Maw Anna M, Morris Megan A, Glasgow Russell E, Barnard Juliana, Ho P Michael, Ortiz-Lopez Carolina, Fleshner Michelle, Kramer Henry R, Grimm Eric, Ytell Kate, Gardner Tiffany, Huebschmann Amy G
Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, USA.
Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, CO, 80045, USA.
Implement Sci Commun. 2022 Aug 12;3(1):89. doi: 10.1186/s43058-022-00334-x.
Lung ultrasound (LUS) is a clinician-performed evidence-based imaging modality that has multiple advantages in the evaluation of dyspnea caused by multiple disease processes, including COVID-19. Despite these advantages, few hospitalists have been trained to perform LUS. The aim of this study was to increase adoption and implementation of LUS during the 2020 COVID-19 pandemic by using recurrent assessments of RE-AIM outcomes to iteratively revise our implementation strategies.
In an academic hospital, we implemented guidelines for the use of LUS in patients with COVID-19 in July 2020. Using a novel "RE-AIM dashboard," we used an iterative process of evaluating the high-priority outcomes of Reach, Adoption, and Implementation at twice monthly intervals to inform revisions of our implementation strategies for LUS delivery (i.e., Iterative RE-AIM process). Using a convergent mixed methods design, we integrated quantitative RE-AIM outcomes with qualitative hospitalist interview data to understand the dynamic determinants of LUS Reach, Adoption, and Implementation.
Over the 1-year study period, 453 LUSs were performed in 298 of 12,567 eligible inpatients with COVID-19 (Reach = 2%). These 453 LUS were ordered by 43 out of 86 eligible hospitalists (LUS order adoption = 50%). However, the LUSs were performed/supervised by only 8 of these 86 hospitalists, 4 of whom were required to complete LUS credentialing as members of the hospitalist procedure service (proceduralist adoption 75% vs 1.2% non-procedural hospitalists adoption). Qualitative and quantitative data obtained to evaluate this Iterative RE-AIM process led to the deployment of six sequential implementation strategies and 3 key findings including (1) there were COVID-19-specific barriers to LUS adoption, (2) hospitalists were more willing to learn to make clinical decisions using LUS images than obtain the images themselves, and (3) mandating the credentialing of a strategically selected sub-group may be a successful strategy for improving Reach.
Mandating use of a strategically selected subset of clinicians may be an effective strategy for improving Reach of LUS. Additionally, use of Iterative RE-AIM allowed for timely adjustments to implementation strategies, facilitating higher levels of LUS Adoption and Reach. Future studies should explore the replicability of these preliminary findings.
肺部超声（LUS）是一种由临床医生操作的循证成像方式，在评估包括新型冠状病毒肺炎（COVID-19）在内的多种疾病过程引起的呼吸困难方面具有多种优势。尽管有这些优势，但很少有住院医生接受过LUS操作培训。本研究的目的是通过反复评估RE-AIM结果来迭代修订我们的实施策略，从而在2020年COVID-19大流行期间增加LUS的采用和实施。
在一家学术医院，我们于2020年7月实施了针对COVID-19患者使用LUS的指南。使用一个新颖的“RE-AIM仪表盘”，我们采用迭代过程，每隔一个月对覆盖范围、采用率和实施情况等高度优先的结果进行评估，以指导我们对LUS实施策略（即迭代RE-AIM过程）的修订。采用收敛性混合方法设计，我们将定量的RE-AIM结果与定性的住院医生访谈数据相结合，以了解LUS覆盖范围、采用率和实施情况的动态决定因素。
在为期1年的研究期间，12567名符合条件的COVID-19住院患者中有298名接受了453次LUS检查（覆盖范围=2%）。这453次LUS检查由86名符合条件的住院医生中的43名开出（LUS检查医嘱采用率=50%）。然而，这86名住院医生中只有8名进行了LUS检查/监督，其中4名作为住院医生程序服务成员需要完成LUS认证（程序医生采用率75%，非程序住院医生采用率1.2%）。为评估这个迭代RE-AIM过程而获得的定性和定量数据导致部署了六个连续的实施策略和三个关键发现，包括（1）存在特定于COVID-19的LUS采用障碍，（2）住院医生更愿意学习使用LUS图像做出临床决策，而不是自己获取图像，以及（3）强制对一个经过战略选择的亚组进行认证可能是提高覆盖范围的成功策略。
强制使用经过战略选择的临床医生子集可能是提高LUS覆盖范围的有效策略。此外，使用迭代RE-AIM允许及时调整实施策略，促进更高水平的LUS采用率和覆盖范围。未来的研究应探索这些初步发现的可重复性。
