Nearly 800,000 patients require invasive mechanical ventilation for acute respiratory failure in the United States each year. Among those who recover to the point of extubation, a substantial proportion remain at high risk for extubation failure, i.e., recurrent respiratory failure requiring reintubation within 48 hours of extubation. For these vulnerable patients, extubation directly to noninvasive ventilation reduces the risk of recurrent respiratory failure, reintubation, and death. Based on evidence from multiple randomized controlled trials, post- extubation noninvasive ventilation among high-risk patients is strongly recommended in recent clinical practice guidelines. Yet, despite these recommendations, the use of this evidence-based practice remains limited, leading to preventable morbidity and mortality. Our long-term objective is to conduct a multicenter, hybrid effectiveness-implementation trial to identify the optimal strategy for promoting the use of post-extubation noninvasive ventilation among high-risk patients recovering from acute respiratory failure. In this application, we propose a series of studies that will culminate in our ability to successfully conduct this trial. Specifically, we plan to achieve the following aims: (1) qualitatively assess barriers and facilitators to the adoption of post- extubation noninvasive ventilation and evaluate the role of educational interventions in improving adoption; (2) develop and pilot test three strategies designed to speed implementation of post-extubation noninvasive ventilation: one control strategy (traditional online continuing medical education) and two novel strategies (interprofessional education and just-in-time education); and (3) finalize preparations for a four-arm, multicenter, hybrid effectiveness-implementation trial conducted within the UPMC Health System to identify the implementation strategy that best promotes use of post-extubation noninvasive ventilation, comparing control with interprofessional education, just-in-time education, and both. This work is important because it will lead directly to a major clinical trial with the potential to improve outcomes for hundreds of thousands of high-risk patients with acute respiratory failure, and it will provide foundational knowledge about the roles of interprofessional education and just-in-time education as implementation strategies in the hospital setting. This work is innovative because it is based on novel theories for organizational learning and behavior change that account for the interprofessional nature of critical care and the unique needs of the adult learner. This work is feasible in our hands because it builds off an existing research infrastructure developed by an accomplished study team with extensive experience conducting both implementation research and multicenter clinical trials in critically ill patients.
Nearly 800,000 patients per year in the United States require invasive mechanical ventilation for acute respiratory failure, a life-threatening condition. Many of those who recover to the point that their breathing tube is removed would benefit from mechanical ventilation delivered through a face mask, but this practice is currently underutilized. This project will compare innovative strategies to overcome barriers to the use of this evidence-based practice.
