Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA.
Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA, USA.
Implement Sci. 2018 Mar 26;13(1):50. doi: 10.1186/s13012-018-0739-4.
Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises.
We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises.
In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation (p = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation (p ≤ 0.0001). More successful implementation was associated with leadership support (p < 0.0001) and dedicated time to train staff (p = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids (p < 0.0001), absence of an implementation champion (p = 0.0126), and unsatisfactory content or design of the cognitive aid (p = 0.0112).
Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes.
手术室（OR）危机是需要快速、协调管理的高风险事件。在紧张的情况下，医疗判断和决策可能会受到影响，而且临床医生可能多年都不会遇到一次危机。对于 OR 中最常见类型的危机，使用认知辅助工具（例如检查表）可能会改善意外和罕见事件期间的管理。虽然用于常规使用的认知辅助工具等创新的实施策略越来越被理解，但很少使用的认知辅助工具还没有得到很好的理解。我们研究了影响手术室危机中认知辅助工具使用的组织背景和实施过程因素。
我们使用基于网络的调查，对 2013 年 1 月至 2016 年 1 月期间从 Ariadne Labs 或斯坦福大学网站下载 OR 认知辅助工具的个人进行了横断面研究。在本文中，我们报告了来自美国医院和门诊手术中心的 368 名受访者的经验。我们分析了更成功实施（衡量标准为在适用的临床事件期间报告定期使用认知辅助工具）与组织背景以及参与多步骤实施过程的关系。我们使用多变量逻辑回归来确定报告的 OR 认知辅助工具在 OR 危机期间的定期使用的显著预测因素。
在多变量逻辑回归中，较小的设施规模与设施报告更成功实施的可能性增加四倍相关（p=0.0092）。完成更多的实施步骤也与更成功的实施显著相关；完成的每一步实施都与高出约 50%的更成功实施的可能性相关（p≤0.0001）。更成功的实施与领导支持相关（p<0.0001）和专门为培训员工分配时间相关（p=0.0189）。实施效果不佳与临床提供者对使用认知辅助工具的抵制相关（p<0.0001）、缺乏实施冠军相关（p=0.0126）和认知辅助工具的内容或设计不满意相关（p=0.0112）。
在 OR 中成功实施认知辅助工具与支持性的组织背景和遵循多步骤实施过程相关。建立强大的组织支持并遵循精心规划的多步骤实施过程，可能会增加术中危机期间 OR 认知辅助工具的使用，从而改善患者的预后。
