Implementation Science in Pediatric Critical Care – Sedation and Analgesia Practices as a Case Study

Abstract

Sedation and analgesia (SA) management is essential practice in the pediatric intensive care unit (PICU). Over the past decade, there has been significant interest in optimal SA management strategy, due to reports of the adverse effects of SA medications and their relationship to ICU delirium. We reviewed 13 studies examining SA practices in the PICU over the past decade for the purposes of reporting the study design, outcomes of interest, SA protocols used, strategies for implementation, and the patient-centered outcomes. We highlighted the paucity of evidence-base for these practices and also described the existing gaps in the intersection of implementation science (IS) and SA protocols in the PICU. Future studies would benefit from a focus on effective implementation strategies to introduce and sustain evidence-based SA protocols, as well as novel quasi-experimental study designs that will help determine their impact on relevant clinical outcomes, such as the occurrence of ICU delirium. Adoption of the available evidence-based practices into routine care in the PICU remains challenging. Using SA practice as an example, we illustrated the need for a structured approach to the implementation science in pediatric critical care. Key components of the successful adoption of evidence-based best practice include the assessment of the local context, both resources and barriers, followed by a context-specific strategy for implementation and a focus on sustainability and integration of the practice into the permanent workflow.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study*

“…ICU-based rehabilitation has been recommended as a standard of care for all critically ill patients (4, 6); however, its adoption into routine practice remains suboptimal in adult ICU and PICU globally, with delirium monitoring, choice of sedation, and early mobilization being the most challenging to implement (12, 36). Evidence-based implementation strategies are therefore crucial for translating evidence into practice (14, 37). This study demonstrates that a bundle consisting of an analgesia-first sedation approach, delirium monitoring and prevention, and early mobilization, can be successfully implemented in two PICUs over 26 months using a clear implementation strategy and process.…”

“…Secondly, this study highlights the importance of using an evidence-based framework for implementing quality improvement, and tailoring the process to the resources and needs of the local setting. Successful implementation does not need to be driven by researchers; it requires leadership, team collaboration, strategic planning, and implementation science methodology (14). We demonstrated that it is possible to introduce a PICU-rehabilitation bundle using large (site 1) and small (site 2) teams, respectively; essential to the process is that the teams consist of stakeholders, there are clear roles and responsibilities, objectives and timelines, and that support and guidance are available.…”

“…3, http://links.lww.com/PCC/C418). 101 (38) 25 (38) Noncomplex chronic condition 32 (19) 36 (14) 33 (18) 25 (20) 67 (25) 12 (18) Chronic complex condition 41 (24) 55 (22) 24 ( 13) 34 (28) 95 (36) 29 (44) PIM3 (31) Nursing workload and unplanned extubation rates did not change significantly in both sites.…”

“…Ineffective implementation results in inadequate adoption into practice, and subsequently unclear impact of the intervention on outcomes (11, 12). There is currently inadequate evidence on how to deliver rehabilitation in a collective and consistent manner in the PICU setting (13, 14). The objectives of this study were to implement an early rehabilitation bundle in two Canadian PICUs, evaluate the factors that influence bundle adoption, and determine the impact of the bundle on clinical practice and patient outcomes.…”

Barriers and facilitators to using procedural pain treatments in pediatric patients: protocol for a systematic review and meta-synthesis

“…Synthesizing the existing barriers and facilitators to using procedural pain treatments in pediatric patients is the premise of developing effective strategies. (37)(38)(39). Therefore, this systematic review will synthesize barriers and facilitators in the literature under the guidance of implementation science and evaluate the importance of different factors (37).…”