Determinants of Evidence-based Practice Uptake in Rural Intensive Care Units. A Mixed Methods Study

Rationale: Evidence-based practices promote quality care for intensive care unit patients but chronic evidence-to-practice gaps limit their reach.Objectives: To characterize key determinants of evidence-based practice uptake in the rural intensive care setting.Methods: A parallel convergent mixed methods design was used with six hospitals receiving a quality improvement intervention. Guided by implementation science principles, we identified barriers and facilitators to uptake using clinician surveys (N = 90), key informant interviews (N = 14), and an implementation tracking log. Uptake was defined as completion of eight practice change steps within 12 months. After completing qualitative and quantitative data analyses for each hospital, site, staff, and program delivery factors were summarized within and across hospitals to identify patterns by uptake status.Results: At the site level, although structural characteristics (hospital size, intensivist staffing) did not vary by uptake status, interviews highlighted variability in staffing patterns and culture that differed by uptake status. At the clinician team level, readiness and self-efficacy were consistently high across sites at baseline with time and financial resources endorsed as primary barriers. However, interviews highlighted that as initiatives progressed, differences across sites in attitudes and ownership of change were key uptake influences. At the program delivery level, mixed methods data highlighted program engagement and leadership variability by uptake status. Higher uptake sites had better training attendance; more program activities completed; and a stable, engaged, collaborative nurse and physician champion team.Conclusions: Results provide an understanding of the multiple dynamic influences on different patterns of evidence-based practice uptake and the importance of implementation support strategies to accelerate uptake in the intensive care setting.