Sinuff Tasnim, Cook Deborah, Giacomini Mita, Heyland Daren, Dodek Peter
Department of Critical Care and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Crit Care Med. 2007 Sep;35(9):2083-9. doi: 10.1097/01.ccm.0000281446.15342.74.
To determine perceived facilitators and barriers to guideline implementation and clinician adherence to guidelines in the intensive care unit (ICU).
Multicenter qualitative study in three university-affiliated ICUs in Canada.
We conducted individual semistructured interviews of 44 ICU clinicians (12 intensivists, two physician directors, 12 nurses, three nurse educators, three nurse managers, nine respiratory therapists, and three respiratory therapist educators). We elicited attitudes and perceptions regarding the facilitators and barriers to adherence to guidelines in the ICU. We transcribed all interviews and analyzed data in duplicate using grounded theory to identify themes and develop a model to describe clinicians' views.
The presence of a culture within the ICU that enabled guideline implementation and clinician adherence to guidelines was considered essential. Central to this culture was an ICU team that believed guidelines would reduce practice variation, help implement research findings at the bedside, and result in a more rapid implementation of best practice. Effective leadership and positive interprofessional team dynamics were deemed requisites for this culture. Important strategies identified by the participants to overcome potential barriers to clinician adherence to guidelines were: the presence of effective leaders to promote adoption of the guideline and its adherence, education tailored to the learning preferences of different professional groups, and repeated educational interventions, reminders, and audit and feedback. Participants suggested that the use of strategies to select and prioritize guidelines, simple guideline formats, and electronic media to implement guidelines may further contribute to successful guideline programs.
Complex ICU practices and unique interprofessional team dynamics influence clinician adherence to guidelines. Initiatives that employ an approach addressing these issues may optimize guideline uptake and adherence. The optimal approach and its effectiveness may be guideline-dependent and requires further study.
确定重症监护病房（ICU）中指南实施的感知促进因素和障碍以及临床医生对指南的遵循情况。
在加拿大三所大学附属医院的ICU进行多中心定性研究。
我们对44名ICU临床医生（12名重症监护医生、2名内科主任、12名护士、3名护士教育工作者、3名护士经理、9名呼吸治疗师和3名呼吸治疗师教育工作者）进行了个人半结构化访谈。我们了解了他们对ICU中遵循指南的促进因素和障碍的态度和看法。我们转录了所有访谈内容，并使用扎根理论对数据进行了双重分析，以确定主题并开发一个模型来描述临床医生的观点。
ICU中存在一种能够促进指南实施和临床医生遵循指南的文化被认为至关重要。这种文化的核心是一个ICU团队，他们相信指南将减少实践差异，有助于在床边实施研究结果，并导致更快地实施最佳实践。有效的领导和积极的跨专业团队动态被认为是这种文化的必要条件。参与者确定的克服临床医生遵循指南潜在障碍的重要策略包括：有有效的领导者来促进指南的采用和遵循、根据不同专业群体的学习偏好进行定制教育、以及重复的教育干预、提醒、审核和反馈。参与者建议，使用策略来选择指南并确定其优先级、采用简单的指南格式以及利用电子媒体实施指南可能会进一步促进成功的指南项目。
复杂的ICU实践和独特的跨专业团队动态会影响临床医生对指南的遵循。采用解决这些问题的方法的举措可能会优化指南的采用和遵循。最佳方法及其有效性可能因指南而异，需要进一步研究。
