Of the 20 hospitals with the highest and lowest adjusted mortality quartiles recruited for this study, 17 facilities agreed to participate. The facilities were geographically distributed across the U.S. and varied in size, patient population, management, and funding structure (Table 2). Among these 17 sites, three contacted clinical leaders denied participation and 31 (15 ICU MDs and 16 ICU RNs) agreed to participate (Table 3). Thematic data saturation was achieved.
Of the 12 themes generated, six were related to implementation facilitators and six were related to implementation barriers. Facilitators promoted the implementation of new critical care practices while barriers hindered the implementation of new critical care practices. We organized these themes into the five CFIR domains: (1) Intervention Characteristics, (2) Outer Setting, (3) Inner Setting, (4) Characteristics of Individuals, and (5) Process. Within these domains, themes mapped to 11 distinct CFIR constructs (Table 4).
I. Intervention Characteristics: The first CFIR domain is related to the characteristics of the innovation being implemented. We identified two major characteristics of new critical care practices that evidently influenced their implementation: (1) the ‘Intervention Source’ of the care practice, or whether it was externally or internally developed; and (2) the perceived ‘Complexity’ of the care practice.
Facilitator: Care practices that were informed by both external and internal sources were successfully adopted and adapted in local ICU settings. Especially given the unprecedented uncertainty around best critical care practices to treat COVID-19 patients, staff had increased confidence in implementing new practices that were externally endorsed and evidence-based. However, interviewees highlighted the need to critically evaluate external guidelines due to their rapidly changing and politically driven tendencies. Therefore, clinical leaders strived to select and implement practices that were informed by both external guidelines and internal review, testing, and refinement to ensure suitability to specific institutional context and needs.
We were relying a lot on WHO and we were trying to follow CDC guidelines. But then, we had such great thought leaders from our infectious disease department and infection practices plus our laboratory practices. Either interpreting those guidelines or modifying to meet our needs as an institution. So, I think our ID and our IPAC lab folks, really pulled a lot of weight and were able to say, ‘Okay, this is what CDC says but are we gonna be more conservative than that, you know? This is their guidance, but how do we wanna interpret it and implement it. And two, is it the right implementation for our institution?’ I mean how do we adapt it, maybe is the better way to say it for our institutional needs. (ICU Supervisor, 101)
Barrier: Increased complexity of COVID-19 critical care practices hindered efficient implementation of procedures. Largely due to high viral infectivity and transmissibility of COVID-19 and consequent increased safety precautions for staff and patients, familiar practices such as intubation, proning, and physically transferring patients required more time and resources.
When we intubate somebody, it was an ordeal. We had to have all of our equipment set up, all of our PPE on, and it was a whole process. It just took a lot longer and was a lot more complex than we normally did, a lot more resource intensive. (MD, 702)
II. Outer Setting: The ‘Outer Setting’ domain includes relationships and interactions a hospital has within the larger economic, political, and social context in which it resides. Within this domain, we identified both implementation facilitators and barriers related to the CFIR construct ‘Cosmopolitanism’, which captures the degree to which an organization is networked with other external organizations. We also identified a barrier tied to ‘External Policies’ that influenced sites’ abilities to prioritize ‘Patient Needs’.
Facilitator: Strong partnerships with external stakeholders, especially community leaders, local businesses, and other healthcare facilities, improved implementation efforts through promoting community support and cross-facility information and resource sharing. Participants revealed that established relationships with surrounding community members, groups, and organizations supported the implementation of new practices through providing needed resources and improving staff morale.
There was really just outstanding communication with our community leaders and with our organization leadership. From the frontline worker perspective, it was just such an intense outpouring of support by our community whether it be people making headbands with buttons to hold up the masks or caps. The community rallied and brought just an incredible amount of drinks and food. It was unbelievable, just the outpouring. It was tangible as far as supplies, too. (ICU Director of Nursing, 301)
Similarly, strong networks with government and other healthcare organizations supported implementation efforts through promoting the sharing of best practices and resources, including medical equipment and staff.
We had really great support from our sister facilities. So, we didn't purchase new things. But if I needed a food warmer, for whatever reason, I would just call another facility and they say, ‘Yep, we'll have it on the loading dock. Sending someone over.’ They would borrow things out to me and that was really nice to know that they would do that. (COVID ICU Manager, 401)
Barrier: Strict external infection prevention measures and policies that isolated patients from providers and families hampered the delivery of patient-centered critical care. Guidelines around infection prevention and social-distancing from external governing agencies such as the Centers for Disease Control and Prevention (CDC) compelled hospital leaders to enforce strict measures that isolated COVID-19 patients away from both providers and family members. The switch to socially-distanced care was consistently cited as one of the most challenging critical care practice changes for all stakeholders to cope with. While the practice was critical to prevent COVID transmission, it hindered staff’s ability to address the holistic needs of patients and their loved ones. Specifically, isolation policies created communication challenges between patients, providers, and families that compromised the social-emotional aspect of patient-centered care.
The physicians were not going into the rooms, so all the rounding was done outside the room. So, obviously that created some [patient-provider] relationship problems…we felt like the patients still deserve the same quality or standard of care that they had gotten prior to COVID and we felt like that was not happening. (RN, 901)
In addition to the patient-provider communication barriers that resulted from these mandates, staff struggled with implementing effective methods for virtually communicating with families.
The day-to-day flow with patients' families changed. That was very hard change for us being very patient and family-centered with our organization…With the change that occurred and families not being able to visit in the same way challenged us to really think outside the box with how we were going to proactively communicate. (ICU Director of Nursing, 301)
Barrier: Lack of consistent, reliable, and peer-reviewed guidance and information from trusted external resources impeded implementation of evidence-based practices. Participants explained the way in which uncertainty around best COVID-19 care practices was exacerbated by the unprecedented paucity of information from reputable sources.
We found that our societies, like the American Medical Association, all the other typical societies, were behind in getting information and processing it, because they weren't on the frontlines. And all the frontline doctors didn't have time to do the studies or do the work to get this information to them. So we weren't getting guidance from our typical resources. (RN, 1101)
In addition to hindering the implementation of evidence-based care for COVID-19 patients, the vacuum of information caused providers to experience frustration, fear, and distrust in decisions around best care practices, further impeding effective delivery of new care protocols.
With the lack of information people started speculating, and if you start speculating then you begin to distrust the process...with the lack of information people were frustrated, and obviously scared because of the unknown. (MD, 402)
III. Inner Setting: Within the third CFIR domain, which pertains to the structural characteristics, networks and communications, available resources, and culture within a hospital, we identified two facilitators and one barrier to implementation of new care practices. Major organizational factors that facilitated implementation efforts included strong ‘Networks and Communications’ and ‘Leadership Engagement’. The most significant barrier was lack of ‘Available Resources’.
Facilitator: Coordinated and collaborative network and communication structures contributed to efficient integration of new care practices. In response to the pandemic, many facilities established an incident command center, which promoted consistent and transparent communication of important information between hospital leaders, managers, and frontline staff.
I think having our incident command center there just to have information funneling through that structure was key to making sure we had good, consistent communication coming out. The cascade flow of information through the structure that we had in place was good. The collaboration, unbelievable collaboration –we already have great communication between our departments here but just the collaboration was at a new level. (ICU Medical Director, 302)
Another common strategy used by clinical leaders to cultivate organized and collaborative communication structures was frequent multidisciplinary meetings and rounds, which facilitated productive discussion and implementation of new care practices.
The key to our not success, but our survival was more the communications that were set up between us using the multidisciplinary rounds, so that we were able to share information throughout our hospital system. We were able to pass it along to everyone, so we could use a larger brain to troubleshoot ideas or bounce ideas or figure things out, as an ICU, we weren't left standing by ourselves trying to figure this out. (MD, 1102)
Facilitator: Strong leadership engagement, accessibility, and physical presence facilitated implementation efforts through supporting the needs of patients and frontline staff. Interviews revealed that the daily presence and direct assistance of mid- and high-level leaders on the floor was instrumental in cultivating a culture of teamwork and addressing implementation challenges related to the increased complexities of procedures and constrained resources.
It was very much a leadership from the front style, literally elbow to elbow with the staff in proning these patients, in intubating these patients and transporting these patients even. There was no hierarchical feel to it, because all of us were learning. (MD, 1702)
The immense appreciation frontline staff had for leadership presence is a testament to the meaningful impact it had on the daily delivery of care through reducing the overwhelming burdens felt by ICU frontline staff.
To see [hospital leaders] walking through and just the recognition rounds and just the appreciation rounds, that was, again, tangible because when you're in that environment, it was very overwhelming for our teams and just to be able to have them there and round through, that was very much appreciated. (RN, 300)
Barrier: Lack of adequate resources, including PPE, medical equipment, ICU-trained staff, space, and technology, often hindered implementation of care. Participants described the ways in which unprecedented resource challenges, especially PPE and medical equipment, disrupted implementation of care practices and infection prevention measures.
We’re reusing PPE. We never did anything like that before…I’ve been in the ICU for 30 years and never ever was in a situation where I had to reuse PPE... We had to change how often we were changing IV tubing because there was a national shortage of IV tubing, so a lot of our infection prevention measures changed because of reusing the PPE. (ICU Director of Nursing, 301)
In addition to inadequate supplies of necessary protective and medical equipment, major staffing shortages during the pandemic impacted delivery of care.
By Memorial Day we had every bed full and I didn't have half the amount of nurses I needed... So, now I have a huge nursing shortage on top of a huge nursing shortage. (COVID ICU Manager, 401)
IV. Characteristics of Individuals: Through elucidating the specific beliefs and characteristics of individuals involved with implementing the intervention or practice, the fourth CFIR domain recognizes that people are not passive recipients of innovations, but rather intimately engage with and influence implementation efforts. The vital role of the ‘Knowledge and Beliefs’ of frontline staff in the implementation of new care practices was evident throughout interviews.
Facilitator: Staff resilience and receptiveness to change promoted successful implementation of new care practices despite barriers. Participants highlighted the way in which staff’s passion for and dedication to critical care supported implementation efforts through fostering a sense of ownership in caring for patients and the overall community.
Besides the fear and the grief, and some of the emotional toll, there was also a call to arms. Like I was invigorated... I don't know, my love for critical care was reaffirmed again. (MD, 1102)
This ownership and commitment also reduced barriers associated with staffing shortages.
The easiest thing was finding people to cover. The vast majority of my colleagues and coworkers, would say, ‘Yeah, this is our job’ and they stepped up to the plate willingly. I think there was almost a sense of pride in that. (MD, 402)
Barrier: Low staff morale and burnout, largely caused by fear and anxiety, staffing shortages, change fatigue, and emotional and physical exhaustion, hindered delivery of quality critical care. ICU staff reported experiencing anxiety due to the uncertainty of the pandemic and fear of exposing themselves and their families to the virus.
It was the fear of the unknown. What would the patients be like? Would we have the tools and resources to care for these patients and the anxiety around the unknown of whether or not we would be able to care properly for the patients and then our own safety, both our physical and psychological safety. (RN, 601)
These negative emotions, exacerbated by feeling overworked, led to remarkable staff burnout, which participants described as disturbing both the healthcare system as a whole and uptake of local ICU practices.
It wasn't until I felt myself break and say I have to step away, did I realize how bad the burnout was. The staff came and really broke down to me...The burnout is real, the burnout, the PTSD, it's real, and the toll it took in healthcare is real. (COVID ICU Manager, 401).
V. Process: The last CFIR domain includes factors involved in the active change processes aimed at achieving individual and organizational implementation of practices. Our data revealed that productively ‘Engaging Staff’ in the change process facilitated implementation efforts, while siloed decision-making by ‘Implementation Leaders’ hindered implementation efforts.
Facilitator: Effectively engaging frontline staff throughout the implementation process fostered a robust, productive, and collaborative workforce highly capable of implementing new practices. Clinical leaders who effectively engaged staff in change processes often did so through soliciting and responding to staff needs and acknowledging staff efforts. Leadership sought out staff input during huddles, rounds, and town hall meetings and incorporated their feedback into decisions about practice changes. Engaging staff in decisions not only garnered staff buy-in around new practices but also generated valuable insights that helped guide selection and integration of practices.
Someone from the leadership team would huddle directly with the staff so that there could be bi-directional communication, questions and answers, if you will, because there were always lots of insightful questions. That's how we gained a lot of our insight was at those huddles. (RN, 601)
Even when leaders couldn’t fully address staff needs, they maintained engagement and support through validating staff concerns and appreciating their efforts.
Connecting with staff was important. Validating their concerns was very important. Because we didn't have solutions to every problem that people raised, being available was such a key thing. Then doing those little things, like ensuring that we acknowledged people when they did a great job taking care of a patient. (MD, 202)
Barrier: Governing the change process by authoritarian decision-making and lack of collaboration across leadership levels and departments hindered implementation efforts. Participants described the challenges associated with this process barrier, expressing the frustrations provoked when hospital leaders and administrators made unilateral decisions about practice changes without consulting providers and frontline staff.
Some frustration, of course, that’s expected when you are not involved with the decisions or know why were they made…We as critical care physicians were never involved much to be honest, like when they made the decision, are we going to open this unit, are we going to open, it was mainly infectious control and the CMO. I don’t think us as critical care physician had any role in that. (MD, 1502)
This authoritarian decision-making process governed by removed high-level hospital leaders also produced problematic decisions about practice changes that were not based on the realities of clinical practice on the floor, thereby exacerbating implementation challenges and tensions between administrators and frontline staff.
The Administrators think oh these things are the best idea ever. But yet they don't come to the bedside and they have no idea about the reality of it…The administrator, I knew how they would think. And I'm like you know what? I'm not even talking to them. Absolutely not. We are clinicians, we're going to make this decision. (ICU Director, 1202)