Determinants of Implementation Success Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts
Determinants of Implementation Success Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts
There is a fundamental gap between the discovery of proven-effective intensive care unit
 (ICU) sedation, mechanical ventilation, mobility, and symptom management strategies and
 approaches that can equip ICU providers with the skills necessary to reliably adopt these
 interventions in everyday practice. Until this gap is filled, the millions of patients with
 heart, lung, and blood disorders admitted to ICUs annually will remain at risk for avoidable
 physical, mental, and cognitive health impairments that may persist for months to years after
 hospital discharge. In the proposed study, the investigative team will continue their
 partnership with the Society of Critical Care Medicine's (SCCM's) ICU Liberation
 Collaborative. Guided by the Consolidated Framework for Implementation Research, the overall
 objective of the Determinants of Implementation Success Coordinating Ventilator, Early
 Ambulation and Rehabilitation Efforts in the ICU (DISCOVER-ICU) study is to develop
 multilevel implementation strategies to enhance sustainable adoption of the ABCDEF (Assess,
 prevent, and manage pain and delirium, both spontaneous awakening and breathing trials,
 choice of sedation, early mobility, family engagement) bundle in routine ICU practice. Using
 a multiphase, sequential, mixed-methods design, this study has three specific aims: 1)
 estimate the effects of patient-level characteristics on ABCDEF bundle adoption; 2) examine
 unit-level variation in ABCDEF bundle adoption and associated provider- and
 organization-level characteristics; and 3) determine which implementation strategies result
 in the greatest adoption of the ABCDEF bundle. Existing deidentified data will be obtained
 from >15,000 patients, >5,000 interprofessional ICU team members, and 68 hospitals
 participating in the ICU Liberation Collaborative to achieve specific aims 1 and 2. For
 specific aim 3, data collection will be extended using interprofessional ICU team surveys, a
 modified Delphi process, and concept mapping to achieve greater understanding of
 implementation strategies that prove most effective for ABCDEF bundle adoption. Results of
 this work will directly lead to the development of implementation strategies that are
 adaptable, responsive to community needs, and account for the cultural and organizational
 factors necessary to increase ABCDEF bundle adoption. These implementation strategies will
 then be tested in a future cluster randomized hybrid II implementation effectiveness trial.
Patients with heart, lung, and blood disorders severe enough to require an intensive care
 unit (ICU) stay frequently experience profound physical, mental, and cognitive health
 impairments that may persist for months to years after hospital discharge. These long-term
 impairments are commonly acquired in the ICU and are often initiated or exacerbated by
 sedation, mechanical ventilation, and symptom management decisions. Indeed, ICU-acquired
 pain, anxiety, delirium, and weakness are associated with numerous adverse health outcomes
 including prolonged mechanical ventilation, post-traumatic stress disorder, depression,
 functional decline, new institutionalization, and severe neurocognitive impairment.
 Considering millions of adults face the challenges of ICU survivorship annually, it is
 essential findings from high-quality research are reliably adopted and sustained in everyday
 clinical practice.

 As outlined in "Clinical Practice Guidelines for the Management of Pain, Agitation, and
 Delirium (PAD) in Adult Patients in the ICU," a robust and growing body of evidence
 demonstrates clinical outcomes are improved when integrated, interprofessional approaches to
 mechanical ventilation and symptom management are applied during the course of critical
 illness. One such approach is the ABCDEF bundle, an evidence-based, multicomponent strategy
 that incorporates many PAD guideline recommendations. While previously shown safe and
 effective when applied in routine ICU practice, the investigators preliminary data
 demonstrate that this bundle has yet to be widely adopted. Pain and delirium remain
 underdiagnosed, and ICU clinicians often fail to maintain patients at a light level of
 sedation, use a protocolized mechanical ventilation discontinuation approach, get patients
 out of bed, or accept flexible bedside family presence. There is, therefore, a clear need for
 studies that use validated implementation frameworks and outcomes to assess strategies for
 improving ABCDEF bundle adoption and the removal of long-held and potentially harmful ICU
 practices.

 In the proposed study, the investigators will continue their three-year partnership with the
 Society of Critical Care Medicine's ICU Liberation Collaborative, a national quality
 improvement (QI) network comprised of 68 ICUs. Guided by the Consolidated Framework for
 Implementation Research, the overall objective of this T4 research is to develop multilevel
 implementation strategies to enhance sustainable adoption of the ABCDEF bundle in routine ICU
 practice. The investigators are particularly interested in discovering how various patient-,
 provider-, and organization-level characteristics and implementation strategies effect ABCDEF
 bundle adoption. Using a multiphase, sequential, mixed-methods design the "Determinants of
 Implementation Success Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts
 in the ICU (DISCOVER-ICU)" study has three specific aims:

 Aim 1: Estimate the effects of patient-level characteristics on ABCDEF bundle adoption.
 Patient-level characteristics are defined as non-modifiable factors exhibited by critically
 ill adults at ICU admission that may influence ABCDEF bundle adoption. Existing data on ≥
 15,000 critically ill adults who spent at least one full day in a participating ICU
 Liberation Collaborative unit will be used to estimate the effects of: (1) demographics, (2)
 body mass index, (3) admitting diagnosis, (4) severity of illness, and (5) preadmission
 residence/mobility status on ABCDEF bundle adoption. The hypothesis is that the ABCDEF bundle
 will less likely be adopted into the care of particularly vulnerable populations (e.g., older
 adults, obese, non-English speaking).

 Aim 2: Examine unit-level variation in ABCDEF bundle adoption and associated provider- and
 organization-level characteristics. Existing data will be obtained from surveys of over 5,000
 interprofessional ICU team members and 68 hospitals participating in the ICU Liberation
 Collaborative. Provider-level characteristics are defined as ICU clinicians': (1) ABCDEF
 bundle-related knowledge and attitudes, (2) self-efficacy, and (3) perceptions of work
 environment (both overall health and degree of teamwork/collaboration). Organization-level
 characteristics are defined as those related to: (1) administrative structure, (2) staffing
 patterns, (3) ICU team composition, and (4) prior QI experience. The hypothesis is that
 ABCDEF bundle adoption will be greater in ICUs where providers value and are more familiar
 with the principles of the bundle, display higher levels of self-efficacy, and report more
 positive teamwork. Secondly, there will be better bundle adoption in organizations with
 greater absorptive capacity for change, more resources, and who use interprofessional ICU
 team models.

 Aim 3: Determine which implementation strategies result in the greatest adoption of the
 ABCDEF bundle. Data collection will be extended by using interprofessional ICU team surveys,
 a modified Delphi process, and concept mapping to achieve greater understanding of
 implementation strategies that prove most effective for ABCDEF bundle adoption. The focus on
 high- and low-ABCDEF bundle-performing units will allow the investigative team to select and
 tailor potential ABCDEF bundle implementation strategies to meet specific local contextual
 needs.

 With expertise in dissemination and implementation science, biostatistics, critical care, and
 QI, the interdisciplinary team investigative is ideally prepared to lead this three-year
 study. The results will directly lead to the development of implementation strategies that
 are adaptable, responsive to community needs, and account for the cultural and organizational
 factors necessary to increase ABCDEF bundle adoption. These implementation strategies will
 then be tested in a future cluster randomized hybrid II implementation-effectiveness trial.
Inclusion Criteria:

 -  ICU patient who was enrolled in ICU Liberation Collaborative (preexisting data)

 -  ICU provider or organization who participated in ICU Liberation Collaborative
 (preexisting data)

 -  ICU provider who was responsible for ABCDEF bundle implementation efforts associated
 with SCCM ICU Liberation Collaborative (prospective collected data)

 Exclusion Criteria:

 -  Did not participate in ICU Liberation Collaborative efforts