Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study.

Background: Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system.

Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH): a type II hybrid effectiveness-implementation cluster-randomized trial.

Background: Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality.

Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation.

Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system.

Delivery of Lung-protective Ventilation for Acute Respiratory Distress Syndrome: A Hybrid Implementation-Effectiveness Trial.

Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS), but adherence remains inadequate. To measure the process and clinical impacts of implementation of a science-based intervention to improve LPV adherence for patients with ARDS, in part by increased use of clinical decision support (CDS). We conducted a type III hybrid implementation/effectiveness pilot trial enrolling adult patients with ARDS admitted to three hospitals before and after the launch of a multimodal implementation intervention to increase the use of mechanical ventilation CDS and improve LPV adherence.

An alert tool to promote lung protective ventilation for possible acute respiratory distress syndrome.

Objective: Computer-aided decision tools may speed recognition of acute respiratory distress syndrome (ARDS) and promote consistent, timely treatment using lung-protective ventilation (LPV). This study evaluated implementation and service (process) outcomes with deployment and use of a clinical decision support (CDS) synchronous alert tool associated with existing computerized ventilator protocols and targeted patients with possible ARDS not receiving LPV.

Materials And Methods: We performed an explanatory mixed methods study from December 2019 to November 2020 to evaluate CDS alert implementation outcomes across 13 intensive care units (ICU) in an integrated healthcare system with >4000 mechanically ventilated patients annually.

Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study.

Study Objective: To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs).

Methods: Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system.

Multi-factorial barriers and facilitators to high adherence to lung-protective ventilation using a computerized protocol: a mixed methods study.

Background: Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through the administration of low tidal volumes (≤ 6.5 ml/kg predicted body weight [PBW]) with co-titration of positive end-expiratory pressure and fraction of inspired oxygen. Many patients with ARDS, however, are not managed with LPV.

Decreasing hospital length of stay for bronchiolitis by using an observation unit and home oxygen therapy.

Importance: Pediatric observation units (OUs) offer the opportunity to safely and efficiently care for common illnesses previously cared for in an inpatient setting. Home oxygen therapy (HOT) has been used to facilitate hospital discharge in patients with hypoxic bronchiolitis. It is unknown how implementation of a hospitalwide bronchiolitis treatment protocol promoting OU-HOT would affect hospital length of stay (LOS).

Sustaining compliance with pediatric asthma inpatient quality measures.

To reduce readmission risk in children hospitalized with asthma, The Joint Commission (JC) mandated hospitals to initiate preventive measures and provide patients/caregivers with a home management plan of care (HMPC) at discharge. Standard methods for recording HMPC compliance require hospitals to commit considerable resources. We developed an asthma-specific "reminder and decision support" (RADS) system to facilitate patient discharge while supporting many clinical and administrative needs, including: 1) providers' compliance with asthma preventive measures, 2) creation of patient's discharge instructions, 3) recording HMPC components for JC accreditation, and 4) creation of discharge summaries with auto-faxing mechanism to primary care providers for follow-up.

Improving transitions of care at hospital discharge--implications for pediatric hospitalists and primary care providers.

Delays, omissions, and inaccuracy of discharge information are common at hospital discharge and put patients at risk for adverse outcomes. We assembled an interdisciplinary team of stakeholders to evaluate our current discharge process between hospitalists and primary care providers (PCPs). We used a fishbone diagram to identify potential causes of suboptimal discharge communication to PCPs.

Enhancing an existing clinical information system to improve study recruitment and census gathering efficiency.

Information technology can improve healthcare efficiency. We developed and implemented a simple and inexpensive tool, the "Automated Case Finding and Alerting System" (ACAS), using data from an existing clinical information system to facilitate identification of potentially eligible patients for clinical trials and patient encounters for billing purposes. We validated the ACAS by calculating the level of agreement in patient identification with data generated from manual identification methods.