A Multisite Exploration of the Association between Critical Care Implementation Factors and Clinical Outcomes during the COVID-19 Pandemic (preprint)

Background Little is known about the strategies used by critical care leaders to implement new practices in response to the COVID-19 pandemic. Prior studies have identified implementation factors, such as structured communication mechanisms and collaborative leadership styles, that facilitate implementation of new clinical practices. However, the association between differing implementation climates and COVID-19 clinical outcomes has not been examined. The purpose of this mixed methods study was to evaluate the relationship between implementation determinants and COVID-19 mortality rates.Methods We used mixed methods guided by the Consolidated Framework for Implementation Research (CFIR) to assess implementation factors that were associated with COVID-19 mortality rates across diverse critical care settings. Semi-structured qualitative interviews were conducted with critical care leaders and analyzed using the CFIR to rate the influence of constructs on implementation of new care practices. Qualitative and quantitative comparisons of CFIR construct ratings were performed between hospital groups with low versus high mortality rates.Results 31 clinical leaders were interviewed across 17 hospitals. Of the 13 relevant CFIR constructs, three constructs (implementation climate, leadership engagement, and engaging staff) had both qualitative and statistically significant quantitative correlations with mortality outcomes. An implementation climate governed by a trial-and-error approach was correlated with high COVID-19 mortality, while leadership engagement and engaging staff were correlated with low mortality. Another three constructs (needs of patient; organizational incentives and rewards; and engaging implementation leaders) were qualitatively different across mortality outcome groups, but these differences were not statistically significant. Seven constructs did not distinguish between low versus high mortality hospitals based on qualitative or quantitative comparison of CFIR construct ratings.Conclusions Application of the CFIR to identify and quantify constructs across critical care settings enabled us to characterize implementation barriers and facilitators at the practice, interpersonal, and provider level that were associated with COVID-19 mortality rates. Improving clinical outcomes during future public health emergencies will require reducing identified barriers associated with high mortality and harnessing salient facilitators associated with low mortality. Our findings suggest that clinical care implementation efforts should focus on avoiding trial-and-error approaches to adopting new practices, while promoting collaborative and engaged leadership styles.

Facilitators and Barriers to the Implementation of New Critical Care Practices during COVID-19: A Multicenter Qualitative Study using the Consolidated Framework for Implementation Research (CFIR) (preprint)

Background The COVID-19 pandemic produced unprecedented demands and rapidly changing evidence and practices within critical care settings. The purpose of this study was to identify factors and strategies that hindered and facilitated effective implementation of new critical care practices and policies in response to the pandemic.   Methods We used a cross-sectional, qualitative study design to conduct semi-structured in-depth interviews with critical care leaders across the United States. The interviews were audio-taped and professionally transcribed verbatim. Guided by the Consolidated Framework for Implementation Research (CFIR), three qualitative researchers used rapid analysis methods to develop relevant codes and identify salient themes. Results: Among the 17 hospitals that agreed to participate in this study, 31 clinical leaders were interviewed. The CFIR-driven rapid analysis of the interview transcripts generated 12 major themes, which included six implementation facilitators (i.e., factors that promoted the implementation of new critical care practices) and six implementation barriers (i.e., factors that hindered the implementation of new critical care practices). These themes spanned the five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals, and Process) and 11 distinct CFIR constructs. Salient facilitators to implementation efforts included staff resilience, commitment, and innovation, which were supported through collaborative feedback and decision-making mechanisms between leadership and frontline staff. Major identified barriers included lack of access to reliable and transferable information, available resources, uncollaborative leadership and communication styles. Conclusions: Through applying the CFIR to organize and synthesize our qualitative data, this study revealed important insights into implementation determinants that influenced the uptake of new critical care practices during COVID-19. As the pandemic continues to burden critical care units, clinical leaders should consider emulating the effective change management strategies identified.  The cultivation of streamlined, engaging, and collaborative leadership and communication mechanisms not only supported implementation of new care practices across sites, but it also helped reduce salient implementation barriers, particularly resource and staffing shortages. Future critical care implementation studies should seek to capitalize on identified facilitators and reduce barriers.