false
Catalog
SCCM Resource Library
Barriers and Solutions in Clinical Implementation
Barriers and Solutions in Clinical Implementation
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
All right. Thanks again for staying on the last day of Congress and staying through the last portion of this session. I know I've learned a lot, and hopefully we can bring some of these things back to our institutions. All right. So my task today was to talk about barriers and solutions in clinical implementation. I'm going to focus on the word clinical here, because I'm speaking to you as a clinician that doesn't necessarily have a background in implementation science. I oftentimes see all those frameworks, and I'm a little bit intimidated myself. And so my task was to kind of talk about these things from that perspective, and to kind of just have some examples for you all in some of those clinical implementation pieces. There's a little bit about me. Note, I have nothing to disclose for this presentation. I've kind of already disclosed, though, that I am not necessarily an implementation scientist, but I am that clinician at bedside that is oftentimes involved with the multidisciplinary team and coming up with these, or talking about these barriers and solutions. And again, I was asked to share some of my kind of experience in that world, and I will say I'm a little bit biased towards the medication management piece of patients in the ICU. So that's kind of what we'll be talking about today. And so for today, my title being barriers and solutions, we're simply going to go through some common barriers and solutions. And within the realm of barriers, we'll introduce some kind of areas of interest that you might see, as well as some examples kind of in that realm. And then when it comes to kind of talking about solutions, we'll talk a little bit about some of the gaps that we oftentimes see within our solutions that maybe can help inform the vision for the future of actual clinical implementation. So when it comes to barriers, talking about the different barriers that we see within the ICU, our first speaker kind of talked about every single area of ICU kind of care that we struggle to implement. Kind of when it comes to searching, doing a cursory search of ICU literature that talks about barriers, kind of similarly, you find something that's pretty far-reaching, right? We see barriers in all areas of different disciplines. You know, we see early mobilization here, things about facilitating ICU discharge. So I think it affects all the disciplines that kind of work together within the ICU. The other thing that you kind of see within common ICU literature related to barriers is that sometimes we can be focusing on a disease state or one kind of marker, such as glucose control or the medication review process. And then, you know, also it can be something that can generate research and obviously something that you all probably are interested in. I mean, our previous speaker talked about early warning signs and how those kind of things are related. So again, this is something that impacts everyone within the ICU and can, whether or not you're primarily maybe even a clinician or researcher or educator, it can impact you kind of that way as well. So I kind of mentioned that I was going to talk about some of my challenges or some example of the things that kind of I've done as a clinician and the barriers that we've faced in clinical implementation. So my institution has a lab available to do beta-lactam therapeutic drug monitoring, but we wanted to expand these services within the ICU. As you guys might well know, our surviving CESSUS guidelines update talked about utilizing extended infusions of our beta-lactams or continuous infusions when available and when available utilizing therapeutic drug monitoring. And since we have this available, we wanted to kind of implement this within our ICU clinical services. The different barriers that we identified at the time of kind of piloting this project out to others was being able to identify the patient population that would most benefit from this intervention. Most of the time that would be somebody maybe that was within the ICU, but also with sepsis or septic shock, different things like that. We also at the same time wanted to be able to risk stratify because as you all might well know, when you identify a lot of patients that can be associated with an intervention, you have to manage kind of the workflow of your clinicians. And oftentimes, risk stratification is a helpful way of knowing which patients are maybe going to get the most benefit from your intervention. We also talked about having the clinician be able to assess these things easily, and this involved dosing calculations and pharmacokinetic calculations, so we wanted to be able to remove the possibility of errors. And then finally, kind of be able to think about the time that it takes not only for the clinician to assess and come up with a plan for that particular patient, but how much time it takes to kind of document that intervention. All right, stepping back, I wanted to go ahead and introduce solutions before I tell you a little bit about the things that our institution was able to do. And I think when we're kind of thinking about the framework of our solutions within this environment, oftentimes you have to think of the medium that you're using as well as the people or the clinicians that you are providing the intervention for. So within the electronic health record, you guys are probably aware there's a variety of ways that you can kind of use different tools, whether or not that is being something that you can embed within your electronic health record, whether or not that's something as a supplement that may use some information from your electronic health record, but it is something that you have to click into outside of that piece, or something that's completely outside of the electronic health record, and kind of knowing what that actually means when you're kind of using those different solutions. I think switching over to thinking about the clinician and what their kind of impact is, or what maybe would be best for them, I think it's also helpful to think about some of the purposes of that intervention. Do you want it to be prescriptive, where it tells you exactly what you need to do? Or do you want it to be something that's more guidance-based and algorithmic, again, something that kind of allows this human decision-making process to keep going? Or do you want it to be more just education-focused? And I think a lot of our solutions can be something that can provide all of these things within one, but that is something to think about when you're kind of coming up with these kind of solutions. All right, so jumping back into my example, we ended up utilizing a multimodal approach to kind of eliminate, or to address all these barriers that we identified. When it comes to patient population identification, we developed within our electronic health record a passive alert for when a patient had an order for a beta-lactam. So it looks a little bit like this, with a little error. And then, for example, in my unit, I have a 24-bed trauma-surgical ICU that I work in. I have this little marker on about 20 of the 24 ICU patients. So being able to actually perform therapeutic drug monitoring on them, assessing them on a daily basis, coming up with a therapeutic plan, was a little bit overwhelming to kind of go from zero of that to 20 patients. And so we developed for our clinicians this risk stratification tool within the score, and there's some transparency there that the clinicians can see the reasons why a patient might be at a higher risk for these beta-lactam therapies. So you can kind of see here in this example that I provided a patient meets criteria based on a BMI, and also based on their calculation for creating clearance, which might make them at risk for augmented renal clearance. So moving on to those two other barriers that we kind of identified initially, when we talk about the clinician assessment and removing those dosing errors that might come into play, unfortunately we had to use something that was completely outside of the electronic health record. But we utilized a dosing calculator within Excel, and the kind of blue highlighted items there are things that the clinician can change, and then there are kind of I guess at the bottom are the rest of the things that kind of predict what kind of dosing strategy you should use and different things like that are things that the clinician cannot necessarily change. And then finally, that piece kind of along with the clinician insight can come up with a plan for that. We are able to communicate that to the team via a documentation, and fortunately our team was able to come up with pre-populated note templates there to kind of help with ease of being able to translate the data that we had calculated outside of the EHR back into the EHR. All right, so now that I've discussed a little bit of example on taking those barriers that we had and coming up with solutions and clinical implementation, I think the other thing that you learn is that this is a process, right? And we had our other speakers talk about some of those other frameworks that you might see within clinical implementation, but the one that I'm most familiar with is the pretty simple quality improvement of plan, do, study, enact. And so once we kind of came up with these solutions, there was potentially responses that we had to make to the things that we kind of included within our solution. So as I mentioned, we did identify patient populations that could benefit from that intervention, but it was a large number of patients and possibly something that our clinicians were not able to add to their workload. And so from that, does that mean then that we're creating another kind of barrier that we need to overcome or another opportunity of expanding a clinical service? I kind of presented the clinical expertise and the idea of being able to risk stratify as a pro, but I think it's also important to remember that having that decision making kind of can also potentially introduce implicit bias there. So kind of keeping in mind that as you go forward with your tools about whether or not you're unintentionally biasing some patient population towards an intervention. And then when it comes to the dosing calculator that we used, it was completely outside of our electronic health record, so there could be errors in kind of translating that information over. And so obviously we really would love for it to be able to communicate with our electronic health record, and honestly ongoing kind of discussions now about how to kind of have those things communicate with each other or auto-populate. And then finally, from our documentation piece, the limitations that we found there, even though we were using a pre-populated template, and so hopefully that was kind of helping with time management, it doesn't necessarily capture the full amount of time that the clinician spent when the decision making process there. And the other kind of piece is we would love to be able to not just make this a pharmacy centric intervention, like to provide education to the multidisciplinary team about what we're doing and why this is potentially optimal. And so oftentimes that requires the clinician to kind of free form that education, right? And so those kind of things are some opportunities kind of as we went forward within this item specifically. All right, so I mentioned that we'd be talking through an example of clinical implementation, but I also kind of wanted to kind of prep us to talk about the visions for the future and some things to think about when we're kind of building these smarter clinical implementation kind of projects. I think kind of as I mentioned before that the area of equity is important to apply within this kind of realm as well. I think we can actually identify and potentially eliminate some of the implicit bias that we see kind of within some of these systems that we've built. I think another thing to think about is the balancing the contribution to workload. And so I kind of talked throughout the time like how you realize that you never want your tools to burden that clinician, right? And so I think being able to discuss that with your clinicians and being able to ask them maybe how much time out of your day do you feel like you can dedicate to this and not necessarily contribute to something like clinician burnout, something that we've had several talks on for this converse. The other kind of thing to think about is I think as a clinician I like to be able to have that feedback on the patient outcomes that I'm potentially seeing within the tools that I'm using. And so being able to kind of have some of those outcomes maybe a little bit more of a feedback situation and maybe in a more easily way for clinicians to be able to see those kind of things. And then finally I think electronic health record optimization, kind of talking about how oftentimes we're having to use things that are outside of the EHR or supplements to the EHR and how some of those limitations can potentially be better optimized if those things were maybe embedded within the workflow of the clinician. All right, in summary, the barriers and solutions that we see within clinical implementation, I think these kind of things reach all disciplines within the ICU and within all aspects of patient care. So they're important to everyone. And I think when we're talking about those solutions that we find to our barriers, you know, being strategic about what medium we're using as well as the clinician that we're impacting I think is important. And in this situation I demonstrated how we utilize the multimodal approach, which is oftentimes the solution that you're going to potentially come up with. Once you've kind of identified those solutions, the kind of dozen in there, oftentimes you're going to see that you might have either a new opportunity or a response to a solution that you can take that might even include more barriers that you need to talk about with your team. And then I finally want to leave you with the idea that I do believe that smarter clinical implementation of these strategies does exist and we should all work together to kind of inform this for the future. Thank you.
Video Summary
In this video, the speaker discusses barriers and solutions in clinical implementation from a clinician's perspective. They mention that implementing frameworks and concepts from implementation science can be intimidating for clinicians. They focus specifically on medication management in the ICU and highlight common barriers such as identifying the patient population that would benefit from a certain intervention, risk stratification, dosing calculations and errors, and documentation. They share an example from their institution where they implemented a multimodal approach to address these barriers. They also discuss the importance of considering the medium and purpose of the intervention, as well as potential limitations and future visions for clinical implementation. The speaker concludes by emphasizing the importance of collaboration and continuous improvement in creating smarter implementations for the future.
Asset Subtitle
Research, Quality and Patient Safety, 2023
Asset Caption
Type: one-hour concurrent | Facilitating Change Management (SessionID 1169225)
Meta Tag
Content Type
Presentation
Knowledge Area
Research
Knowledge Area
Quality and Patient Safety
Membership Level
Professional
Membership Level
Select
Tag
Evidence Based Medicine
Year
2023
Keywords
clinical implementation
barriers
solutions
implementation science
medication management
Society of Critical Care Medicine
500 Midway Drive
Mount Prospect,
IL 60056 USA
Phone: +1 847 827-6888
Fax: +1 847 439-7226
Email:
support@sccm.org
Contact Us
About SCCM
Newsroom
Advertising & Sponsorship
DONATE
MySCCM
LearnICU
Patients & Families
Surviving Sepsis Campaign
Critical Care Societies Collaborative
GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. |
Privacy Statement
|
Terms & Conditions
The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.
×
Please select your language
1
English