Red Blood Cell Transfusions
Conditions
Keywords
Red blood cell transfusions, Pediatric critical care medicine, Implementation Science, Clinical Recommendations
Brief summary
Evidence demonstrates that the risks of red blood cell transfusions outweigh benefits in many patients who are hospitalized in the pediatric intensive care unit with increased risk of organ dysfunction, infection, delirium, and death. Recommendations have been developed to restrict transfusion in patients who are unlikely to benefit; however, these recommendations have not been consistently adopted into clinical practice. This study examines use of targeted efforts (implementation strategies) to improve implementation of the recommendations, with a goal of reducing unnecessary transfusions and improving patient outcomes in critically ill children.
Interventions
OTHERImplementation strategies to increase use of transfusion recommendations
Five implementation strategies will be employed in this study to enhance use of the blood transfusion recommendations. These include 1) building consensus, 2) provider education, 3) identifying and empowering champions ,4) use of computerized clinical decision support tools, and 5) provide quantitative metric-based feedback. Strategies 1-3 will occur prior to initiation of CCDS tools. All patients admitted to the PICU following the date of CCDS tool initiation will be considered to be part of the post-implementation phase. The investigators will collect data from the EHR on CCDS use and conduct provider surveys and interviews following CCDS tool initiation. Surveys and interviews will be both be conducted at 6 and 12 months post-CCDS tool initiation. Process and outcomes measures will be assessed before an after use of the implementation strategies.
Sponsors
Lucile Packard Children's Hospital
Children's Hospital of Philadelphia
Agency for Healthcare Research and Quality (AHRQ)
Stanford University
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
This study is best characterized as an interventional prospective cohort study. The investigators will deploy 5 implementation strategies intended to increase use of the red blood cell transfusion recommendations in two pediatric intensive care units. While all strategies will all be used, the investigators anticipate that implementation of the Computerized Clinical Decision Support (CCDS) tools will pose the greatest operational challenges in future studies and thus the focus of this study is on the implementation evaluation of these CCDS tools using an implementation framework (RE-AIM) customized for clinical informatics interventions. The investigators will prospectively evaluate the CCDS tools using the RE-AIM framework using a mixed methods approach that includes data collection from the Electronic Health Record (EHR) based on CCDS use, provider surveys, and data from brief, focused provider interviews.
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Employed at Lucile Packard Children's Hospital at Stanford University or the Children's Hospital of Philadelphia AND * Employed in one of the following roles: * PICU nurse * PICU attending * PICU fellow * PICU resident * PICU advanced practice provider * Other physician or surgeon in subspecialties whose patients regularly receive transfusions in the PICU * PICU TRIP implementation team member * PICU nursing leader * PICU physician leader * Bood bank leader.
Exclusion criteria
* Unwilling to participate * Directly report to the primary investigator.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Mean change from baseline in transfusion recommendation adherence at 18 months (evidence-based threshold alert) | 18 months | The investigators will assess the mean rate of nonadherent transfusions at monthly intervals in the pre- (12 months prior to CCDS tool initiation) and post-implementation period (18 months following CCDS tool initiation). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Mean change from baseline in transfusion recommendation adherence at 18 months (transfusions that require clinical judgement) | 18 months | The investigators will assess the mean rate of nonadherent transfusions at monthly intervals in the pre- (12 months prior to CCDS tool initiation) and post-implementation period (18 months following CCDS tool initiation) for transfusions that require provider clinical judgement. Data analysis will be exploratory. |
| Reach of computerized clinical decision support (CCDS) tools | 18 months | We will assess Reach of the CCDS tools by assessing the number of triggered CCDS alerts as compared with the total number of patients at risk for unnecessary transfusion (as determined through the PEDSnet database under IRB 16-012878, PEDSnet Master Secondary Use Protocol, under amendment 96, Appendix 28). |
Other
| Measure | Time frame | Description |
|---|---|---|
| Unintended consequences of CCDS tools - Interviews 12 months | Provider surveys and interviews at 12months post-CCDS implementation | Provider interview questions will explore any unintended consequences of the CCDS tools. There is no specific tool or scale that will be used. |
| Impact of CCDS tools on quality of care - Surveys - 6 months | Provider surveys at 6 months post-CCDS implementation | Provider survey questions will explore provider's subjective assessment of impact of the CCDS tools on the quality of care. There is no specific tool or scale that will be used. |
| Impact of CCDS tools on quality of care - Surveys - 12 months | Provider surveys at 12 months post-CCDS implementation | Provider survey questions will explore provider's subjective assessment of impact of the CCDS tools on the quality of care. There is no specific tool or scale that will be used. |
| Impact of CCDS tools on quality of care - Interviews - 6 months | Provider interviews at 6 months post-CCDS implementation | Provider interview questions will explore provider's subjective assessment of impact of the CCDS tools on the quality of care. There is no specific tool or scale that will be used. |
| Impact of CCDS tools on quality of care - Interviews - 12 months | Provider interviews at 12 months post-CCDS implementation | Provider interview questions will explore provider's subjective assessment of impact of the CCDS tools on the quality of care. There is no specific tool or scale that will be used. |
| Adoption of CCDS tools | Provider surveys post-CCDS implementation | Provider survey questions will address if providers reference the guidelines, if providers have encountered the CCDS alerts, the frequency with which they encounter the CCDS alerts, resources used to learn about the guidelines, and willingness and comfort using the CCDS alert recommendations. There is no specific score or scale being used for this outcome. |
| Barriers to CCDS implementation - Surveys - 6 months | Provider surveys and interviews at 6 months post-CCDS implementation | Surveys will explore barriers to CCDS implementation at the individual, unit, and hospital levels. |
| Unintended consequences of CCDS tools - Surveys - 6 months | Provider surveys at 6 months post-CCDS implementation | Provider survey questions will explore any unintended consequences of the CCDS tools. There is no published specific tool or scale that will be used. |
| Barriers to CCDS implementation - Interviews - 6 months | Provider interviews at 6 months post-CCDS implementation | Interviews will explore barriers to CCDS implementation at the individual, unit, and hospital levels. Provider interviews will also inquire about enabling factors in the following areas: CCDS tool delivery and intended use, time and resources needed to integrate the CCDS tools. |
| Barriers to CCDS implementation - Interviews - 12 months | Provider interviews at 12 months post-CCDS implementation | Interviews will explore barriers to CCDS implementation at the individual, unit, and hospital levels. Provider interviews will also inquire about enabling factors in the following areas: CCDS tool delivery and intended use, time and resources needed to integrate the CCDS tools. |
| Enabling factors to CCDS implementation - Surveys - 6 months | Provider surveys at 6 months post-CCDS implementation | Surveys will explore enabling factors to CCDS implementation at the individual, unit, and hospital levels. |
| Enabling factors to CCDS implementation - Surveys - 12 months | Provider surveys at 12 months post-CCDS implementation | Surveys will explore enabling factors to CCDS implementation at the individual, unit, and hospital levels. |
| Enabling factors to CCDS implementation - Interviews - 6 months | Provider interviews at 6 months post-CCDS implementation | Interviews will explore enabling factors to CCDS implementation at the individual, unit, and hospital levels. Provider interviews will inquire about enabling factors in the following areas: CCDS tool delivery and intended use, time and resources needed to integrate the CCDS tools. |
| Enabling factors to CCDS implementation - Interviews - 12 months | Provider interviews at 12 months post-CCDS implementation | Interviews will explore enabling factors to CCDS implementation at the individual, unit, and hospital levels. Provider interviews will inquire about enabling factors in the following areas: CCDS tool delivery and intended use, time and resources needed to integrate the CCDS tools. |
| Barriers to CCDS implementation - Surveys - 12 months | Provider surveys and interviews at 12 months post-CCDS implementation | Surveys will explore barriers to CCDS implementation at the individual, unit, and hospital levels. |
| Unintended consequences of CCDS tools - Surveys - 12 months | Provider surveys at 12 months post-CCDS implementation | Provider survey questions will explore any unintended consequences of the CCDS tools. There is no published specific tool or scale that will be used. |
| Unintended consequences of CCDS tools - Interviews 6 months | Provider surveys and interviews at 6 months post-CCDS implementation | Provider interview questions will explore any unintended consequences of the CCDS tools. There is no specific tool or scale that will be used. |
Countries
United States
Outcome results
None listed