High adherence to evidence-based clinical practice (EBP) is associated with improved patient outcomes and lower costs.1 Despite this, adherence to EBP in care delivery remains inconsistent.2 Individual and system-level challenges in implementation of EBP contribute to the persistent research-to-practice gap in health care delivery.
Intermountain Healthcare (Intermountain) has long sought to achieve consistent and sustained adherence to EBPs as a tenet of the organization's quality structure. To assist in efficient dissemination of these practices throughout our system of 24 hospitals, more than 200 clinics, and more than 6500 employed/affiliated physicians caring for more than a million patients annually, Intermountain has historically engaged multidisciplinary clinical and operational experts in the development of Care Process Models (CPMs). Care Process Models characterize existing evidence and local management strategies to deploy best evidence while providing a foundational model for the evaluation, diagnosis, and management of a specific disease or condition, often in a particular care setting. Although CPM work has made important contributions to Intermountain's understanding of evidence-based care, implementation of CPMs with high reliability has been a challenge across the clinical delivery system.3
To improve adherence to EBP, Intermountain's Healthcare Delivery Institute recently began pairing a team of applied implementation science researchers, health system engineers, and biomedical informaticians with clinical teams to better understand and address barriers to reliable implementation of EBP. Once a high-potential EBP is identified, Intermountain commences a 5-phase CPM deployment process using a Best Practice Implementation Model developed by Intermountain to adapt the CPM and ready it for spread within the system.3 As a learning health system, Intermountain benefits from this stable, transdisciplinary model that provides deep clinical implementation expertise and longitudinal organization memory.
THE ROLE OF CLINICIAL SETTING IN IMPLEMENTATION
Although a set of core implementation strategies are common to most successful implementations, one of the most compelling early findings we are seeing from this multiyear effort is the potentially generalizable role that the clinical setting (primary care clinic, urgent care, etc) plays in adapting standard implementation plans to increase the likelihood of improved performance. Patient characteristics and care delivery resources vary substantially by clinical setting and influence the goals of care, provider characteristics, treatment decisions, course of care, and design of underlying workflows needed to deliver quality care—all important factors in understanding barriers to adherence. Given this, better understanding of more distinct characteristics of clinical settings could aid in predicting which implementation strategies will be more likely to succeed in a given clinical setting.
Similar to recent work identifying distinctive contextual features of urgent care,4 we are also seeing important distinctions when implementing EBP and enabling computerized decision support protocols in our intensive care units (ICUs). The setting-specific contextual features identified have influenced the implementation strategies we are deploying and the relative resource intensity required to successfully promote EBP with high adherence in this clinical setting.
THE CRITICAL CARE CLINICAL SETTING
Intensive care units represent the highest level of acute care and are designed to meet the needs of patients with severe or life-threatening conditions, often associated with complex comorbidities and end-of-life care.
The ICU is a highly specialized unit. The care team delivers an often complex, well-organized, and technically sophisticated level of care in a highly structured environment. Care delivery within the ICU involves a multidisciplinary team led by the intensivist with support from numerous technical experts.
Unlike the rotating clinical staff in other units, clinicians often work solely in the ICU. This adds consistency and enhances the ICU's level of ownership over work processes.
Patients are admitted to an ICU from other facilities, units, or departments, introducing non-ICU stakeholders in EBP and involving ICU clinicians in EBP initiated prior to ICU admission.
ICU providers are called upon to consult in crisis, responding to patient deterioration and arrests outside of the ICU. This experience as expert consultant can prove challenging when implementing EBP developed outside the ICU.
Provider-patient ratios are low to ensure close patient supervision in a “low patient volume” care environment.
Clinical decisions in the ICU are often highly complex. Developing standardized protocols and checklists can be a challenge for patients with complex comorbid conditions.
Patient care decisions are more frequently made by proxy. Many ICU patients are often unable to clearly communicate their wants and needs to clinical caregivers due to the severity of their illness. This enhances the role of the patient's family or representative as an advocate. Joint decision making often requires particularly skilled communication and substantial investment by clinicians.
Patient care plans are individualized and unstable. Given the often-complex and rapidly evolving clinical circumstances, care is highly changeable and tailored to a specific patient's needs.
Continuous monitoring results in frequent alerts, which can create alarm fatigue and lessen the effectiveness of some technology-based EBP solutions. An ICU care team may evaluate more than 2000 data points daily for critically ill patients and will receive dozens of passive and active alerts for each patient.5
Utilization of telemedicine in critical care is increasing. More than 10% of critically ill adult patients are supported by telemedicine,6 presenting new challenges when coordinating the implementation of an EBP across diverse, connected settings.
IMPLEMENTING IN CRITICAL CARE SETTINGS
The critical care infrastructure has evolved over the past 70 years into a highly technological environment with a multidisciplinary team of providers working to better address high-acuity patient care. Understanding clinical setting features can guide the identification of barriers to EBP in this setting and inform both the selection and intensity of strategies deployed. Although there is no “silver bullet” implementation strategy guaranteed to succeed, the likelihood of sustainable, cost-effective implementation in a clinical setting may increase when strategies are informed by an understanding of the clinical team's shared mental model in that setting as well as the existing operational and cultural structures. In the ICU, strategies that are adaptable for complex, highly structured, yet rapidly evolving low patient volume clinical care and capitalize on opportunities for interdisciplinary collaboration are more likely to succeed.
Practice changes that disrupt complex clinical decisions require particularly compelling clinical evidence to alter established practice. Evidence-based clinical practices must be fully and publicly embraced by the organization's clinical and operational leadership to be accepted by frontline providers. Time should be taken to ensure that frontline providers clearly understand the proposed change and the specific evidence to support the change. Creating frontline multidisciplinary “champions” associated with each team role can disrupt the perception of a top-down change message and create peer-to-peer accountability for improvement.
Given the team-based care in the ICU, strategies to improve adherence to EBP should actively engage all ICU staff. Clear, concise, and relevant communication should be tailored to each role on the care team, as well as the interactions between roles, and capitalize on existing structures for interdisciplinary collaboration (ie, rounds and huddles). Even roles that appear auxiliary to the implementation effort should be engaged and well-informed.
Given the highly structured nature of workflows and the interaction between various care team roles, existing workflows should be documented first to gain consensus on baseline practice. This background can guide the introduction of change into the workflow in the least obtrusive way possible to increase the likelihood of acceptance. A multidisciplinary team should participate in workflow redesign. Checklists, protocols, and algorithms can make it easier for providers dealing with a complicated procedure to do the right thing at the right time. For maximum effect, aids should be transparent in reasoning and integrated into the newly designed workflow.
Providing benchmarking data and developing a robust mechanism for individualized performance feedback can assist in obtaining buy-in. Performance measures should acknowledge patient complexity and account for appropriate exceptions to the EBP. Given the low volume, and high complexity nature of each patient, the case level of analysis is particularly feasible in this environment. Case reviews can be performed regularly by the ICU team to examine nonadherent situations to ensure that the EBP is being appropriately applied. This information can guide field-level efforts to sustain the change over time.
Care must be taken to ensure that EBPs and CPMs are flexible enough to allow critical thinking in the complex environment in which multiple caregivers must perform with high fidelity. Intermountain Healthcare continues to work to understand the characteristics of each clinical setting in our effort toward sustained adherence to evidence-based practice and high-quality care.
1. James BC, Savitz LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Aff (Project Hope). 2011;30(6):1185–1191.
2. Institute of Medicine Committee on Quality of Health Care in A. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.
3. Knighton AJ, McLaughlin M, Blackburn R, et al. Increasing adherence to evidence-based clinical practice. Qual Manag Health Care. 2019;28(1):65–67.
4. Brunisholz KD, Stenehjem E, Hersh AL, et al. Antibiotic prescribing in urgent care: implementing evidence-based medicine in a rapidly emerging health care delivery setting. Qual Manag Health Care. 2020;29(1):46–47.
5. Kizzier-Carnahan V, Artis KA, Mohan V, Gold JA. Frequency of passive EHR alerts in the ICU: another form of alert fatigue? J Patient Saf. 2019;15(3):246–250.
6. Lilly CM, Zubrow MT, Kempner KM, et al.; Society of Critical Care Medicine Tele-ICU Committee. Critical care telemedicine: evolution and state of the art. Crit Care Med. 2014;42(11):2429–2436.