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Delve into the realm of implementation science and its significance in bridging the gap between research-based evidence and critical care practice. Host Marilyn N. Bulloch, PharmD, BCPS, FCCM, is joined by Anne E. Sales, PhD, RN, to discuss the complexity of implementation science, which involves understanding human behavior change within organizational constraints. They explore examples such as hypertension treatment to illustrate the challenges and opportunities of implementing evidence-based practices. They discuss the importance of context, resources, and stakeholder engagement in successful implementation efforts in the critical care setting where complex interventions and rapid changes are common.
Dr. Sales is a nurse and professor at the Sinclair School of Nursing and the Department of Family and Community Medicine in the School of Medicine at the University of Missouri, and associate dean for implementation research and health delivery effectiveness in the School of Medicine. She is a research scientist at the Center for Clinical Management Research at the VA Ann Arbor Health System in Ann Arbor, Michigan, USA.
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Transcript:
Dr. Bulloch: Hello and welcome to the 2024 Congress edition of the Society of Critical Care Medicine Podcast. I’m your host, Marilyn Bulloch. Today, I’m joined by Anne E. Sales, PhD, RN, to discuss the fascinating realm of implementation science. Dr. Sales is a nurse and professor in the Sinclair School of Nursing and the Department of Family and Community Medicine in the School of Medicine at the University of Missouri. She is also the associate dean for implementation research and health delivery effectiveness in the School of Medicine. She serves as a research scientist at the Center for Clinical Management Research at the VA Ann Arbor Health System. Welcome, Dr. Sales. Before we start, do you have any disclosures to report?
Dr. Sales: I do not.
Dr. Bulloch: Well, we’re really excited to have you here on our podcast, and you’re going to be one of our thought leaders for our Congress today, and we’re very excited that you’re joining us. Just to start off, I think implementation science is something that we in critical care kind of have our feet wet in, but we’re not maybe as into it as many of us would like to be. So, to start off and just give the listener just a very broad overview about, what exactly is implementation science?
Dr. Sales: Sure. I think it’s important to start off with, what is implementation? Implementation is something that humans have been doing for probably millennia. It’s what we do when we try to incorporate something new into our work or into our behavior in general, but I think of it as focusing much more on work than, for example, health behavior. The way I define implementation, and I’m not alone in this definition, is that it’s a planned process of human behavior change, and this is the piece I think is important for health, is that it’s under organizational constraints. It’s not just an individual decision-making process, it’s a decision process and behavior process that is related to the work we do, related to the organizations that we’re part of, and those have an effect on our behavior. That’s implementation.
Implementation science is just studying that. That part’s not so complicated, but I think there’s one more piece I’d like to add, and that is there’s also implementation practice, because a lot of what we call implementation science is really actually practicing it, not doing very much study of it, and implementation practice, I would say, is very like the quality improvement activities that most people in healthcare are very familiar with, especially in acute care settings.
We’ve been practicing quality improvement for the last 30-odd years. It’s become quite routine, but it’s been separate from implementation science, so the practice of implementation, I would argue, is using tools that we’ve developed from implementation science, applying them, and using them as we improve quality of care. So I think they’re really kind of those three things you need to think about, whether it’s implementation, whether it’s implementation science, and whether it’s implementation practice, as you think about this whole domain.
Dr. Bulloch: It seems fascinating to me, and I want to talk about, maybe just go a little bit further on the significance of implementation science. It’s something that plays a crucial role in bridging the gap between research-based evidence and routine practice, which we’re all in, addressing the complexities and evidence of use. How does it bridge that gap?
Dr. Sales: That brings up a really important kind of connector piece, and that’s that implementation science, which is arguably 30 to 40 years old, although its roots go further back than that.
Dr. Bulloch: I didn’t realize it was that much history.
Dr. Sales: Well, I think it is anyway. People argue about that a little bit, but it really has its roots in evidence-based practice, and I would go further and say evidence-based medicine, which is really the earliest movement toward really saying, we need to practice based on evidence, not just based on belief, not just based on what we learned in school or the people that we look up to, but this is evidence-based.
That movement started in about the 1950s and 60s, and it’s very much associated with Archie Cochrane, who started the Cochrane Collaboration, which has really been in the forefront of synthesizing evidence, developing guidelines, trying to get people to understand what the evidence base for their practice really is. That’s spurred, of course, a whole lot of evidence generation.
How do we create new evidence? Largely through clinical trials, but also through experience, through practice, and other things. All of those kind of come together and form a strong basis for implementation practice and science. This is another place where quality improvement and implementation practice and science diverge a little bit, because quality improvement doesn’t have necessarily a strong commitment to evidence.
I would argue that most people doing quality improvement do, but it’s not embedded in quality improvement, which really comes out of industrial manufacturing processes. You can argue that the processes of process improvement in manufacturing are evidence-based, but the evidence base isn’t nearly as clear to people. It’s not discussed. It’s not in the literature in the same way that it is in healthcare.
In healthcare, without that strong commitment to the practice change that you’re putting in place being evidence based, quality improvement can sometimes be about what the team that’s involved in the quality improvement project thinks is the best thing to do, which usually probably aligns with evidence reasonably well but doesn’t necessarily completely follow the evidence. I think that’s one of the things that makes implementation science and implementation practice, again, a little bit different, but it really means that the commitment is to, what do we spend our energy doing implementation on? You know, that whole planned process, which is systematic, takes a lot of time and energy and resources. And I would say the answer is to things that have a clear evidence base.
Dr. Bulloch: You touched on the manufacturing industry just a minute ago. Give us a great example in your memory, in your career, where this implementation scientist has changed practice that we may not even be aware of, you know, that’s the way it’s been for me my whole career. Is there something that stands out to you like that?
Dr. Sales: That’s an interesting question. I would say that implementation science to date has been kind of following the trends rather than leading the trends, and I think there are good reasons for that. That’s a little bit of what I plan to talk about today in the thought leader talk. I think that, without the data to know what current practice really is, it’s been really hard for implementation scientists to know what they should be focusing on. So what we’ve been doing is often using data from as much as 5, 10, 15 years ago to sort of plot a course and say, okay, here’s an area that needs work.
Let’s take, for example, hypertension. Actually, rates of uncontrolled hypertension have been falling in the United States. Some of that has some implementation science component to it, but more of it has to do with what I would call the diffusion of innovation. The new drugs, the better understanding of treatment issues, better understanding of what makes it hard for patients to adhere to treatment, better understanding of causal patterns and reasons for why people have hypertension, and addressing those reasons more effectively.
But in the implementation science world, we’ve been trying to figure out how to get effective medications into practice. One example is the ALLHAT trial, which is one that a lot of people have mixed feelings about, because on the one hand, the ALLHAT trial was about hydrochlorothiazide, which is a drug that’s been around for a very long time, purely generic. There are probably proprietary mixtures of it that people market, but not even that. I think that’s an interesting example where the ALLHAT trial showed, this was evidence generation, showed that hydrochlorothiazide is very effective as a primary first-line drug treating hypertension.
But it isn’t for everybody. And, given the range of new medications we have for treating hypertension, I think that the efforts to get people to use hydrochlorothiazide, again, have really not done as well as they might have in a different world, where perhaps cost was much more of an issue than it is for most people in the U.S. And even where cost is an issue, we’ve developed so many workarounds for dealing with costs through insurance, prior authorization, and the drug companies themselves offering drugs to people who can’t afford to pay for them.
So that’s a case where we’ve seen innovation diffuse rapidly through the new drugs being taken on. The evidence about hydrochlorothiazide, it’s not necessarily as salient to people or as compelling to people. And there are some side effects with hydrochlorothiazide that are not so evident with some of the newer drugs.
Dr. Bulloch: That’s very true.
Dr. Sales: That’s a big issue that wasn’t part of the ALLHAT trial, really. They were looking for efficacy and effectiveness. Dealing with the fact that then you have people who have to deal with all the problems of diuresis and the things that that causes, the difficulties in their lives, as well as the other side effects. People still prefer to use newer drugs. But that’s an example where I would say implementation science has had an effect, not the effect necessarily that we want, but it has certainly opened up the conversation about how we’re treating hypertension.
Coupled with a lot of other trends that are in society, we’re actively working as implementation scientists to understand not necessarily how to get people to use hydrochlorothiazide, but how to get them to use the most effective and most efficient combination of therapies, ideally the lowest cost, that will allow people to manage their hypertension.
Dr. Bulloch: I’m a critical care pharmacist. In the acute care realm, we’re always talking about drugs and costs and not just drugs, but procedures. That’s been a big theme. We are here at a critical care congress, and critical care really stands out as an ideal field for implementing implementation science. It’s complex. We’ve got a lot of complex interventions. Not only do they come in medically complex, but then they have a lot of acute complexity going on. Nothing stays the same from day to day. It provides what I think are opportunities to enhance evidence-based practices. Would you agree?
Dr. Sales: Absolutely. But what I would say is you used the word “complex” several times.
Dr. Bulloch: Right.
Dr. Sales: And that’s really true. When you have both complex interventions, like for example, the ventilator liberation bundles, ABCDEF, or the prevention of ventilator-associated events, those are all complex interventions in a very complex environment where you have a lot going on all the time. And I think that there is huge opportunity to learn a lot, but there’s also a lot of opportunity for things not to succeed because overcoming those complexities, this is one of the things about implementation science, at least as we’ve done it to date, is that we are working in the real world. So we don’t have controlled environments to work in. I think we need to try to develop that a bit more, probably through various kinds of simulation.
And we need to try things out in that kind of simulated, controlled setting before we try to launch it in the real world, as people do with drugs and other kinds of approaches and interventions. But we’re still a ways from being able to do that effectively. When we work in the real world, there’s always the probability that things are going to fall apart, not because we’re not doing the right thing but because the circumstances change.
One of those circumstances is always a really critical issue around leadership. As you know, leadership turns over and changes rapidly and, in critical care, you can argue that leadership changes potentially from moment to moment, because of who’s on the unit, who’s doing what, who has responsibility for which patients, under what circumstances, to do what things, is rapidly changing and shifting constantly. And leadership shifts with those.
Just to take an example that’s not a simple one, lung-protective ventilation and, for example, spontaneous breathing trials. The group that probably controls that the most is respiratory therapy. But there are other people involved in it. Nursing has to be involved, physicians have to be involved. And the question of how do you coordinate the activities of all these people who have their own work to do and are dealing with different people and different things going on simultaneously becomes a very complex thing to organize. So, great area for study, but really tough area for necessarily getting the change that you expect and want to make.
Dr. Bulloch: One of the things that you have highlighted is through the feasibility of changing practices in critical care so that we can incorporate this new evidence. That’s really important. We get very excited in critical care when what we think is practice-changing information comes out, and we all race back to our institutions to go implement it, only to find out later, it doesn’t work in our specific patient population. That’s a challenge, right? One that we have dealt with, I think, repeatedly, at least in my career. What are some ways that we can maybe emphasize the potential for acceleration and taking care of these things but still be very cautious and making sure that we’re not harming the patient too?
Dr. Sales: I think a real key is to understand the context you’re in, and to know what your resources are. As you say, this is rapidly changing. Taking Veterans Health Administration as an example, this is the largest integrated health system in the country. We have hospitals that range from very small, what would be, outside of the VA, would probably be critical access hospitals, to large tertiary academic, academically affiliated medical centers. So the context there is really different.
If you have a small hospital with, let’s say, 20 beds, and three of them are designated as critical care beds, but what that really means is they’re in one room or one end of a long corridor or ward. And patients who aren’t as stable get put there with whatever supports are available, possibly all the way through to mechanical ventilation, but possibly not, because do you have staff who can adequately and safely treat people who are being mechanically ventilated? Do you have people who can use high-acuity, IV-administered medications like pressors? Do you have people who can do high-volume fluids rather than just a regular IV line?
Those are really important questions. And in a high-end academic medical center, in general, the answer to all those things is yes, absolutely. But in the moment, you may not have enough of those things. So that seventh or eighth mechanically ventilated patient who hits the unit who needs a certain kind of nursing care, if you’re short-staffed that day, you may or may not be able to provide the optimal treatment based on, as you say, the new evidence and the new information.
I think the other question is, even in the context of critical care where acuity is high, rapid response is necessary, is it still possible to pause long enough to really consider, okay, what are our resources? What can we actually do in this situation? As opposed to just saying, we have this protocol and our protocol says we do this, this, and this, whether or not we have the resources to actually deliver it safely.
Dr. Bulloch: You bring up such a good point. You and I both work in clinical settings and academic settings. Those are not necessarily, well, at least mine is not, the largest centers. I tell people I practice at a large community teaching hospital. We do what I think is phenomenal clinical services, but we’re still limited because we are community, we are not this massive center. So sometimes when we come to conferences like Critical Care Congress and we learn about some of these big ideas, these big things, these new machines, I look at people and I’m like, we’re not going to have that for a while. We’re just not.
They’re telling us, oh, you should be doing this and you should be doing that. And we just don’t have the resources. Even if we had the financial ability, the other resources are not always there. What are some practical tools that can be routinely applied maybe to expedite the adoption of really what we know are good evidence-based practices in healthcare, maybe even globally, but also particularly for some of those settings, which I think incorporates most of the country, if we’re being honest, that just don’t have the luxury of unlimited resources?
Dr. Sales: I think you’re bringing up some really, really good, but difficult questions.
Dr. Bulloch: That’s why I’m here.
Dr. Sales: Let’s just take ECMO as an example. Should everywhere be doing ECMO? If, you know, blue-sky world, everybody could afford it and have the technology, actually have the machines available? I would argue no, because there’s far more than the machine. You need the human resources and you need to have the backup that makes it possible to use something as intensive as taking people’s blood out of their bodies and oxygenating it outside the body. That’s a big deal. If you have nursing staff, for example, who don’t know how to treat the kinds of routine things that happen when people are experiencing that kind of therapy, then you’re probably going to run into problems.
I think a lot of people would say, well, this is what tele-ICU is all about, possibly, that, okay, you can have the machine. The expertise is somewhere else, probably in the large academic medical center, sitting in a box, watching what’s going on, prompting, coaching, and sometimes clearly directing the people who are on the ground actually delivering care. I think it’s an ideal that may make sense someday in the future. I don’t think we’re there, because it isn’t that easy to keep this all going all the time.
This is really, especially if you think about something like ECMO, where you can’t just walk away and say, oh, I’ll be back and check on this person in a couple hours when I’ve done the other things I have to do during the day. It requires a level of integration of systems that I would argue probably should be thought of as regional in nature.
This is what we decided, when I say we, the policymakers in the VA decided many years ago, when they looked at what’s out there in terms of real critical care services in the VA, where, like I said, you’ve got community hospitals, you’ve got essentially critical access hospitals. The policy that they wrote was, get people stabilized and move them as fast as you can. The goal is, when somebody really needs critical care, especially high-level tertiary critical care, you move them to the place where they can get that.
That raises another whole set of issues, of course, because then family members aren’t close, people are outside their communities, and you lose knowledge and history. All kinds of things happen in transit, and the person often arrives without adequate information about what’s really going on with them. And it raises a lot of issues about what I think is a crux issue that we’re going to be dealing with more and more in critical care and across the entire spectrum, continuum of care, and that is, what do we do when what we really need is palliation and not definitive treatment, not curative therapy? We’re very far from having good answers to this.
Although a piece of work that I’ve been doing for several years now with colleagues in the VA I think is very related to this, and that’s about goals-of-care conversations, which are common in critical care but not probably common enough and are often really hard when, for example, the family and loved ones are not physically able to be in the same place as the person who’s receiving care.
Dr. Bulloch: And sometimes it’s sudden.
Dr. Sales: That’s right. Things emerge really quickly, and you suddenly realize that what you had hoped you could achieve is not achievable, and the decisions have to be made quickly at that point. Those are all things that I think argue for, as we think about this sort of engine of growth and innovation, and do more and more and more because more and more and more is possible technologically and feasibly, we also need to think about, how do we then de-escalate, or how do we not even escalate in the first place when we can recognize that the situation doesn’t call for escalation, it really calls for thinking through, what else can we offer this person and meet their needs?
Dr. Bulloch: You have expressed an enthusiasm, which I appreciate, for engaging with critical care professionals, emphasizing the motivation within the field to provide exceptional care and the value of dialogue in advancing implementation science. How can we do that? How can we make that happen?
Dr. Sales: I’ll just say that someone whose work I’ve respected for a long time, Dr. Mary Dixon-Woods, who’s at Cambridge University in the UK, gave a keynote talk at the Dissemination and Implementation Conference in DC in December, and it was the best talk I’ve heard about the whole notion of codesign, stakeholder engagement, what do these things mean? Because we’ve accepted in implementation practice and science for many years now that we have to be in dialogue with people, that for me to sit behind my desk staring at my computer and come up with, this is the solution, is a really bad idea for all kinds of reasons.
I think that what we’ve done to date is to sort of have these mandated, figure out how to first identify stakeholders, then figure out how to get them engaged, try to extract information from them, and that’s actually often what we’re doing, is extracting stuff from them rather than necessarily engaging in bidirectional dialogue. In critical care, that is hard because, unless people are willing to take time outside of their work time, when they’re at work, they’re really busy most of the time.
Not always. I mean, you can catch people at moments when they’ve got a little bit of a break, but often when they have a break, there are other things they would like to do, like eat or go to the bathroom or something like that. Yet we come in, especially as researchers, with this imposition of, now we need your time, because if we don’t take your time, then we’re not dialoguing with you, we’re not figuring out how to make this work. Her suggestion is to make things really a lot more asynchronous, and not expect people to do it, certainly not in the moment, but even like right after their shift, or some other time.
I’ll just say parenthetically, organizationally, to offer to backfill and have extra people come on so that people can take time during their shift, doesn’t work. I’ve tried it and it just is too complex. The organizations can’t make it happen, and we can’t make it happen for them because you can’t just substitute anyone in. They have to have the right skills and they have to have the right expertise and there’s a whole bunch of other things that make that hard.
Her idea, which I think is a really good one, is use video, use asynchronous platforms, try to make it engaging, easy, and simple for people to, for example, watch a video that says, this is a different way that you might do things. Tell me what you think. Tell me how this would fit with the current workflow you have. Tell me where it won’t fit. And ask people, prompting people to, don’t think we’d even need for them to enter through a keyboard. People can just talk at the computer now and, with voice recognition, we can get a lot of good data that way.
But the point is to really think about how to make this easy for people to be able to share their expertise, because people want to do that. People are not sitting there going, I don’t want to talk to you. It’s more that, I don’t have time to talk to you, and we keep asking them to do that. So I think we need to figure out how to make this a lot simpler.
Dr. Bulloch: I think there’s a lot of good science that has come out over the years after the fact. Like, oh, well, what are you doing for this? You know, we’re doing this over here. You hear it in the hallway here all the time. It’s almost as important, I think, to have those conversations with your colleagues and know what people are doing around the country as it is to read some of the articles themselves in a lot of ways.
Dr. Sales: I think you’re pointing out a really important thing, and this is something we’re not using well. Time of the conference. For example, if somebody is interested in implementation of the ventilator bundle, then perhaps you could organize a session where there’s no speaker, but there’s a facilitated opportunity to essentially do a focus group where people share their experiences, their best practices, the things that have and haven’t worked for them. That would be, I would say, probably as beneficial as making them take time off or after work in their work setting.
Dr. Bulloch: You bring up a good point. We have, for those of our listeners who may not realize it, the Critical Care Congress every year, we have what we call roundtables, and it’s exactly what you’re talking about. There are different topics. Some of them are more clinical based, some of them are more professional development based, but it’s exactly what you’re talking about. They’re just facilitated conversations, and they’re usually packed, very well attended. People want to have those conversations, and they want to have that dialogue and hear what’s going on.
I think that that brings the point that I’m sure other organizations are probably doing that as well but, if they’re not, I mean, it speaks to how much people want that, how much we as healthcare clinicians need that social aspect of our professional development.
Dr. Sales: Right. That is really a key piece of this. We do have this implementation strategy that uses this kind of thinking, learning collaboratives, which were actually in many ways pioneered by CMS a couple of decades ago and used widely across the country for a number of initiatives.
The problem was that they were really expensive because what you did was you brought a team of three to five people from multiple organizations together for usually a three-day meeting where they would share data and then talk about their practices, share best practices, and then go back to their institutions and implement them. They work well when they’re done well, but they’re really expensive. I think we need to just be smarter about that and think about, where are the opportunities where people are gathered anyway, you know, when they come to Congress, when they come to another professional meeting, or something like that.
Or again, can we figure out ways to do this collaboratively online that don’t just drain people? I think we’re all Zoomed out, so we have to be more thoughtful and innovative about it than just saying, okay, we’re going to have a Zoom call about this.
Dr. Bulloch: It’s almost like you’re going back old school and leveraging the old chat rooms or the forums or something along those lines where you can pop in when it’s convenient to you and then make your contributions and also get what you might need and all of that kind of thing.
Dr. Sales: Yeah, but I think a key is facilitation because those chat rooms were usually unmoderated and it kind of was...
Dr. Bulloch: Oh, it could be the wild, wild west.
Dr. Sales: Right, right. They can deteriorate quickly if people start using intemperate language or just not being thoughtful about other people and how they may react to you saying something.
Dr. Bulloch: Well, this has been fascinating. I have learned a lot and am very interested in how your session is going to go today. For our listeners who may not be here with us at the Critical Care Congress, Dr. Sales’ talk, for those of you who have digital access to Congress, will be recorded and available. I highly encourage all of you to watch it later. Even if you were at the session today, I encourage you to watch it again later. Before we leave, Dr. Sales, is there anything you would like to leave us with about this topic?
Dr. Sales: I would just say I think implementation science as a discipline is hard to break into and it does take a lot of training and frankly a lot of reading because we do have a pretty extensive literature in the field now, which I think is daunting for people. I would also say that, at the moment, there aren’t a lot of critical care clinicians who are actively engaged in implementation research. There are some, absolutely. I think there’s been interest in this area on the part of critical care researchers for many years. Unfortunately, COVID set that back a lot because people just didn’t have the time to engage in anything other than providing care or doing research on the clinical issues that we were facing.
But at the same time, I think COVID has also given a lot of innovation to the field. I think it may be time to try to sort of harvest that and figure out how to move it forward. I think, to do that, we need more people who are critical care clinicians who are actively interested, willing to do some work to train, and then to do the trial-and-error work of actually trying to do this work in practice and in the real-world setting. I think there’s a huge opportunity there.
Dr. Bulloch: And I think our specialty is always one that’s looking for those types of opportunities. Well, Dr. Sales, I really want to thank you for joining us today. This has been an excellent podcast. This concludes another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Marilyn Bulloch.
Announcer: Marilyn N. Bulloch, PharmD, BCPS, FCCM, is an associate clinical professor and director of strategic operations at Auburn University Harrison School of Pharmacy. She is also an adjunct associate professor in the Department of Family, Internal, and Rural Medicine at the University of Alabama in Tuscaloosa, Alabama, USA, and the University of Alabama Birmingham School of Medicine.
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