key: cord-0837851-8c5poy9x
authors: McNett, Molly; O’Mathúna, Dónal; Tucker, Sharon; Roberts, Haley; Mion, Lorraine C.; Balas, Michele C.
title: A Scoping Review of Implementation Science in Adult Critical Care Settings
date: 2020-12-16
journal: Crit Care Explor
DOI: 10.1097/cce.0000000000000301
sha: c555321c09dd8b44f273935622a28a7dedb02d29
doc_id: 837851
cord_uid: 8c5poy9x

OBJECTIVES: The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation. DATA SOURCES: A librarian-assisted search was performed using three electronic databases. STUDY SELECTION: Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included. DATA EXTRACTION: Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. DATA SYNTHESIS: Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes. CONCLUSIONS: The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.

I mplementation science (IS) is a field of study that seeks to identify optimal methods for accelerating the systematic uptake of research findings and other evidence-based practices (EBPs) into routine clinical care (1) . An evolving area of inquiry and growing priority for health-related funding agencies, IS applies theories borrowed from other disciplines (e.g., psychology, sociology, organizational change) as well as field-specific conceptual models and frameworks. These theories are generally used to: 1) describe the process of translating research into practice (process models), 2) understand what contextual factors serve as barriers and facilitators to implementation (determinant frameworks), 3) provide a structure for evaluating implementation endeavors and outcomes (evaluation frameworks), and 4) describe how change can occur in areas where intention to change is absent (classic theories) (2, 3) . The number of theories, models, and frameworks are prolific, and integration of these into complex health systems often requires additional considerations regarding change mechanisms, meditators, moderators, and both proximal and distal outcomes (3, 4) . Identification of an applicable model for implementation is critical in complex healthcare systems where sustained application of EBPs can improve quality and safety of care, limit harmful practice variability, and reduce soaring costs. Model-based approaches to evidence implementation and practice change can also be www.ccejournal.org 2020 • Volume 2 • e0301 considerably effective in high priority, time sensitive initiatives, such as those recently experienced in the setting of the coronavirus disease 2019 pandemic.

IS overlaps with several other fields, including quality improvement (QI), dissemination science, and knowledge translation. Approaches are similar in terms of populations of interest, metrics to evaluate process and clinical outcomes, incorporation of existing clinical data, emphasis on stakeholder involvement, and goal of bridging the research to practice gap to improve health (1) . The main distinction between fields lies in their focal intent. IS aims to produce "generalizable knowledge" and evidence about effective strategies and outcomes associated with sustained integration of established but underutilized EBPs into routine practice (1) . In contrast, QI mainly aims to streamline processes and eliminate inefficient practices locally, commonly via rapid-cycle improvement. In QI, the change initiative may be linked to a best practice or scientific evidence, but this is not a requirement, as many initiatives focus solely on process improvement. The focus of QI is generally narrower than dissemination and IS. Dissemination science has a broader focus on studying the targeted distribution of information and intervention materials to a specific public health or clinical practice audience and spreading information using communication and education strategies (5) . Finally, knowledge translation refers to a dynamic and iterative process of synthesis, dissemination, exchange, and application of knowledge. Knowledge translation promotes information not only from research to practice but also from practice back to research to identify gaps and guide future research priorities (1) .

A key development in IS is a common nomenclature for implementation strategy terms, definitions, and categories that can be used to guide implementation research and practice across settings (6) . This work evolves from leaders in IS (7) who advocate that knowledge of EBPs must be accompanied by knowledge of implementation in order to successfully integrate evidence-based interventions. Implementation strategies are organized into categories to provide guidance on approaches to successfully implement evidence-based interventions. For example, Flodgren et al (8) used select systematic reviews produced by the Cochrane Effective Practice and Organisation of Care group to identify, define and provide evidence for seven general strategies (i.e., printed educational materials, educational meetings, educational outreach, local opinion leaders, audit and feedback, computerized reminders, and tailored interventions). A separate taxonomy includes four domains (professional, financial, organizational, and regulatory) and 49 distinct strategies (9) . Additionally, Powell et al (10) established a compilation of 73 implementation strategies, called the Expert Recommendations for Implementing Change (ERIC) strategies. Ultimately, local contextual need and assessment of facilitators and barriers should be primary drivers influencing selection of implementation strategies (8) .

While there is evidence on the effectiveness of certain implementation strategies to increase EBP utilization in a variety of settings, the feasibility of these strategies in critical care units is unknown. In addition to the complexity of interventions, the very nature of the critical care environment poses unique considerations and contexts for EBP integration. A growing body of literature demonstrates a large proportion of critically ill patients do not receive evidence-based or guideline recommended care (11) . This failure to apply EBPs during critical illness often leads to significant short-and long-term morbidity and mortality (11) . Establishing the current state of knowledge regarding common strategies and IS efforts in critical care settings is an important step in addressing how to best sustain delivery of evidence-based interventions.

The purpose of this scoping review is to provide a synthesis of the available literature related to IS in critical care in terms of the volume, nature, and characteristics of studies conducted to identify existing knowledge gaps. We were specifically interested in identifying which EBPs were targeted for improvement, which implementation strategies were used to foster change, and which outcomes were evaluated.

This scoping review was conducted by a research team with expertise in IS, critical care, EBP, and systematic review methodology. The review adhered to the process outlined by Grant and Booth (12) and the checklist for Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (13) . The Covidence systematic review software was used for all stages of the review process, including title and abstract screening, full text review, and data extraction.

The research question guiding the scoping review was, "What are the implementation strategies, associated EBPs, and outcomes evaluated in studies conducted in critical care settings?"

A librarian-assisted search was performed on October 30, 2019, using three electronic databases: Medline, PubMed, and Cumulative Index to Nursing and Allied Health Literature. The databases were selected to be comprehensive and cover a range of disciplines. The following key words were used: IS, implementation, critical care, ICU, and EBP (Appendix A, http://links. lww.com/CCX/A455). The search was limited to articles published between January 1999 and July 2019 to coincide with the EBP movement and development of the relatively new field of IS. Reference lists of included articles were reviewed and hand searching was performed to identify other relevant literature not captured by the electronic search.

Articles were included if they: 1) reported outcomes of a research study, QI effort, or program aimed at disseminating, implementing, or sustaining an EBP, 2) described use of any of the 73 implementation strategies outlined in the ERIC project (8) , 3) were conducted in a critical care unit, and 4) involved adults. Because of limited resources for translation, articles published in languages other than English were excluded. We also excluded reviews, commentaries, editorials, abstracts, and conference proceedings on the basis that these would not provide the level of detail sought in our review. Finally, literature that included work conducted outside the critical care setting or involving children was excluded, as evidence-based interventions/practices would likely differ by level of care and age.

Two reviewers (M.M., M.C.B.) independently screened titles and abstracts of identified articles to determine eligibility. The same two reviewers then performed full text review in duplicate, with conflicts resolved by an independent third reviewer (D.O.). Reviewers customized data extraction fields in Covidence to align with aims of the review. Two reviewers tested extraction fields for consistency and fidelity to project aims (M.M., H.R.). The same two reviewers independently extracted data from articles into required fields. Extracted data were compared between reviewers for consensus prior to finalizing the extraction forms. The following data were extracted from included articles: year and country of publication, project aim, design, theory or framework used to guide the project, setting, EBP implemented, components of the EBP intervention, implementation strategies, and clinical/implementation outcomes.

The combination of search terms with selection criteria and limits yielded 1,707 studies. Of these, 40 duplicates were removed, leaving 1,667 studies for title and abstract screening (Fig. 1) . Of these, 1,426 were excluded for not meeting initial inclusion criteria (i.e., title or abstract indicated nonadult population, noncritical care setting, or literature review), resulting in 241 articles that underwent full text review, with a moderate level of agreement (ĸ = 0.450), of which an additional 159 were excluded for the following reasons: literature review (n = 69), non-ICU setting (n = 41), noneligible study design (n = 31), did not evaluate an implementation strategy (n = 16), or not in English (n = 2). A total of 82 studies were included in the final review.

Of the studies that met inclusion criteria for this review, some (n = 20) were specifically described by the authors as IS studies and a similar number (n = 19) designated as QI projects. The remaining studies (n = 43) were identified neither as IS or QI by their authors but rather described a variety of prospective implementation (PI) evaluations or designs, such as prospective cohort, time series, or pre/post evaluation study designs. Such studies will be referred to here as having PI designs. Figure 2 displays these design categories according to year of publication. The PI designs were the most common type in every time period, with the largest number occurring during the period 2005-2009. QI designs were used less frequently in the earlier time periods, with substantial increases in recent years. Similarly, there were few IS designs for the initial time periods, but reports have doubled within the last 5 years. None of the studies included in this review examined systematic de-implementation of low value practices.

Supplemental Table 1 (http://links.lww.com/CCX/A456) provides an overview of the studies included in the review according to the design categories. Studies using IS designs were conducted most often in the United States (n = 9) (14-22) and Canada (n = 7) (23-29) followed by Australia (n = 2) (30, 31), the Netherlands (n = 1) (32), and the United Kingdom (n = 1) (33) . Within the PI category, studies were conducted most frequently in the United States (75), and the United Kingdom (56) . Studies that reported using a QI design were conducted in the United States (n = 11) (76-86), Australia (n = 2) (87, 88) , and one each in Brazil (89), Canada (90), China (91), Sweden (92) , Taiwan (93) , and the United Kingdom (94) . Many studies (30/82, 36.5%) included more than one critical care unit in their investigation. Figure 3 displays the EBPs implemented in the 82 studies. The studies addressed a variety of EBPs, classified into 18 categories. The most common EBPs included: ventilator-associated pneumonia (VAP) prevention bundles (12/82, 14.6%) (14, 33, 39, 49, 54, 55, 57, 59, 60, 63, 73, 86) , nutritional support/management protocols (9/82, 10.9%) (25, 26, 30, 35, 38, 40, 61, 88, 90) , the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility (ABCDE/ABCDEF) bundle (7/82, 8.5%) (15-19, 47, 76) , central line-associated bloodstream infection (CLABSI) prevention bundles (6/82, 7.3%) (22, 37, 42, 52, 53, 80) , and mechanical ventilation liberation/weaning protocols (6/82, 7.3%) (36, 62, 69, 72, 90, 93) . Sixteen studies involved ICU mobilization protocols (4/82, 4.8%) (34, 46, 70, 78) , use of checklists (4/82, 4.8%) (41, 81, 84, 89) , hand hygiene/infection control bundles (n = 4/82, 4.8%) (21, 66, 71, 95) , and initiatives targeting multiple EBPs (4/82, 4.8%) (24, 51, 56, 77) . The remaining studies focused on antibiotic stewardship (3/82, 3.6%) (22, 65, 67) , analgesia/sedation protocols (3/82, 3.6%) (68, 75, 96) , palliative/end-of-life care bundles (3/82, 3.6%) (20, 32, 85) , pressure ulcer prevention (3/82, 3.6%) (43, 83, 94) , venous thromboembolism (VTE) prophylaxis (2/82, 2.4%) (28, 29) , laboratory reduction guidelines (2/82, 2.4%) (48, 87) , the surviving sepsis campaign bundles (2/82, 2.4%) (64, 82) , interdisciplinary rounding/handover tools (2/82, 2.4%) (31, 58) , and "other" EBPs (7/82, 8.5%) (27, 44, 45, 50, 74, 79, 92) .

Temporal trends were noted by EBP category. For example, studies involving nutritional support and management, VAP, and CLABSI prevention practices were more commonly published between 2004 and 2011, while those focusing on palliative/end-of-life care, the ABCDE/ABCDEF bundle, and interdisciplinary rounding were more recent. Similarly, the complexity and number of components included in the EBP change initiatives appeared to change over time. For example, early VAP prevention bundles targeted the use of head of bed elevation, oral care, ventilator tubing condensate removal, and hand hygiene/glove use, while more recent bundles added sedation and mechanical ventilation liberation procedures and protocols. Similarly, more recent studies generally included EBPs involving members of an interdisciplinary team working together to deliver the EBP, rather than a single discipline. Figure 4 displays implementation strategies used in the included studies. Sixteen different ERIC strategies were described and include: educational meetings, audit and feedback, develop tools, local opinion leaders, develop effective materials, inform stakeholders, ongoing consultation, distribute materials, ongoing training, develop systems, facilitators and barriers, scale up, academic partnerships, financial incentives, and building a coalition. Of these strategies, educational meetings (56/82, 68.2%), auditing and feedback (55/82, 67.1%), developing tools (26/82, 31.7%), and use of local opinion leaders (18/82, 21.9%) were used most frequently. Most studies (76/82, 92.6%) reported using more than one strategy when implementing an EBP. Twelve studies reported use of a single strategy for EBP implementation. Single strategy approaches included auditing and feedback (23, 26, 27, 65, 66) , facilitators and barriers (15, 16, 18, 32) , financial incentives (36), building a coalition (19) , and educational training (72) . Across all types of designs, none specifically explored the role of mediators for their effect on implementation or clinical outcomes or as causal components in the relationship between implementation strategies and outcomes.

Studies reported both clinical and implementation outcomes (Supplemental Table 2 (15-20, 24, 27, 28, 32, 51, 57, 67, 95, 96) , and some reported both clinical and implementation outcomes (22/82, 26 .8%) (14, 21, 23, 25, 26, 29, 30, 32, 39, 42, 53, 58, 59, 62, 71, 73, 74, 76, 82, 84, 86, 89) . Primary clinical outcomes were most often linked to the EBP that was evaluated (e.g., VAP bundle implementation reported VAP rates), rather than solely surrogate metrics such as mortality or length of stay. The most frequently reported primary clinical outcomes included VAP rates www.ccejournal.org 2020 • Volume 2 • e0301 (14, 33, 39, 54, 55, 59, 60, 62, 63, 75, 86) , ventilator days/duration of mechanical ventilation (33, 34, 38, 46, 47, 62, 68, 72, 75, 78, 91) , catheter-related bloodstream infection/CLABSI (21, 22, 37, 42, 52, 53, 81, 83) , nutrition adequacy (25, 26, 40, 61) , or time/duration of nutrition therapy (35, 38, 44, 88, 90) . Primary clinical outcomes were reported as rates or continuous values, rather than through use of standardized outcome scales. Implementation outcomes are those identified by Proctor et al (97) and include acceptability, adoption, appropriateness, feasibility, fidelity, cost, penetration, and sustainability. The most frequently reported implementation outcome was fidelity, often reported as either percentage of adherence or compliance to the EBP that was implemented, rather than through use of standardized tools or scales (14, 18-26, 29, 30, 32, 33, 39, 42, 51, 53, 57-59, 62, 67, 71, 73, 74, 76, 82, 84, 86, 89, 95, 96) . Other implementation outcomes included adoption (14, 22, 23, 30, 31) , or qualitative evaluations of facilitators/barriers and perceptions of the EBP, and descriptions of team composition/ building a coalition (15-17, 19, 26-28, 31) . For both clinical and implementation outcomes, reporting of the various metrics across all study types was substantially heterogeneous by measurement type, duration, and frequency, rendering pooling of data difficult. However, the majority of studies reported positive improvements in both clinical and/or implementation outcomes, regardless of study design.

Given our specific interest in IS in critical care units, we identified a subset of articles (n = 20) as having a specific IS design, including an established IS framework, and evaluating effectiveness of implementation strategies specifically on implementation outcomes (97) . The frameworks, aims, strategies, and outcomes of these studies are listed in Table 1 . Various models or frameworks guided the implementation studies, with the Knowledge to Action Framework used most often (25, 26, 31) , followed by The Grol Model of Implementation (21, 32) . Other implementation models are listed in Table 1 . Many of the studies (n = 11) included multiple ICUs. Specific EBPs evaluated in these studies included VAP prevention bundles (14, 33) , ABCDEF bundle (15) (16) (17) (18) (19) , nutrition therapy (25) (26) (27) 30) , antibiotic use (23), communication practices (31), palliative care consultation (20) , CLABSI prevention (21, 22) , VTE prophylaxis (28, 29) , and multiple EBPs (24). One additional study specifically evaluated readiness for and barriers to implementation of EBPs (32) .

A variety of implementation strategies were evaluated within this subset of IS specific designs ( Table 1) . The majority of studies (n = 13) evaluated more than one IS strategy, with auditing and feedback incorporated most often across studies (n = 13) (14, 17, 20-22, 25-27, 29-31, 33) . Eight studies evaluated a single implementation strategy (15, 16, 18, 19, 23, 26, 27, 32) , namely identifying facilitators and barriers (15, 16, 18, 32) , building a coalition (19) , and auditing and feedback (22, 26, 27) .

Outcomes evaluated across the IS studies included implementation and clinical outcomes as described by Proctor et al (97) . The most frequent implementation outcome evaluated was fidelity (reported as adherence) to the EBP (17, 19-21, 23, 24, 26, 29-33) . Only one study included adoption as an implementation outcome (14) .

Additionally, a subset of studies specifically evaluated facilitators and barriers to implementation (15, 16) , effective implementation strategies (28) , or perceptions of auditing and feedback as a strategy using a qualitative approach (27) . In addition to implementation outcomes, five of the studies also evaluated clinical outcomes; these included VAP rates and/or ventilator days (14, 33) , mortality (30) , and CLABSI rates (21, 22) .

This is one of the first reviews to synthesize the available literature related to IS in critical care. We found significant variability in project nomenclature and designs aimed at evaluating strategies to implement an EBP and determine effect on outcomes. Despite these variations, findings across all project designs did demonstrate positive effects on clinical outcomes, highlighting the importance of EBPs in critical care. Within the dates of our review, the number of published studies in the critical care literature that reported being guided by IS has increased steadily, doubling in the last 5 years. The complexity and number of components included in the EBPs selected for improvement has similarly increased over time. Most of the EBPs studied required the input, decision-making, and performance of tasks by multiple ICU team members, rather than relying on a single disciple for implementation. While a variety of methods were used to foster adoption of these EBPs into critical care, a limited number of ERIC strategies were used (16/73) , and few projects evaluated implementation outcomes, making it difficult to definitely conclude which strategies were most effective.

An inherent challenge to advancing IS work in critical care settings is the vast heterogeneity of strategies and outcomes used across projects that precludes pooling and synthesis of findings. Many projects in this review evaluated specific IS strategies, yet used a variety of terms to describe the project, and did not use consistent mechanisms for measuring and evaluating the strategies. The field of IS has had major gains in this area by using concept mapping, developing operational definitions and categories for implementation strategies, and establishing measurement tools to provide a consistent and scientific approach to these investigations. Nevertheless, this review confirms mixed evidence as to which design approach is most effective, which specific strategies are superior, and whether multiple strategies versus a single strategy is effective for successful practice change (6) . In addition, the extent to which mediating factors are present and influence effectiveness of strategies warrants consideration, given the complexity of critical care environments. Ultimately, a systematic approach is needed using standardized designs, strategies, and both clinical and implementation outcomes in critical care settings to increase widespread adoption of EBPs.

We also found significant variation in outcomes evaluated in our review. Across all project designs, many only reported clinical outcomes. Among the few that reported implementation outcomes, these were limited to fidelity (adherence and compliance) and adoption. While these are certainly important components of initial EBP implementation, other outcomes such as acceptability, appropriateness, penetration, and sustainability would yield critical information on characteristics of the EBP that would advance widespread integration over time and across settings. Integration of these additional outcomes using an IS approach can generate important data on effective mechanisms for EBP change that is sustainable in complex critical care environments. The field of IS allows multiple approaches to project evaluation, including hybrid designs that establish priorities for clinical and implementation outcomes, and mechanisms for systematically measuring and reporting findings. Many IS approaches also include a QI component to integrate rapid cycle change and streamline processes to improve both clinical and implementation outcomes under investigation. This systematic approach to implementation becomes critical when working to develop a body of generalizable evidence on the most effective strategies to promote EBP utilization and evaluate impact on clinicians, organizations, patients, and populations. Among the specific IS designs in critical care, the most comprehensively investigated EBP was the ABCDE/F bundle. Although investigations were guided by different frameworks or models, all systematically contributed information on factors influencing successful uptake of the ABCDE/F bundle into routine clinical care. Various strategies were evaluated and formal investigations into assessment of readiness and barriers were performed. This body of knowledge regarding implementation of the bundle has resulted in development of toolkits to guide clinicians through the implementation process.

As a result of this review, there are several priority areas that should be addressed to move the science of implementation forward in critical care. First, clinicians and scientists are encouraged to use established models or frameworks for implementation of best practices to provide a systematic approach to implementation and increase likelihood of generalizability and sustainability over time. Second, selection, measurement, and reporting of implementation strategies should align with current nomenclature to provide consistency of methods across studies and build evidence regarding effectiveness. Third, outcome reporting should extend beyond solely clinical outcomes and include measures of implementation outcomes using established terminology and mechanisms. There is a need for additional investigations to explore the role of mediators on clinical and implementation outcomes, as well as systematic approaches to de-implementation of low value or wasteful practices in critical care settings. Dissemination of these conceptual and methodological efforts is critical to advance widespread integration of EBPs into routine clinical care.

Having a structured and systematic approach to integrating EBPs into practice using an IS approach holds great potential in critical care settings and should remain a key component of critical care research agendas for all EBPs. The work should not cease upon publication of study findings on clinical effectiveness or upon publication of an evidence-based guideline. Rather, the next logical step scientifically is to identify optimal strategies to embed the findings into routine clinical care. Evaluation and dissemination of the effectiveness of these strategies on both clinical and implementation outcomes then generates evidence to promote sustainable practice change. This is exactly the aim of IS and must be addressed by developing critical care teams who are experienced in IS methodology and committed to advancing the science specifically related to acceleration of adoption and uptake of evolving effective critical care interventions that optimize patient outcomes.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://journals.lww.com/ccxjournal).

Dr. Mion has research support from the National Institutes of Health (NIH). Dr. Balas currently receives research support from the National Heart, Lung, and Blood Institute of the NIH under award number R01HL14678-01 and the American Association of Critical Care Nurse's Impact Research Grant. She has received past honoraria from the Society of Critical Care Medicine for her work related to the ICU Liberation Collaborative and is currently an educational consultant for H3C, LLC. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: mcnett.21@osu.edu

Welcome to implementation science

Making sense of implementation theories, models and frameworks

A scoping review of fullspectrum knowledge translation theories, models, and frameworks

A systematic review of empirical studies examining mechanisms of implementation in health

Implementation science: What is it and why should I care?

Enhancing the impact of implementation strategies in healthcare: A research agenda

Evidence-based implementation of evidence-based medicine

Tools developed and disseminated by guideline producers to promote the uptake of their guidelines

Refining a taxonomy for guideline implementation: Results of an exercise in abstract classification

A refined compilation of implementation strategies: Results from the expert recommendations for implementing change (ERIC) project

ATS Ad Hoc Committee on Implementation Science: An official American Thoracic Society research statement: Implementation science in pulmonary, critical care, and sleep medicine

A typology of reviews: An analysis of 14 review types and associated methodologies

PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation

Adoption of a ventilator-associated pneumonia clinical practice guideline

Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU pain, agitation, and delirium guidelines

Ability to predict team members' behaviors in ICU teams is associated with routine ABCDE implementation

Organizational domains and variation in attitudes of intensive care providers toward the ABCDE bundle

Contextual issues influencing implementation and outcomes associated with an integrated approach to managing pain, agitation, and delirium in adult ICUs

ICU team composition and its association with ABCDE implementation in a quality collaborative

Implementation and evaluation of a network-based pilot program to improve palliative care in the intensive care unit

Implementation strategies to improve evidence-based bathing practices in a neuro ICU

Use of implementation science for a sustained reduction of central-line-associated bloodstream infections in a high-volume, regional burn unit

Audit and feedback to reduce broadspectrum antibiotic use among intensive care unit patients: A controlled interrupted time series analysis

Knowledge translation in critical care: Factors associated with prescription of commonly recommended best practices for critically ill patients

Dissemination of the Canadian clinical practice guidelines for nutrition support: Results of a cluster randomized controlled trial

The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: A multicenter observational study

A qualitative study of the variable effects of audit and feedback in the ICU

Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative

A multicentre controlled prepost trial of an implementation science intervention to improve venous thromboembolism prophylaxis in critically ill patients

Nutrition Guidelines Investigators of the ANZICS Clinical Trials Group: Effect of evidence-based feeding guidelines on mortality of critically ill adults: A cluster randomized controlled trial

Implementation of an evidencebased practice nursing handover tool in intensive care using the knowledge-to-action framework

Effectiveness of supporting intensive care units on implementing the guideline 'End-of-life care in the intensive care unit, nursing care': A cluster randomized controlled trial

Reduction of ventilator-associated pneumonia: Active versus passive guideline implementation

Electronic health record tool to promote team communication and early patient mobility in the intensive care unit

Evidence-based practice strategy: Increasing timely nutrition in mechanically ventilated trauma surgical patients

Effects of physician-targeted pay for performance on use of spontaneous breathing trials in mechanically ventilated patients

Use of simulation-based education to reduce catheter-related bloodstream infections

Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol

Implementing a unit-level intervention to reduce the probability of ventilator-associated pneumonia

Implementation of an evidence-based feeding protocol and aspiration risk reduction algorithm

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices

The impact of bedside behavior on catheter-related bacteremia in the intensive care unit

Use of an intervention bundle to eliminate pressure ulcers in critical care

Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit

Impact of a restraint management bundle on restraint use in an intensive care unit

The economic and clinical impact of sustained use of a progressive mobility program in a neuro-ICU

Implementation of the ABCDE bundle to improve patient outcomes in the intensive care unit in a rural community hospital

Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit

IMPACT-HAP Study Group: Development and implementation of a performance improvement project in adult intensive care units: Overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study

Red blood cell transfusion practices in two surgical intensive care units: A mixed methods assessment of barriers to evidence-based practice

Empowering critical care nurses to improve compliance with protocols in the intensive care unit

Interventions to decrease catheter-related bloodstream infections in the ICU: The Keystone Intensive Care Unit Project

Evidence-based practice to reduce central line infections

Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia

The impact of an evidence-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia

Using 'nudge' principles for order set design: A before and after evaluation of an electronic prescribing template in critical care

Evidence-based practice: Use of the ventilator bundle to prevent ventilator-associated pneumonia

Impact of surgical intensive care unit interdisciplinary rounds on interprofessional collaboration and quality of care: Mixed qualitative-quantitative study

Implementation of a realtime compliance dashboard to help reduce SICU ventilator-associated pneumonia with the ventilator bundle

Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia

Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit

Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: Outcomes after an implementation program

Prevention of ventilator-associated pneumonia: The multimodal approach of the Spanish ICU "Pneumonia Zero" program

Impact of the surviving sepsis campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasiexperimental study

Antimicrobial stewardship programme in critical care medicine: A prospective interventional study

Implementing and evaluating a rotating surveillance system and infection control guidelines in 4 intensive care units

Use of evidence-based recommendations in an antibiotic care bundle for the intensive care unit

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit

Dissemination of research-based knowledge in an intensive care unit-a qualitative study

Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units

Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina

Practising evidence-based medicine: The design and implementation of a multidisciplinary team-driven extubation protocol

A multifaceted program to prevent ventilator-associated pneumonia: Impact on compliance with preventive measures

Development and implementation of a clinical pathway for cardiac surgery in the intensive care unit: Effects on protocol adherence

Changing sedation practices in the intensive care unit -protocol implementation, multifaceted multidisciplinary approach and teamwork

Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients

Results of a collaborative quality improvement program on outcomes and costs in a tertiary critical care unit

Mobilizing outcomes: Implementation of a nurse-led multidisciplinary mobility program

Expanding a performance improvement initiative in critical care from hospital to system

Use of corporate six sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU

The "TRAUMA LIFE" initiative: The impact of a multidisciplinary checklist process on outcomes and communication in a trauma intensive care unit

The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis

Prevention of medical devicerelated pressure injuries associated with respiratory equipment use in a critical care unit: A quality improvement project

Measurable outcomes of quality improvement using a daily quality rounds checklist: Two-year prospective analysis of sustainability in a surgical intensive care unit

Implementing primary palliative care best practices in critical care with the care and communication bundle

Implementing a ventilator bundle in a community hospital

Strategies to reduce inappropriate laboratory blood test orders in intensive care are effective and safe: A before-and-after quality improvement study

Failure of a quality improvement process to increase nutrition delivery to intensive care patients

Writing Group for the CHECKLIST-ICU Investigators ane the Brazilian Research in Intensive Care Network (BRICNet): Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: A randomized clinical trial

Southwestern Ontario Critical Care Research Network: Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT)

Effect of a quality improvement program on weaning from mechanical ventilation: A cluster randomized trial

Effects of a multifaceted intervention QI program to improve ICU performance

Multidisciplinary interventions and continuous quality improvement to reduce unplanned extubation in adult intensive care units: A 15-year experience

Reducing the incidence of pressure ulcers in critical care units: A 4-year quality improvement

Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units

Implementation of a pain management algorithm in intensive care units and evaluation of nurses' level of adherence with the algorithm

Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda