Nudging implementation of low tidal volume ventilation: a stepped wedge, cluster randomized trial

Implementation Science · 2026-05-07

BACKGROUND: "Nudges" embedded in the electronic health record (EHR) facilitate desired decisions while preserving autonomy and may provide a scalable strategy to overcome the common implementation barrier of lack of knowledge about a best practice. We sought to test whether EHR-based nudges targeting two intensive care unit (ICU) clinician groups would safely increase evidence-based use of low tidal volume ventilation. METHODS: We performed a stepped-wedge, cluster randomized, hybrid type 3 effectiveness-implementation trial in 12 ICUs from February 2021 to May 2023 to test three nudges targeting clinicians responsible for order entry and respiratory therapists responsible for operationalizing orders and documentation. A default ventilation order auto-populated a low tidal volume setting; an accountable justification order required a free-text justification to order high tidal volume; and an accountable justification flowsheet required a free-text justification to document delivery of high tidal volume. ICUs were randomly assigned to launch one of the two order nudges on a pre-specified date, followed by the flowsheet nudge six months thereafter. The primary outcome was fidelity to low tidal volume ventilation, defined as percentage of time during the first 72 h of ventilation with low tidal volumes. For additional contextual inquiry, we conducted qualitative interviews with ICU clinicians regarding their perspectives on low tidal volume ventilation and study nudges. RESULTS: The primary analysis included 4412 patients. Unadjusted median fidelity to low tidal volume ventilation was 45.7%. Using multivariable mixed effects regression, marginal estimates of fidelity to low tidal volume ventilation ranged from 47.1% to 57.8% across study groups, with no significant differences after Holm adjustment for multiple comparisons. ICUs experienced variable changes with nudges in fidelity to low tidal volume ventilation. Clinician interviews revealed potential explanations for this variability, including the possibility of differential effects by experience level of clinicians and culture of interprofessional collaboration, and influence of the COVID-19 pandemic on familiarity with and use of low tidal volume ventilation. CONCLUSIONS: EHR-based default and accountable justification nudges did not increase utilization of low tidal volume ventilation in a broad population of mechanically ventilated patients; however, nudge effectiveness varied by ICU. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04663802. Registered 10 December 2020, https://clinicaltrials.gov/study/NCT04663802.

Enhancing the Impact of Implementation Strategies in Healthcare: A Research Agenda

UNC Libraries · 2025-12-19

The field of implementation science was developed to better understand the factors that facilitate or impede implementation and generate evidence for implementation strategies. In this article, we briefly review progress in implementation science, and suggest five priorities for enhancing the impact of implementation strategies. Specifically, we suggest the need to: (1) enhance methods for designing and tailoring implementation strategies; (2) specify and test mechanisms of change; (3) conduct more effectiveness research on discrete, multi-faceted, and tailored implementation strategies; (4) increase economic evaluations of implementation strategies; and (5) improve the tracking and reporting of implementation strategies. We believe that pursuing these priorities will advance implementation science by helping us to understand when, where, why, and how implementation strategies improve implementation effectiveness and subsequent health outcomes.

Systemic inequities, dignity, and trust in the context of HIV care: a qualitative analysis

International Journal for Equity in Health · 2025-05-06

Adherence and retention in care are key targets to achieve favorable health outcomes for people with HIV. Challenges with adherence and retention are pronounced for marginalized communities facing intersectional structural oppression. Community health worker delivery of Managed Problem Solving (MAPS+), an evidence-based behavioral intervention, has the potential to improve adherence and retention, yet understanding structural inequities affecting people with HIV is necessary to increase the likelihood of equitable implementation. The current study explores systemic inequities influencing HIV care adherence and retention, and approaches to address these challenges. We conducted semi-structured interviews with 13 clinics and 4 constituent groups: prescribing clinicians, non-prescribing clinical team members (e.g., medical case managers), clinic administrators, and policymakers. Through reflexive thematic analysis within a constructionist paradigm, we identified two key themes. The first elucidated experiences of systemic inequities such as access to resources, healthcare system navigation difficulties, power differentials, medical mistrust, intersectional stigma and potential patient burden associated with MAPS+. The second theme highlighted the ways in which staff and clinicians shoulder the burden of addressing inequities by approaching people with HIV with dignity and developing trusting relationships and how MAPS + can bolster this approach by partnering with and centering patient needs. While these individual and organizational efforts are valuable, ending the HIV epidemic requires structural changes to address systemic inequities directly. This research underscores the complex interplay between structural oppression and HIV care, calling for comprehensive approaches to achieve health equity.

Data‐Driven Implementation Trials: Realizing Their Full Potential in Achieving the Promise of Learning Health Systems

Learning Health Systems · 2025-10-19

The digital transformation of healthcare has generated unprecedented volumes of routine clinical data, enabling health system leaders, including quality improvement (QI) efforts, to optimize care using real-time analytics. However, health system QI typically focuses on changes within localized environments; it is often limited in its ability to address systemic barriers or scale evidence-based strategies across diverse settings. Thoughtful integration of implementation science (IS) approaches addresses this gap by systematically integrating interventions into diverse practice settings and defining generalizable implementation strategies. These attributes position IS as a cornerstone of learning health systems (LHS), which strive for population-wide improvements through continuous, data-driven learning. Within this paradigm, randomized implementation trials provide the gold standard for comparing and optimizing implementation strategies. By leveraging routine data, these trials generate causal evidence on the effectiveness of different approaches and offer rigorous insights for health system decision-makers. In this viewpoint, we highlight data-driven implementation trials as catalysts for rigorous and scalable health system transformation. Specifically, we articulate the value proposition of data-driven implementation trials, examine their transformative potential toward learning health systems, and outline persistent challenges. Drawing on experiences from the UK and the US in large health systems, we propose actionable recommendations to optimize infrastructure, foster collaboration, secure health system-level commitments, and cultivate a culture that is grounded in IS while augmenting the impact of QI-critical steps toward realizing scalable, equitable healthcare innovation.

Suicide Prevention Among People of Different Races and Ethnicities in Large Health Systems: Implications for Practice

Psychiatric Services · 2025-11-06 · 1 citations

OBJECTIVE: This study examined receipt of three components (screening, risk assessment, and intervention) of the national Zero Suicide model among patients of various races-ethnicities who were treated in six large health systems. METHODS: The data included outpatient psychiatry and addiction medicine visits (N=4,682,918) during 2019 for patients age 13 and older. Documentation in the electronic health record of administration of the nine-item Patient Health Questionnaire, the Columbia-Suicide Severity Rating Scale, and lethal means counseling and provision of crisis resources (with or without a full Stanley-Brown Safety Plan) were used to define having received suicide screening, risk assessment, and intervention, respectively. RESULTS: After adjustment for age, sex, and health system, analyses indicated that Black patients were 12%-20% less likely (odds ratio [OR] range 1.12-1.20), and Asian patients were 5%-15% more likely (OR range 1.05-1.15), to be screened for suicidal ideation compared with patients of other races-ethnicities. Compared with White patients, patients of other races-ethnicities were found to be more likely (OR range 1.08-1.24) to receive risk assessment, and Asian and Black patients were found to be 17% (95% CI=1.02-1.35) and 15% (95% CI=1.01-1.32) more likely, respectively, to receive an evidence-based intervention for suicide prevention. American Indian/Alaska Native (AI/AN) patients had the lowest unadjusted rates of receiving an intervention (65.8%). CONCLUSIONS: The adjusted analyses suggested that more focus is needed on population-based screening for suicidal ideation and to improve delivery of evidence-based interventions for suicide prevention among White patients. The descriptive findings suggest that more research is needed to improve intervention delivery to AI/AN patients at risk of suicide.

Caregiver experiences with deimplementation of continuous pulse oximetry monitoring for children hospitalized with bronchiolitis: A qualitative study

Journal of Hospital Medicine · 2025-07-03

BACKGROUND: Continuous pulse oximetry monitoring in stable children with bronchiolitis not requiring supplemental oxygen has been identified as a low-value practice. However, little is known about how parents and other caregivers experience efforts to deimplement this practice. OBJECTIVES: This study investigated caregivers' experiences during their child's recent hospitalization for bronchiolitis on units involved in a deimplementation trial. METHODS: We conducted semi-structured qualitative interviews with 15 caregivers of children hospitalized with bronchiolitis at 11 hospitals participating in deimplementation strategies to reduce unnecessary continuous pulse oximetry monitoring as part of the Eliminating Monitoring Overuse (EMO) trial. Interviews were recorded, transcribed, and coded using an integrative analytic approach. RESULTS: Caregivers were a mean (SD) 31.1 (5.7) years old, predominantly female (93.3%), white (73.3%), and Non-Hispanic (86.7%). Previous hospitalization experiences and prior knowledge and training influenced caregiver perceptions of the value of monitoring. Participants did not discuss noticing changes in monitoring practices in interviews. CONCLUSIONS: Findings suggest that tailored education about monitoring may lessen caregiver concerns.

Zero Suicide Model Implementation and Suicide Attempt Rates in Outpatient Mental Health Care

JAMA Network Open · 2025-04-07 · 15 citations

Importance: Suicide is a major public health concern, and as most individuals have contact with health care practitioners before suicide, health systems are essential for suicide prevention. The Zero Suicide (ZS) model is the recommended approach for suicide prevention in health systems, but more evidence is needed to support its widespread adoption. Objective: To examine suicide attempt rates associated with implementation of the ZS model in outpatient mental health care within 6 US health systems. Design, Setting, and Participants: This quality improvement study with an interrupted time series design used data collected from January 2012 through December 2019, from patients aged 13 years or older who received mental health care at outpatient mental health specialty settings within 6 US health systems located in 5 states: California, Oregon, Washington, Colorado, and Michigan. Analyses were conducted from January through December 2024. Exposure: The ZS model was implemented in 4 health systems at different points during the observation period (2012-2019) and compared with health systems that implemented the model before the observation period (postimplementation). Implementation included suicide risk screening, assessment, brief intervention (safety plan, means safety protocol), and behavioral health treatment. Main Outcomes and Measures: The primary outcome was a measure of standardized monthly suicide attempt rates captured using health system records and government mortality records. Suicide death rates were also measured as a secondary outcome. Results: There was a median of 309 107 (range, 55 354-451 837) unique patients per month. In 2017, there were 317 939 eligible individuals (63.2% female). Baseline suicide attempt rates were at least 30 to 40 per 100 000 individuals at each implementation site and decreased to less than 30 per 100 000 individuals at 3 sites by 2019. Decreases in suicide attempt rates were observed at 3 intervention health systems after site-specific implementation: health systems A and B had decreases of 0.7 per 100 000 individuals per month and C, 0.1 per 100 000 individuals per month. System D evidenced a similar suicide attempt rate after implementation (before implementation: median rate: 35.0 [range, 11.0-50.3] per 100 000 patients per month; after implementation: median rate: 34.3 [range, 18.5-42.0] per 100 000 patients per month). The 2 postimplementation health systems maintained low or declining suicide attempt rates throughout the observation period. The rate at system Y decreased by 0.3 per 100 000 individuals per month across the observation period. The rate at system Z began at 11 per 100 000 individuals per month and declined by 0.03 per 100 000 individuals per month during the observation period. Two systems evidenced reductions in the suicide death rate after implementation: system B declined by 0.2 per 100 000 individuals per month and system C by 0.1 per 100 000 individuals per month. Conclusions and Relevance: In this quality improvement study, ZS model implementation was associated with a reduction in suicide attempt rates among patients accessing outpatient mental health care at most study sites, which supports widespread efforts to implement the ZS model in these settings within US health systems.

Pediatric Healthcare Worker Perspectives on Implementation of a Secure Firearm Storage Program: A Qualitative Study

BMC Pediatrics · 2025-10-08 · 1 citations

OBJECTIVE: Primary care-based secure firearm storage programs are well-positioned to prevent firearm-related injury, the leading cause of death for young people in the United States. While recommended by the American Academy of Pediatrics and US Surgeon General, these programs have yet to become routine practice. Our cluster randomized hybrid effectiveness-implementation trial studied implementation of a universal evidence-based secure firearm storage program, S.A.F.E. Firearm (Suicide and Accident Prevention through Family Education) across 30 clinics in two large health systems. S.A.F.E. Firearm includes a brief discussion between a clinician and parent on secure firearm storage and an offer of free cable locks at pediatric well-child visits for youth ages 5-17. The ASPIRE trial demonstrated meaningful clinician behavior change, with S.A.F.E. Firearm delivered to 49% of patient families in the clinics that received both trial implementation strategies. The present study qualitatively explores factors broadly influencing the successful implementation of S.A.F.E. Firearm, centering healthcare worker (HCW) perspectives. METHODS: Semi-structured qualitative interviews were conducted with leaders, clinic change agents, and clinicians involved in implementation from 2023 to 2024 (N = 38). The interview guide was informed by the original and updated Consolidated Framework for Implementation Research. Interviews were coded and analyzed using an abductive, integrated (i.e., deductive and inductive) approach. Inter-rater reliability (Kappa = 0.87) was strong. RESULTS: Interviews elucidated four interconnecting themes. HCWs unanimously expressed pediatric HCWs' responsibility to promote firearm safety (role of pediatrics in firearm safety) across heterogeneous community and healthcare firearm cultures. By preserving families' autonomy and privacy around firearms, S.A.F.E. Firearm's nonjudgemental and universal approach promoted program acceptability and delivery. Consequently, HCWs' understanding versus confusion around this universal, privacy-focused harm reduction approach was foundational to implementation. CONCLUSION: Health systems can harness HCWs' shared commitment to firearm safety by deploying brief programs that preserve recipient autonomy and privacy. To scale these evidence-based approaches, we recommend offering clear, simple trainings and collaboratively adapting programs to meet the needs of HCWs and recipients. TRIAL REGISTRATION: Registry https://clinicaltrials.gov/study/NCT04844021, TRN NCT04844021, first registered on April 14, 2021.

Improving the implementation and sustainment of evidence-based practices in community mental health organizations: a study protocol for a matched-pair cluster randomized pilot study of the Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS)

UNC Libraries · 2025-12-19

Harnessing Behavioral Economics to Accelerate Implementation in Rehabilitation

American Journal of Physical Medicine & Rehabilitation · 2025-05-09 · 3 citations

ABSTRACT: The rehabilitation field is advancing in the implementation of evidence-based practices into clinical care. Significant gaps remain, however, because of the complexity of patient populations and interventions, and resource intensive implementation strategies. Furthermore, implementation strategies are often designed for how clinicians ought to behave not how they actually behave. Translating evidence-based practices into practice requires behavior change among clinicians within organizational constraints. Behavioral economics is a field that combines insights from economics and psychology to explain human decision making and its impact on behavior. Nudges are strategies that are rooted in behavioral economic principles and guide decision-making without restricting choice. Nudges seek to make the optimal choice the easiest choice, without increasing clinician burden. This paper explores five applications from previous work that may accelerate implementation of evidence-based practice in the rehabilitation field: (1) embedding nudges within the electronic health record, (2) developing clinical decision support tools, (3) framing of performance feedback, (4) aligning nudges with existing workflows, and (5) applying the Easy-Attractive-Social-Timely Framework to ensure nudges are appropriately designed for the clinician and setting. Lastly, we discuss the special considerations of designing a nudge to avoid unintended consequences such as increased clinician burnout or alert fatigue.