Good afternoon, everyone. It is my pleasure to introduce you to Dr. Ann Sales, who will be presenting this year's Norma J. Schumacher Honorary Lecture. Dr. Sales is a nurse and a 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, Columbia. She is the Associate Dean for Implementation Research and Health Delivery Effectiveness in the School of Medicine and also a research scientist at the Center for Clinical Management Research at the VA Ann Arbor Health Care System. Her training is in nursing, sociology, health economics, econometrics, and general health research. Her work involves theory-based designs of implementation interventions, including understanding how feedback reports affect provider behavior and through behavior change have an impact on patient outcomes, the role of social networks and implementation interventions, and effective implementation methods using electronic health records and digital interventions. Dr. Sales has completed over 40 funded research projects, many focused in implementation research, and she is a founding co-editor of Implementation Science Communication. Please join me in welcoming Dr. Ann Sales as she presents Implementation Science Applied to Critical Care. Thank you. It's a real honor to be here, and I am incredibly grateful for the invitation, so thanks to the Organizing Committee and the members of the Congress. This is this is a real opportunity, and I hope an opportunity for a little bit of dialogue as we talk today. So, I'm going to talk to you a little bit about what I'm going to be talking about today, and I'm going to talk a little bit about readily available, and we're not using it much of the time. And a lot of it's not needed except in the moment when you're actually delivering care. It won't necessarily make sense, you know, even five days later or a month later. So that's a really important difference between critical care and all other healthcare settings, I would argue, that instead of sparse health data, you have dense data, but the density may not always be where you most need the data to be. And an example of that is that you may have lots and lots of data about, you know, someone's central blood pressure, but you don't necessarily know how they're feeling at any given point in time, because those data can't be easily monitored through equipment and put up on a screen. So moving on from data, and these things are all overlapping and interrelated, so let me just say that these are not distinct and separate and mutually exclusive. Acuity is in many ways the definition of critical care. It's what makes care critical, that somebody is acutely ill and unstable and needs both stabilization and acute treatment. So this raises another whole set of issues. Again, this is thinking about potential scientific study and research that we can be doing in the context of critical care and implementation. Issues around adequacy of staffing, and when we talk about staffing in today's world, we're not just talking about the physical individuals, the humans who are in person in a unit. We're talking about what's available through telehealth, and we're talking about what's available through other forms of consultation, rapid or slow. We're also dealing with unstable and rapidly changing patient status, which in and of itself produces complexity and a lack of immediacy and often a focus of attention that requires that you can't necessarily think about all the things going on around you if you have to think about the care for this patient in this moment. Issues around deterioration and improvement, the literature in that area is large, but we still are sort of in our infancy of figuring it out. We don't really understand why people deteriorate, when they do, how they do, and how best to treat deterioration. And in a couple of minutes, I'm going to talk about boundaries, but this is a critical area of boundaries between a person who's being cared for in one setting and the need to increase the level and intensity of the care that they're receiving. And then the last thing I would say about the broad topic of acuity is that it's a highly charged environment. Because we're dealing with critical illness, the people around the person who's receiving care are often very stressed, very anxious, and this creates another whole level of things you have to think about, work with, and deal with. So this is a topic that's near and dear to my heart and many of our hearts, I think. The notion of teams and what teamwork means in a critical care environment. Teams are essential throughout health care. There's very little we do in health care that doesn't require a team somewhere, at least in the background, if not right present as care is being delivered. But in many other settings, those teams can be pretty backstage, like in the lab or off doing paperwork while a single provider is interacting directly with a patient or family. In critical care, the team has to be there and it has to be functioning together in order to coordinate care and make sure that the care is delivered as it has to be delivered. So teams are absolutely inherent and they're central. But I will argue that we don't understand teams in health care very well at all. And some of that is the way we work, that people get scheduled not on the basis of what team they belong to. And you'll find that that's not true in the military, where a lot of the team research that's been done has been done in military and it's been done in aviation. And those are both places where people actually consider the team as they do scheduling. But in health care, we typically don't. We simply say, OK, your schedule is X. What X means is you'll be working with this group of people during your day, your shift, your week, whatever that is. And you're seldom choosing those people. Sometimes you might be able to, but most of the time you can't. This means that there's this shifting aspect to teamwork. And stable relationships are hard to create. They're hard to maintain. And over time, a unit can definitely develop a cohesiveness and coherence across the unit. But it doesn't mean that every team within that unit is coherent and cohesive. There's a lot that we need to think about. And a lot of the work that's been done in teams in settings other than critical care doesn't have the urgency around teamwork that critical care does. So I would argue there's a huge area of study here. And there are many people who are engaged in that study. But I think we need more. And I think we need more focus on some of these unique aspects and thinking about it a little bit differently from taking it from the military work that's been done or teams in industry and manufacturing, firefighting, and assuming that some of the things we've learned are going to hold in these other specifically critical care settings. And then I'll just mention the notion of social networks, which is really important and is again a sort of an emerging piece within implementation science. Actually social networks underlie the early stuff in implementation science and particularly Everett Rogers' work in diffusion of innovations, which extended from the 40s through into the 70s. And there have been quite a bit of social network analysis and research done focusing on to some extent teamwork, but also processes of implementation and spread of innovation. But it's still in its infancy. And we still are trying to figure out how we can measure the social networks that are inherent in the teams that work together in health settings and especially in critical care without the intrusion and the burden of filling out massive surveys and other ways of collecting the data that we need. So I'd like to switch quickly and talk about the boundaries between different settings. Because critical care is not an island and it doesn't exist in a vacuum. It is a continuous flow between acute care for sure, but also direct from the community, direct from the emergency department. The whole emergency medical system is intricately related to critical care settings. So we have all of these boundaries, which are frankly pretty unexplored. And we've got protocols and ways of dealing with them. And I would argue mostly just ways we deal with them that haven't necessarily been thought through very well. But there's a huge scope for research in this area. And some of that work is being done. Work on handoffs, rapid response teams, triage issues, issues around rationing of care, which was a big topic during COVID when we didn't have enough ventilators in a lot of settings to be able to offer a ventilator to everybody who might need one. And then the notion of just bed pressure. What do you do when there is no bed available in the setting that a patient needs to receive care in? These are all things that I would argue require a lot more attention and thought as we think about both innovation and new interventions for improving quality of care, but also implementing things that we do have some information about already. So thinking about how to move forward, increasing numbers of people who are critical care clinicians have been trained, have trained themselves, have learned about implementation science, and I would say and implementation practice. And the boundary between the science and the practice isn't at all clear. It's very, very fuzzy and very gray. So there's a question of how can those folks be deployed? Is there a way that people could come together perhaps in some kind of loose collaboration? And frankly, in science, loose collaborations are better than tight ones. To think about how to work together to answer some of these questions and begin to address some of these topics in ways that will allow us to move our evidence forward and move the science forward. So new evidence is being generated all the time. As I said, new treatments are very important. And we know that we don't know enough about how to treat people who are critically ill. But that's not the only evidence that we need. And in fact, at this point, if you really stop to think about it, we have probably a backlog of things that should be implemented that would actually make care better, improve outcomes, improve quality of life, both for providers and for patients that aren't being used in part because getting them into practice is hard. And it's especially hard to do in complex settings, as we've just been talking about. I think we need to think a lot more about behavior. We talk about practice and we talk about workflow and we talk about the way we do things. All of that, the pieces inside each of those words or phrases, are discrete behaviors that people are undertaking. Right now, I'm engaged in the behavior of talking. Hopefully, many of you at least are engaged in the behavior of listening and thinking. Those are different behaviors. And when you think about your work setting and the work you do when you're taking care of patients, your time to listen and your time to think are different from the actions that you're taking. And as we think about it, we need to get much more granular about our descriptions and our identification of behavior. We also need to think about behavior of many more people than we usually do. It's not just the behavior of a provider. It's also the behavior of a patient. Some patients are so sedated and their level of consciousness is so low that they aren't able to sustain or do much behavior, but many patients can and do. And how they behave matters. Certainly outside of critical care, patient behavior is critical and essential to understanding behavior change. Family members, managers, a group of people that we don't think about often enough. And then I'll just say IT staff are really important. We recognize that, but we also don't work with IT staff very effectively or probably enough. Issues of fast and slow thinking have been discussed and are thought about. But heuristics, which are a characteristic of fast thinking, are really important. And I would argue that in critical care practice, essential is part of why people train for years to become expert clinicians in critical care settings. But we need to stop and think about when can we use heuristics effectively and safely, and when should we not use heuristics? When should we stop and really evaluate the situation and take a moment for pause? We need to use the evidence we have. We really, you know, we are wasting a lot of life and a lot of time, energy, and people's emotional and physical well-being as providers, as well as patients, by not using what we know effectively. And we need to be thinking about the high burden, high volume conditions as much as we think about those sort of things that I care about the most. Maybe because they've affected me in my life in some way, but what are the things that affect people broadly and within the settings in which you work, the more common things for which we may not have very good evidence? When we think about evidence generation and what to spend our energy and time on, we should be focusing there. And we need to think about what evidence most needs to be implemented. As an implementation researcher, I know that I have done things because I think they're important, not because society thinks they're important. But they're things that are interests or passions of mine, and all of us will do that. We need to be passionate about the things that we engage in and spend energy on. But we also need to be thinking about how to align our interests with broader interests, and in particular, with the things that really do need implementation. So I'm just going to close by saying that there's a lot that's out there. This is just a tiny, tiny little piece of snapshots of some of the papers that are out there. And this is part of what makes the science of implementation so complex. We're not one science. We're actually a very synthetic field that draws from all kinds of sciences and all kinds of disciplines to form this rapidly evolving and emerging discipline. And I would urge people to take a look at, hopefully, some of the papers I'm suggesting you look at here. And I'll just say they probably will raise more questions than answers if you do that. But I would strongly encourage you to think about doing that and to think about applying it to the important questions that I think are central to critical care and to improving the evidence base and also the implementation of that evidence base in care. So thank you again. I really appreciate this opportunity. And I hope we have time for some discussion.

Implementation Science

Critical Care

Team Dynamics

Telehealth

Interdisciplinary

Behavior-focused Studies