From the Department of Anesthesiology, Duke University Healthcare System, Durham, North Carolina.
Anesthesiology Service, Durham Veterans Affairs (VA) Healthcare System, Durham, North Carolina.
Anesth Analg. 2018 Sep;127(3):623-631. doi: 10.1213/ANE.0000000000003565.
Complementary integrative health therapies have a perioperative role in the reduction of pain, analgesic use, and anxiety, and increasing patient satisfaction. However, long implementation lags have been quantified. The Consolidated Framework for Implementation Research (CFIR) can help mitigate this translational problem.
We reviewed evidence for several nonpharmacological treatments (CFIR domain: characteristics of interventions) and studied external context and organizational readiness for change by surveying providers at 11 Veterans Affairs (VA) hospitals (domains: outer and inner settings). We asked patients about their willingness to receive music and studied the association between this and known risk factors for opioid use (domain: characteristics of individuals). We implemented a protocol for the perioperative use of digital music players loaded with veteran-preferred playlists and evaluated its penetration in a subgroup of patients undergoing joint replacements over a 6-month period (domain: process of implementation). We then extracted data on postoperative recovery time and other outcomes, comparing them with historic and contemporary cohorts.
Evidence varied from strong and direct for perioperative music and acupuncture, to modest or weak and indirect for mindfulness, yoga, and tai chi, respectively. Readiness for change surveys completed by 97 perioperative providers showed overall positive scores (mean >0 on a scale from -2 to +2, equivalent to >2.5 on the 5-point Likert scale). Readiness was higher at Durham (+0.47) versus most other VA hospitals (range +0.05 to +0.63). Of 3307 veterans asked about willingness to receive music, approximately 68% (n = 2252) answered "yes." In multivariable analyses, a positive response (acceptability) was independently predicted by younger age and higher mean preoperative pain scores (>4 out of 10 over 90 days before admission), factors associated with opioid overuse. Penetration was modest in the targeted subset (39 received music out of a possible 81 recipients), potentially reduced by device nonavailability due to diffusion into nontargeted populations. Postoperative recovery time was not changed, suggesting smooth integration into workflow.
CFIR-guided implementation of perioperative music was feasible at a tertiary VA hospital, with moderate penetration in a high-risk subset of patients. Use of digital music players with preferred playlists was supported by strong evidence, tension for change, modest readiness among providers, good acceptability among patients (especially those at risk for opioid overuse), and a protocolized approach. Further study is needed to identify similar frameworks for effective knowledge-translation activities.
补充性综合健康疗法在减轻疼痛、减少镇痛药物使用和焦虑以及提高患者满意度方面具有围手术期作用。然而，长期的实施滞后已经被量化。综合实施研究框架（CFIR）可以帮助缓解这一转化问题。
我们回顾了几种非药物治疗方法的证据（CFIR 领域：干预措施的特征），并通过对 11 家退伍军人事务部（VA）医院的提供者进行调查研究了外部环境和组织变革准备情况（领域：外部和内部环境）。我们询问了患者是否愿意接受音乐治疗，并研究了这与阿片类药物使用的已知风险因素之间的关联（领域：个体特征）。我们实施了一项围手术期使用数字音乐播放器的方案，这些播放器上加载了退伍军人喜欢的播放列表，并在 6 个月的时间内对接受关节置换手术的患者进行了评估（领域：实施过程）。然后，我们提取了术后恢复时间和其他结果的数据，并将其与历史和当代队列进行了比较。
围手术期音乐和针灸的证据是强有力且直接的，而正念、瑜伽和太极的证据分别是适度或微弱且间接的。由 97 名围手术期提供者完成的变革准备情况调查显示出总体上积极的评分（均值>0，范围为-2 到+2，相当于 5 点李克特量表上的>2.5）。在杜伦（Durham）的准备情况（+0.47）高于其他大多数 VA 医院（范围+0.05 至+0.63）。在 3307 名被问及是否愿意接受音乐治疗的退伍军人中，约有 68%（n=2252）回答“是”。在多变量分析中，积极的反应（可接受性）独立地由较年轻的年龄和较高的术前平均疼痛评分（入院前 90 天内超过 4 分/10 分）预测，这些因素与阿片类药物过度使用有关。在目标人群中，这一比例适中（81 名可能的接受者中有 39 名接受了音乐治疗），由于设备扩散到非目标人群中，可能会减少接受者的数量。术后恢复时间没有改变，这表明该方法已顺利融入工作流程。
在一家三级 VA 医院，以 CFIR 为指导的围手术期音乐实施是可行的，在高危患者亚组中实施率适中。使用带有首选播放列表的数字音乐播放器的证据确凿，变革的动力充足，提供者的准备程度适度，患者的可接受性良好（尤其是那些阿片类药物过度使用风险较高的患者），并且采用了规范化的方法。需要进一步研究以确定用于有效知识转化活动的类似框架。
