Simpson Fiona, Doig Gordon S
Intensive Care Unit, Royal North Shore Hospital, Sydney and Human Nutrition Unit, University of Sydney, Sydeney, Australia.
J Eval Clin Pract. 2007 Oct;13(5):709-15. doi: 10.1111/j.1365-2753.2006.00717.x.
Changing practice to reflect current best evidence can be costly and time-consuming. The purpose of this survey was to determine the optimal combination of practice change interventions needed to overcome barriers to practice change commonly encountered in the intensive care unit (ICU).
A survey instrument delivered by mail with email follow-up reminders.
Fourteen hospitals throughout Australia and New Zealand.
Individuals responsible for implementing an evidence-based guideline for nutritional support in the ICU.
Practice change interventions were ranked in order of effectiveness and barriers to change were ranked in order of how frequently they were encountered.
A response rate of 100% was achieved. Interventions traditionally regarded as strong (academic detailing, active reminders) were ranked higher than those traditionally regarded as moderate (audit and feedback), or weak (posters, mouse mats). The high ranks of the site initiation visit (educational outreach, modest) and in-servicing (didactic lectures, weak) were unexpected, as was the relatively low rank of educationally influential, peer-nominated opinion leaders. Four hospitals reported the same doctor-related barrier as 'most common' and the remaining 10 hospitals reported three different doctor-related barriers, two nursing-related barriers and three organizational barriers as most common.
When designing a multifaceted, multi-centre change strategy, the selection of individual practice change interventions should be based on: (1) an assessment of available resources; (2) recognition of the importance of different types of barriers to different sites; (3) the potential for combinations of interventions to have a synergistic effect on practice change, and (4) the potential for combinations of interventions to actually reduce workload.
改变医疗实践以反映当前最佳证据可能既昂贵又耗时。本次调查的目的是确定在重症监护病房（ICU）中克服常见实践变革障碍所需的实践变革干预措施的最佳组合。
通过邮件发放调查问卷，并通过电子邮件发送跟进提醒。
澳大利亚和新西兰的14家医院。
负责在ICU实施营养支持循证指南的人员。
对实践变革干预措施按有效性进行排序，对变革障碍按出现频率进行排序。
实现了100%的回复率。传统上被视为强效的干预措施（学术详述、主动提醒）的排名高于传统上被视为中等效力的措施（审核与反馈）或效力较弱的措施（海报、鼠标垫）。现场启动访问（教育推广，中等效力）和在职培训（讲授式讲座，效力较弱）的高排名出乎意料，教育影响力较大、同行提名的意见领袖的排名相对较低也出乎意料。四家医院报告相同的与医生相关的障碍为“最常见”，其余10家医院报告了三种不同的与医生相关的障碍、两种与护理相关的障碍和三种组织障碍为最常见。
在设计多方面、多中心的变革策略时，个体实践变革干预措施的选择应基于：（1）对可用资源的评估；（2）认识到不同类型的障碍对不同场所的重要性；（3）干预措施组合对实践变革产生协同效应的可能性；以及（4）干预措施组合实际减轻工作量的可能性。
