TABLE 1.
Summary of Implementation Science Specific Designs and Studies (n = 20)
| References | Country | Framework | Study Aim | Strategies | Study Outcome |
|---|---|---|---|---|---|
| Abbott et al (14) | United States | Academic Center for Evidence-Based Practice star model; Predisposing, reinforcing, enabling constructs in educational diagnosis and evaluation/policy, regulatory, and organizational constructs in educational and environmental development | Determine effect of VAP prevention bundle on VAP rates | Stakeholders, audit and feedback, education, develop systems | VAP frequency: Variable across three ICUs; initial decrease below benchmark but not sustained Adoption: head of bed 77–69%; oral care 22–30%; empty condensate 94–93%; gloves 74–90% |
| Balas et al (15) | United States | Consolidated framework for implementation research | Identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise mobility bundle adoption; evaluate if bundle implementation was effective, sustainable, and conducive to dissemination | Assess readiness and barriers | Facilitators: Evidence, leadership Barriers: Adaptability, complexity, workload, staff, communication, documentation |
| Boehm et al (17) | United States | Outcome production model | Understand the relationship between organizational domains and provider attitudes towards implementation of the ABCDEF bundle | Develop tools, audit and feedback, local opinion leader, education | Adherence: Increased with use of tools (protocols) (r = 0.37–0.58), role clarity (r = 0.38–0.59), training (r = 0.33–0.46), local opinion leaders (r = 0.37–0.48), teamwork (r = 0.36–0.44) |
| Boltey et al (16) | United States | Shared mental model | Examine how components of shared mental model impact implementation of ABCDEF bundle | Assess readiness and barriers | Facilitators: Awareness of shared mental model can impact routine implementation Adherence via self-report (84% adherence sometimes; 51% routine adherence) |
| Carrothers et al (18) | United States | Not stated; survey | Identify which contextual factors facilitate/hinder implementation of ABCDE bundle in four San Francisco Bay ICUs | Assess readiness and barriers | Facilitators: Leadership, culture, champion, training, and support Barriers: Resources, turnover, knowledge, staffing |
| Costa et al (19) | United States | Not stated; survey | The purpose of this study was to describe team composition in ABCDE delivery and test the hypothesis that frequent involvement of a diverse team was associated with high levels of ABCDE implementation | Implementation teams | Adherence: Higher odds of adherence to spontaneous awakening trials (OR, 4.2), delirium management (OR, 3.6), and mobility (OR, 2.3) when team approach utilized |
| Doig et al (30) | Australia and New Zealand | Browman’s clinical practice guideline development cycle | Determine whether evidence-based feeding guidelines could be implemented using a multifaceted practice chance strategy to improve feeding and mortality among ICU patients | Local opinion leader education, reminders audit and feedback, ongoing training | Mortality: Similar between guideline vs control groups (28.9% vs 27.4%, respectively) Days to initiate feed: 0.75 d for guideline group vs 1.37 d for control group Adherence: 94% for guideline group; 72% for control group |
| Elligsen et al (23) | Canada | Not stated | Evaluate the impact of prospective audit and feedback on broad spectrum antimicrobial use among critical care patients | Audit and feedback | Antibiotic use: Decreased from 644 to 503 d of therapy per 1,000 patient-days |
| Hawe et al (33) | United Kingdom | Not stated | Describe the effects of an active multifaceted implementation of a VAP prevention bundle designed to improve staff compliance with evidence-based actions and reduce the frequency of VAP | Education, written materials, auditing and feedback; passive (phase I) vs active implementation (phase II) | Adherence: Increased from 0% to 54%VAP frequency: Decreased from 19.2 to 7.5 per 1,000 ventilator days Ventilator days: Decreased from 2,556 to 1,327 |
| Ilan et al (24) | Canada | Not stated | Describe prescription rates of commonly recommended best practices for critically ill patients and determine factors associated with increased rates of prescription | Standardized order sets, specialty consultation | Adherence: VTE prophylaxis: 95.3% Antibiotic prophylaxis: 94.1% Stress ulcer prophylaxis: 89.7% Enteral nutrition: 72.4% Insulin infusion: 58.8% Low tidal ventilation: 53.8% Perioperative beta blockers: 40% Steroids for shock: 20% Specialty mattress: 17.6% Interruption of sedation: 8.3% |
| Jain et al (25) | Canada | Knowledge to action framework | Compare the effectiveness of active to passive dissemination of the Canadian clinical practice guidelines for nutrition support for the mechanically ventilated critically ill adult patient | Local opinion leader, education, audit and feedback, develop tools, tailor strategies, education, distribute materials, develop effective materials, ongoing consultation | Enteral nutrition adequacy: Increased from 42% to 50% Enteral nutrition initiation: Increased from 52% to 58% |
| Noome et al (32) | The Netherlands | Grol and Grimshaw model for implementation | Examine the effectiveness of supporting ICUs on implementing the guidelines | Assess readiness and barriers | Adherence: 0.71 mean scores for control; 0.72 mean scores for intervention group |
| Penrod et al (20) | United States | Provonost model for knowledge translation | Evaluate implementation of care and communication bundle for palliative care | Audit and feedback, develop tools, education, ongoing consultation | Bundle adherence: Increased from a range of 13–40% to 20–60% |
| Reynolds et al (21) | United States | Grol and Wensing model of implementation | Determine whether using tailored, multifaceted strategies would improve implementation of daily chlorhexidine bathing and decrease CLABSIs | Educational outreach, audit and feedback, local opinion leaders, printed educational materials | Compliance: Increased from 57% to 80% CLABSI rates: Decreased from 2.8 to 1.2 per 1,000 central line days |
| Sauro et al (28) | United States | TRIP model | Describe use of IS at the unit level and organizational level to guide an intervention to reduce CLABSI in BICU | Inform/engage stakeholder, develop systems, audit and feedback, develop tools | CLABSI rates: Decreased from 15.5 to 0 per 1,000 central line days |
| Sinuff et al (27) | Canada | Qualitative/IS | Identify clinician perspectives of auditing and feedback | Audit and feedback | Perceptions of audit and feedback: Poor transparency, feedback should be timely, communication should be continuous, encourage peer to peer discussion/leadership engagement |
| Sinuff et al (26) | Canada | Knowledge to action framework | Determine whether auditing practice and providing feedback in the form of benchmarked reports site reports is an effective strategy to improve adherence to nutrition guidelines | Audit and feedback, develop tools, education, develop systems, develop effective materials | Adherence: Increased from 71% to 81% |
| Sood et al (22) | United States | TRIP model | Describe use of IS at the unit level and organizational level to guide an intervention to reduce CLABSI in BICU | Inform/engage stakeholder, develop systems, audit and feedback, develop tools | CLABSI rates decreased from 15.5 to 0 per 1,000 central line days |
| Spooner et al (31) | Australia | Know to action framework | Implement and evaluate an evidence-based electronic minimum data set for nursing team leader shift to shift handover in the ICU using the knowledge to action framework | Assess readiness and barriers, tailor strategies, education, local opinion leaders, develop tools, develop effective materials, audit and feedback | Adherence: 78% |
| Stelfox et al (29) | Canada | Theoretical domains framework | Test whether a multicomponent intervention would increase use of low-molecular-weight heparin over unfractionated heparin for VTE prophylaxis in critically ill patients | Education, develop tools, reminders, audit and feedback | Adherence: Increased for intervention group: 45.9–78.3%; increased for control group: 37.9–53.3% VTE: Remained same for intervention group: 3–3%; decreased slightly for control group: 2.4–2.1% Deep vein thrombosis: Increased for intervention group: 1.9–2.1%; remained same for control group: 1.4–1.4% Pulmonary embolism: Decreased for intervention group: 1.3–1.1%; decreased for control group: 1.2–0.8% |
ABCDEF = Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility, BICU = burn ICU, CLABSI = central line-associated bloodstream infection, IS = implementation science, OR = odds ratio, TRIP = translating research into practice, VAP = ventilator-associated pneumonia, VTE = venous thromboembolism.