TY - JOUR
T1 - A realist review of the effective implementation of the ICU Liberation Bundle in the paediatric intensive care unit setting
AU - Dodds, Elizabeth
AU - Kudchadkar, Sapna Ravi
AU - Choong, Karen
AU - Manning, Joseph C.
N1 - Funding Information:
There were minimal references to the outer setting domain in either the MRT CFIR or the empirical CFIR. Evidence from both identified working with the ICU Liberation Collaborative which was the collaboration set up by the SCCM and used internationally as a source of support, education, and resources.32,36,38 No further reference was made to the outer setting in the empirical studies.Analysis and comparison of the MRT and the empirical papers suggest that for a successful intervention to take place, a solid understanding of the localised context prior to implementation is vital.21,38,41,42 This should include a baseline understanding of what is already in place on the unit and baseline measurement for all patient outcomes that are planned to be evaluated. This baseline assessment would inform the tailoring of the ICU Liberation Bundle elements to best fit the context it is being implemented into. A recognition of the need for, and benefits of, the intervention combined with senior and frontline buy-in is the second key contextual element that has a strong impact on successful implementation of the ICU Liberation Bundle.35,40,43 Existing literature on complex intervention supports these findings. A study providing Medical Research Council guidance on developing complex intervention states that adapting an intervention to fit local circumstances can work better than using a standardised approach, provided the process is clearly documented.44 An analysis study on complex interventions further discusses the importance of understanding the context, not just when planning an intervention but also when assessing whether an intervention that had success in one setting would work in a different setting.45 This also may partially account for why the multicentre RCT37 did not demonstrate positive results for the primary outcomes as by nature of the study design, it was not possible for each PICU involved to take an individualised approach. Furthermore, the literature on implementation science highlights the importance of this contextual understanding, providing evidence that the implementation climate (a construct representing workers perceptions on how innovation use is expected, supported, and rewarded) of an area is highly dependent on context.46 Further literature recognises the need to consider both macro and micro factors when assessing an organisation's readiness for change.47 When considered together, the findings from these studies suggest support for the use of realist reviews as a way to gather evidence prior to considering the implementation of a complex intervention such as the ICU Liberation Bundle. Of note, all the included papers were based in North America, with most providing very minimal information about the broader context of their PICU, such as unit size, the staff structure within it, or the type of hospital. No information was given regarding the socio-economic context which is reflected in the minimal findings in the CFIR ‘outer setting’ domain and warrants further exploration.The strengths of this study lie in the use of the realist review framework as it has enabled exploration of the factors involved in effective implementation of the ICU Liberation Bundle within a PICU setting. Furthermore, the protocol was published on PROSPERO prior the study completion to provide transparency to the process. Experts in the field were consulted during the review process, including topic and clinical experts and medical librarians, this ensuring a rigorous and robust review was carried out. Clear checking and conforming mechanisms were also in place as well as an audit trail of decision-making processes. Furthermore, the findings from this study provide support to the suggestions provided by the two articles that give guidance on the implementation of the ICU Liberation Bundle into PICUs,43,55 both of which draw on the adult literature and research examining the individual components of the bundle. This review provides further insights into these reviews by taking a novel look at the existing research and provides extra depth when considering how the ICU Liberation Bundle may be successfully implemented into PICUs in varying contexts, such as in centres with different team cultures, in different socio-economic settings, and within different healthcare settings. This is vital as the negative impact of PICU-acquired complications on patients is well recognised, and when the potential benefits of the ICU Liberation Bundle are considered, every PICU should have the option to implement it, not just those in high-resource/high-income settings.This review does recognise some limitations. It cannot be ruled out that eligible papers may have been discarded as elements that were in place were not clearly discussed, and thus, the shortlist was discussed with the review panel of topic experts to prevent this happening. Time constraints prevented contact being made with every author; however, every author of grey literature was contacted to provide rigour. Finally, in the planning stages of this review, it was considered that much of the contextual findings would consider the broader healthcare setting, particularly as most of the papers were based in the USA where health care is funded, organised, and delivered differently than other nations globally which may impact the intervention, however, none of the papers mentioned this in any detail. It must be also be acknowledged that this is an emerging field of research with studies published since the search for this review ended. It could be considered that in the future, a ‘living’ realist review may be a novel way of informing implementation science.
Publisher Copyright:
© 2022 Australian College of Critical Care Nurses Ltd
PY - 2022
Y1 - 2022
N2 - Objective: The objective of this study was to produce an evidence base of what works, for whom, and in what context when implementing the ICU Liberation Bundle into the paediatric intensive care unit (PICU). Review method used: This is a realist review (a review that considers what works, for whom, and in what context) of contemporary international literature. Data sources: Data were collected via electronic searches of CINAHL, PubMed, EMBASE and MEDLINE, Google Scholar, and Web of Science for articles published before October 2020. Review method: An initial scoping search identified the underpinning theory of the implementation of the ICU Liberation Bundle (a multifactor intervention aimed at improving patient outcomes) which was mapped onto the Consolidated Framework for Implementation Research (CFIR). We identified 547 unique citations; 12 full-text papers were included that reported eight studies. Data were extracted and mapped to the CFIR domains. Results: Data mapped to all CFIR domains. Characteristics of individuals included involvement of key stakeholders, champions, and parents and understanding of staff attitudes and perceptions of the intervention, and all bedside staff members were involved and given training. Within the inner setting, understanding of unit culture, ensuring effective support systems in place, knowledge of the baseline, and leadership support, and buy-in were important. Culture of family-centred care and alignment of the intervention to national guidelines related to the outer setting. Intervention characteristics included the number and timings of interventions, de-escalation rounding checklists, the use of age-appropriate and validated assessment tools, and local policies for the bundle. The process included set training program, senior unit/hospital team consultation on all processes, continual audit adherence to the bundle and feedback, and celebration of successes. Conclusions: This novel realist review of the literature identified that successful implementation of the ICU Liberation Bundle into PICU settings involves the following: (i) a thorough understanding of the PICU context, including baseline metrics, resources, and staff attitudes; (ii) using contextual information to adapt the intervention elements to ensure fit; and (iii) both clinical effectiveness and implementation outcomes must be measured. Registration of review: PROSPERO 2020 CRD42020211944.
AB - Objective: The objective of this study was to produce an evidence base of what works, for whom, and in what context when implementing the ICU Liberation Bundle into the paediatric intensive care unit (PICU). Review method used: This is a realist review (a review that considers what works, for whom, and in what context) of contemporary international literature. Data sources: Data were collected via electronic searches of CINAHL, PubMed, EMBASE and MEDLINE, Google Scholar, and Web of Science for articles published before October 2020. Review method: An initial scoping search identified the underpinning theory of the implementation of the ICU Liberation Bundle (a multifactor intervention aimed at improving patient outcomes) which was mapped onto the Consolidated Framework for Implementation Research (CFIR). We identified 547 unique citations; 12 full-text papers were included that reported eight studies. Data were extracted and mapped to the CFIR domains. Results: Data mapped to all CFIR domains. Characteristics of individuals included involvement of key stakeholders, champions, and parents and understanding of staff attitudes and perceptions of the intervention, and all bedside staff members were involved and given training. Within the inner setting, understanding of unit culture, ensuring effective support systems in place, knowledge of the baseline, and leadership support, and buy-in were important. Culture of family-centred care and alignment of the intervention to national guidelines related to the outer setting. Intervention characteristics included the number and timings of interventions, de-escalation rounding checklists, the use of age-appropriate and validated assessment tools, and local policies for the bundle. The process included set training program, senior unit/hospital team consultation on all processes, continual audit adherence to the bundle and feedback, and celebration of successes. Conclusions: This novel realist review of the literature identified that successful implementation of the ICU Liberation Bundle into PICU settings involves the following: (i) a thorough understanding of the PICU context, including baseline metrics, resources, and staff attitudes; (ii) using contextual information to adapt the intervention elements to ensure fit; and (iii) both clinical effectiveness and implementation outcomes must be measured. Registration of review: PROSPERO 2020 CRD42020211944.
KW - Deconditioning
KW - ICU Liberation
KW - PICS (intensive care syndrome)
KW - PICU
KW - Review
UR - http://www.scopus.com/inward/record.url?scp=85146686409&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85146686409&partnerID=8YFLogxK
U2 - 10.1016/j.aucc.2022.11.007
DO - 10.1016/j.aucc.2022.11.007
M3 - Review article
C2 - 36581506
AN - SCOPUS:85146686409
SN - 1036-7314
JO - Australian Critical Care
JF - Australian Critical Care
ER -