement in 2012 recommending family and nurse participation in rounds as a standard practice.OBJECTIVE: To synthesize available evidence on the state of the implementation of family-centered rounds (FCRs), including identified barriers to stakeholder acceptance and participation in FCRs in pediatric inpatient settings and implementation strategies to increase adherence and related outcomes.DATA SOURCES: PubMed and Medline and the Cochrane Database of Systematic Reviews.STUDY SELECTION: Observational and experimental studies from January 2009 to July 2020.DATA EXTRACTON: Two reviewers independently screened each study to determine eligibility and extract data. Initial evidence quality was evaluated on the basis of study design.RESULTS: A total of 53 studies were included in the final synthesis. FCRs are increasingly accepted by stakeholders, although participation lags. Structural barriers to nurse and family attendance persist. Limited high-quality evidence exists regarding the effectiveness of FCRs and related implementation strategies in improving patient outcomes. The lack of a clear, consistent definition of the elements that combine for a successful FCR encounter remains a significant barrier to measuring its effect.CONCLUSIONS: Standardized research methods for improving the quality and comparability of FCR studies are needed to enhance the existing guidelines for FCR use. Structural changes in care delivery may be required to ensure the rounding process remains amenable to the needs of patients and their families.

Background The rapid spread of severe acute respiratory syndrome coronavirus-2 or SARS-CoV-2 necessitated a scaled treatment response to the novel coronavirus disease 2019 (COVID-19). Objective This study aimed to characterize the design and rapid implementation of a complex, multimodal, technology response to COVID-19 led by the Intermountain Healthcare's (Intermountain's) Care Transformation Information Systems (CTIS) organization to build pandemic surge capacity. Methods Intermountain has active community-spread cases of COVID-19 that are increasing. We used the Centers for Disease Control and Prevention Pandemic Intervals Framework (the Framework) to characterize CTIS leadership's multimodal technology response to COVID-19 at Intermountain. We provide results on implementation feasibility and sustainability of health information technology (HIT) interventions as of June 30, 2020, characterize lessons learned and identify persistent barriers to sustained deployment. Results We characterize the CTIS organization's multimodal technology response to COVID-19 in five relevant areas of the Framework enabling (1) incident management, (2) surveillance, (3) laboratory testing, (4) community mitigation, and (5) medical care and countermeasures. We are seeing increased use of traditionally slow-to-adopt technologies that create additional surge capacity while sustaining patient safety and care quality. CTIS leadership recognized early that a multimodal technology intervention could enable additional surge capacity for health care delivery systems with a broad geographic and service scope. A statewide central tracking system to coordinate capacity planning and management response is needed. Order interoperability between health care systems remains a barrier to an integrated response. Conclusion The rate of future pandemics is estimated to increase. The pandemic response of health care systems, like Intermountain, offers a blueprint for the leadership role that HIT organizations can play in mainstream care delivery, enabling a nimbler, virtual health care delivery system that is more responsive to current and future needs. We reviewed this work with our Institutional Review Board and concluded it was not human subjects research. Received: 22 April 2020 Accepted: 24 September 2020 Publication Date: 16 December 2020 (online) © 2020. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany