Effective Strategies to Change Practice

It is important to distinguish studies that demonstrate benefit of a particular approach to mechanical ventilation from studies that are primarily interested in implementing this approach. Two studies by Ely clarify this distinction. In the first, a randomized controlled trial, the value of a daily weaning screen followed by a protocolized spontaneous breathing trial and a physician prompt was shown to reduce duration of mechanical ventilation by 1.5 days [59]. In the second study, the investigators studied the effect of "graded, staged educational interventions" directed at respiratory therapists to implement the protocol found to be effective in the clinical trial [57]. Implementation research is not designed to identify effective treatment strategies. The research question is not whether a specific ventilator technique improves outcome this is presumed to be known. The question is whether this technique can be deployed in a larger community. The effect of the intervention onpatient outcome is important,but is asecondaryresearch question.

There have been no large scale, multicenter, community based programs to improve the quality of care to mechanically ventilated patients. A computerized decision support tool to direct mechanical ventilation in patients with ARDS was implemented in a randomized clinical trial at 10 academic sites, however, this study was directed as much at evaluating the efficacy of the ventilator strategy as the feasibility of using a computer to effect practice change [60]. Other models have been explored for changing ventilator practice. Pronovost and colleagues used a 'quality improvement' model to reduce failed extubations in a single ICU study [6l]. Structural approaches including a nurse-practitioner run ICU for chronically critically ill patients and a ventilator team consult model have been explored to improve ventilator outcomes [62-64]. The evidence from other fields suggests that effective implementation studies ofventilator practices will require a multi-faceted approach that incorporates: local 'buy-in' of the treatment, local opinion leaders, staff education, audit and feedback, and timely prompts.

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