Rak Kimberly J, Kahn Jeremy M, Linstrum Kelsey, Caplan Erin A, Argote Linda, Barnes Barbara, Chang Chung-Chou H, George Elisabeth L, Hess Dean R, Russell Jennifer L, Seaman Jennifer B, Angus Derek C, Girard Timothy D
Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine.
Center of Organizational Learning, Innovation and Knowledge, Tepper School of Business, Carnegie Mellon University, Pittsburgh, Pennsylvania.
ATS Sch. 2021 Aug 17;2(3):370-385. doi: 10.34197/ats-scholar.2020-0169OC. eCollection 2021 Sep.
Many critical care interventions that require teamwork are adopted slowly and variably despite strong evidence supporting their use. We hypothesize that educational interventions that target the entire interprofessional team (rather than professions in isolation) are one effective way to enhance implementation of complex interventions in the intensive care unit (ICU). As a first step toward testing this hypothesis, we sought to qualitatively solicit opinions about team dynamics, evidence translation, and interprofessional education as well as current knowledge, attitudes, and practices surrounding the use of one example of a team-based practice in the ICU-preventive postextubation noninvasive ventilation (NIV). We conducted a qualitative evaluation using semistructured interviews and focus groups with nurses, respiratory therapists, and physicians working in four ICUs in four hospitals within an integrated health system. ICUs were selected based on variation in academic versus community status. We iteratively analyzed transcripts using a thematic content analysis approach. From December 2018 to January 2019, we conducted 32 interviews (34 people) and 3 focus groups (20 people). Participants included 31 nurses, 15 respiratory therapists, and 8 physicians. Participants had favorable views of how their teams work together but discussed ways team dynamics (e.g., leader inclusiveness) impact care coordination. Participants viewed interprofessional education favorably and shared suggestions regarding preferred content and delivery (e.g., include both profession-specific and team-oriented content). Though participants reported frequently using NIV as a treatment, they described rarely using NIV as a preventive strategy, and nurses and respiratory therapists described challenges to use such as perceived patient discomfort. There were ICU-specific differences in management of patients at a high risk for respiratory failure after extubation, with some preferring to delay extubation. Participants reported optimism that interprofessional education can be an acceptable and effective way to improve translation of evidence into practice. Participants also detailed patient-specific and ICU-wide barriers to the implementation of preventive postextubation NIV. This information about teamwork in the ICU, suggestions for interprofessional education, and barriers and facilitators to use of a target evidence-based practice can inform the development of novel educational strategies in ways that increase acceptability, appropriateness, and feasibility of the intervention.
尽管有强有力的证据支持,但许多需要团队合作的重症监护干预措施的采用速度缓慢且参差不齐。我们假设,针对整个跨专业团队(而非孤立的专业)的教育干预措施是加强重症监护病房(ICU)复杂干预措施实施的一种有效方法。作为检验这一假设的第一步,我们试图定性地征求关于团队动态、证据转化和跨专业教育的意见,以及围绕ICU中一种基于团队的实践——拔管后预防性无创通气(NIV)的使用的当前知识、态度和实践。我们使用半结构化访谈和焦点小组对综合医疗系统内四家医院的四个ICU中的护士、呼吸治疗师和医生进行了定性评估。根据学术地位与社区地位的差异选择了ICU。我们采用主题内容分析方法对访谈记录进行迭代分析。2018年12月至2019年1月,我们进行了32次访谈(34人)和3次焦点小组讨论(20人)。参与者包括31名护士、15名呼吸治疗师和8名医生。参与者对他们的团队协作方式持积极看法,但也讨论了团队动态(如领导者的包容性)如何影响护理协调。参与者对跨专业教育持积极看法,并就首选内容和授课方式分享了建议(如包括专业特定内容和团队导向内容)。尽管参与者报告经常将NIV用作治疗方法,但他们描述很少将NIV用作预防策略,护士和呼吸治疗师描述了使用NIV的挑战,如患者感到不适。拔管后呼吸衰竭高危患者的管理在不同ICU之间存在差异,一些人更倾向于延迟拔管。参与者表示乐观地认为跨专业教育可以成为将证据转化为实践的一种可接受且有效的方式。参与者还详细说明了实施拔管后预防性NIV的患者特异性和ICU层面的障碍。这些关于ICU团队合作的信息、跨专业教育的建议以及使用目标循证实践的障碍和促进因素,可以为制定新的教育策略提供参考,从而提高干预措施的可接受性、适宜性和可行性。