Isabelle Zerfas
PharmD Candidate
University of Pittsburgh School of Pharmacy
Pittsburgh, Pennsylvania
Disclosure information not submitted.
Nicole Hume, PharmD (she/her/hers)
University of Kentucky HealthCare
Lexington, Kentucky
Disclosure information not submitted.
.jpg "Adrian Wong, BCCCP, MPH, PharmD photo")
Adrian Wong, BCCCP, MPH, PharmD
Assistant Professor
MCPHS University
Boston, Massachusetts
Disclosure information not submitted.
Michele Klein-Fedyshin, MSLS, BA, BSN, RN
Research and Clinical Instruction Librarian
University of Pittsburgh, United States
Disclosure information not submitted.
Pamela Smithburger, PharmD, MS, BCPS, BCCCP, FCCP, FCCM
Associate Professor
University of Pittsburgh School of Pharmacy
Jefferson Hills, Pennsylvania, United States
Disclosure information not submitted.
Mitchell Buckley, BCCCP, PharmD, FCCP
Clinical Pharmacy Specialist
Banner University Medical Center Phoenix
Phoenix, Arizona
Disclosure information not submitted.
John Devlin, BCCCP, PharmD, MCCM
Professor
Northeastern University
Boston, Massachusetts, United States
Disclosure information not submitted.
Sandra Kane-Gill, MSc, PharmD, FCCP
Professor of Pharmacy and Therapeutics
University of Pittsburgh School of Pharmacy
Pittsburgh, Pennsylvania, United States
Disclosure information not submitted.
Title: Implementation Strategies for PAD/PADIS & Related ICU Outcomes: A Systematic Review & Meta-analysis
Background/Hypothesis: Recommendations from the 2013 PAD and 2018 PADIS guidelines have been widely incorporated in practice but the effectiveness of PAD/PADIS implementation strategies remains unclear. We hypothesize the number and types of implementation strategies used for PAD/PADIS will influence ICU outcome.
Methods: PubMed, CINAHL, Scopus, and Web of Science (1/2012-4/2021) were searched for adult ICU studies focused on increasing PAD/PADIS use (≥2 domains), where implementation strategy(s) use versus no use was compared, and relevant ICU outcomes were reported. Two authors independently-screened studies for eligibility, included articles through consensus, and evaluated study quality. Study design, ICU type, number of PAD/PADIS domains and the use of 17-different Cochrane Effective Practice and Organization of Care (EPOC)-defined implementation methods were extracted. Random-effects meta-analyses were performed to evaluate the association between PAD/PADIS implementation strategy use and risk for short-term mortality (within 45 days of ICU admission) and delirium occurrence and days of mechanical ventilation (MV) and ICU length of stay (LOS).
Results: The 22 included studies implemented 3.5[2-5] guideline domains and incorporated 5[2-9] different Cochrane EPOC implementation strategies. Educational meetings 21(95%), provider-oriented interventions 18(82%), educational materials 17(77%), opinion leader input 14(64%), and structural interventions (e.g., ABCDEF bundle use) 10(45%) were most frequently used. Most studies (64%) had a high risk of bias. Despite the use of multiple EPOC strategies to boost PAD/PADIS recommendation use, neither mortality (RR 1.0, 95% CI 0.9-1.1; I2 = 1.5%), delirium (RR 0.99, 95% CI 0.79-1.25; I2 =83%) or ICU LOS (WMD -0.84 95% -1.69-0.01; I2 =91%) was reduced. Days of MV (WMD -0.85, 95% CI -1.43 to -0.28; I2 =63%) was reduced by nearly 1 day. Neither total EPOC strategy use (≥5 vs. < 5) or ABCDE(F) bundle use affected the mortality result.
Conclusion: Current literature, from primarily very low-quality comparative studies, demonstrate the use of multiple strategies to implement PAD/PADIS guideline domains do not help improve ICU outcomes. The implementation strategies most effective for PAD/PADIS quality improvement efforts requires further high-quality research.