Implementation Science
Lynn Martin MD
The March 9, 2024 PAAD: A game changing way to better secure an IV catheter? evoked an enormous amount of reader response and I’m hoping changed your practice. When we posted it, I asked one of that PAAD’s authors and a member of our executive council, Dr. Lynn Martin, if he could take a deeper dive into the subject of implementation science. In case you missed that PAAD, I’m reposting the articles. Myron Yaster MD
Original article
Charters B, Foster K, Lawton B, Lee L, Byrnes J, Mihala G, Cassidy C, Schults J, Kleidon TM, McCaffery R, Van K, Funk V, Ullman A. Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial. JAMA Pediatr. 2024 Apr 1:e240167. doi: 10.1001/jamapediatrics.2024.0167. Epub ahead of print. PMID: 38558161; PMCID: PMC10985620.
Editorial
Bettencourt A, Ruppel H, Bonafide CP. Advancing Evidence-Based Peripheral Intravenous Catheter Securement. JAMA Pediatr. 2024 Apr 1. doi: 10.1001/jamapediatrics.2024.0177. Epub ahead of print. PMID: 38557797.
Previously the PAAD reviewed Charters et al.1 publication regarding the best method to secure a peripheral intravenous catheter. There also was an accompanying editorial discussing the use of evidenced-based implementation science methods to successfully change well established clinical practices.2 What is Implementation Science? It is commonly asserted that there is a 17-year gap between the initial publication of scientific evidence and its widespread use in healthcare.3 This gap likely increases morbidity and mortality rates, wastes precious healthcare resources, and added unnecessary expenses. The field of implementation science emerged in the 1990s as the solution to this ‘evidence to practice’ gap.4 The definition of implementation science is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care. A recent addition to this definition is the inclusion of the concept of de-implementation or the discontinuation of practice known to not be effective.
Detailed reviews of implementation science are available, including in the perioperative setting have been published.5,6 Rapport et al describe the foundational concepts to implementation science in five categories: diffusion (spontaneous spread of ideas, behaviors and practices), dissemination (active spreading of evidence-based interventions to targeted audiences), implementation (using research evidence applied to practice through implementation procedures), adoption (the degree of uptake of new ideas, behaviors, practices , and organizational structures), and sustainability (the logical endpoint which creates a feedback loop that demands monitoring, adaption, and extended uptake to that changes become entrenched into the culture-‘the way we do things here’).5 Lane-Fall and colleagues cite two specific examples where they suggest application of implementation science methods could like yield better clinical outcomes.6 The first is the implementation of enhance recovery after surgery (ERASâ) pathways in which multimodal perioperative care programs are designed to reduce recovery time, hospital length of stay, and surgical complications. Unfortunately, meta-analyses of ERASâ programs across surgical subspecialties have shown the desired reductions in length of stay and complications, but also report pathway compliance rates as low as 65%. Given that pathway adherence is associated with improved outcomes, it is to understand factors linked to ERASâ pathway adherence. The second example of evidence-based practice is the Surgical Safety Checklist (SSC). The SSC is modeled after safety checklists used in high-reliability organizations includes multiple elements checked in one of three times during surgery: before induction of anesthesia, before skin incision, and at the end of surgery. High compliance with SSC is associated with improved risk-adjusted clinical outcomes. In spite of this compelling evidence, several studies show variable compliance with all elements of the SSC. Methods of implementation science could (should) be used to increase adherence with all SSC elements; hopefully dropping the surgical complication rates.
It is also critically important to distinguish between implementation science and the more commonly practice Improvement Science. Fortunately, there is an excellent review to help us differentiate between thee two.7 I strongly encourage readers to take the time to read this review in full. Implementation science is frequently defined as the scientific study of ways to promote the systematic uptake of research findings and other evidence-based practices into routine clinical practice to improve the quality and effectiveness of health care services and care. The spread of implementation science has been facilitated by developments in information technology, especially electronic databases and the Internet, which allow providers to identify, collate disseminate, and access research on a global scale. Although the term ‘science of improvement’ was first used in 1996, most of the approaches to today’s improvement practices date back to the 20th century with foundations in industry. Pioneers like Walter Shewhart, Willian Edwards Deming, and Joseph Juran developed many of the key improvement tools, such as control charts to manage process variation, Plan-Do-Study-Act (PDSA) improvement cycles, and the Juran Triology (planning, control, and improvement). Interest in QI methods increased dramatically in the 1980s and was accelerated with the publication by Institutes of Medicine of the landmark articles To Err is Human in 1999 and Crossing the Quality Chasm in 2001. The latter article was the catalyst that transformed my career focus from clinical (translational) research to quality improvement. This personal journey was also significantly influenced by my intolerance for delays in improving clinical practice commonly seen in translational research. The two fields have different origins but have a shared goal of using scientific methods to understand and explain how healthcare services can be improved by the end users. The authors recommend increased collaboration between implementation and improvement scholars to further address contextual influences on implementation and improvement efforts and share and use theory to support strategy development, delivery, and evaluation.
Finally, in the editorial by Bettencourt et al,2 to move the new PIV securement methods into routine clinical practice, they recommend a new (type 3) hybrid approach combining effectiveness and implementation into the study design to be more informative and increase generalizability.8 A type 1 hybrid focuses primarily on effectiveness outcomes of the intervention while exploring the ‘implementability’ of the intervention. A type 2 hybrid has a dual focus on effectiveness and implementation outcomes, allowing the testing of implementation strategies during the effectiveness trial. A type 3 hybrid focuses primarily on implementation outcomes while also collecting effectiveness outcomes. This latter approach would provide guidance on the most effective and highest yield strategies for implementing new PIV catheter secure procedures. In addition, they still would collect additional data on the effectiveness of the intervention on clinical outcomes. The type 3 trial would further demonstrate generalizability of the securement methods and refine the implementation strategies for areas outside of the original clinical study. These hybrid approach could potentially reduce the gap from evidence to routine clinical practice and accelerate the spread of this new practice world-wide.
In summary, clinical and improvement scholars could learn much from implementation scientists and their methods. This collaboration would likely enhance the probability of successful implementation of new and improved behaviors and processes into routine clinical practice thereby improving our shared goal: improving clinical outcomes. Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Charters B, Foster K, Lawton B, et al. Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial. JAMA pediatrics 2024 (In eng). DOI: 10.1001/jamapediatrics.2024.0167.
2. Bettencourt A, Ruppel H, Bonafide CP. Advancing Evidence-Based Peripheral Intravenous Catheter Securement. JAMA pediatrics 2024 (In eng). DOI: 10.1001/jamapediatrics.2024.0177.
3. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med 2011;104(12):510-20. (In eng). DOI: 10.1258/jrsm.2011.110180.
4. Dearing JW, Kee KF. Historical Roots of Dissemination and Implementation Science. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and Implementation Research in Health: Translating Science to Practice, 3d edition. 3d ed: Oxford University Press; 2023.
5. Rapport F, Clay-Williams R, Churruca K, Shih P, Hogden A, Braithwaite J. The struggle of translating science into action: Foundational concepts of implementation science. Journal of evaluation in clinical practice 2018;24(1):117-126. (In eng). DOI: 10.1111/jep.12741.
6. Lane-Fall MB, Cobb BT, Cené CW, Beidas RS. Implementation Science in Perioperative Care. Anesthesiology clinics 2018;36(1):1-15. (In eng). DOI: 10.1016/j.anclin.2017.10.004.
7. Nilsen P, Thor J, Bender M, Leeman J, Andersson-Gäre B, Sevdalis N. Bridging the Silos: A Comparative Analysis of Implementation Science and Improvement Science. Front Health Serv 2021;1:817750. (In eng). DOI: 10.3389/frhs.2021.817750.
8. Landes SJ, McBain SA, Curran GM. An introduction to effectiveness-implementation hybrid designs. Psychiatry Res 2019;280:112513. (In eng). DOI: 10.1016/j.psychres.2019.112513.