Strategies for the implementation of clinical practice guidelines in the intensive care : a systematic review

Implementation strategies for the use of clinical practice guidelines are an integral component in bridging the gap between the best research evidence and clinical practice. However, despite some remarkable investments in health research regarding clinical practice guidelines implementation strategies, it is not yet known which of these are the most effective for intensive care units. The purpose of this research study was to systematically identify and /or search, appraise, extract and synthesize the best available evidence for clinical practice guidelines implementation strategies in intensive care units, in order to develop a draft guideline for clinical practice guidelines implementation strategies in the intensive care units. A systematic review design was used to systematically identify and /or search, appraise, extract and synthesize the best available evidence from the eligible included Level 2 studies (randomized controlled trials and quasi-experimental studies). Level 2 studies were applicable because they present robust evidence in the research results regarding effectiveness of clinical practice guideline implementation strategies. Furthermore, although other systematic reviews conducted in this area before, they included studies of In addition, no systematic review was identified that reviewed Level 2 studies and developed a guideline for clinical practice guideline implementation strategies in the intensive care units. Hence, including only Level 2 studies was distinctive to this research study. Databases searched included: CINAHL with full text, Google Scholar, Academic search complete, Cochrane Register for Randomized Controlled Trials Issue 8 of 12, August 2013, and MEDLINE via PUBMED. Hand search in bound journals was also done. The search strategy identified 315 potentially relevant studies. After the process of critical appraisal, thirteen Level 2 studies were identified as relevant for the review. Of the 13 relevant studies, 10 were randomized controlled trials and three were quasi experimental studies. After the critical appraisal ten RCTs were included in the systematic review. Three studies (quasi-experimental) were excluded on the basis of methodological quality after the critical appraisal and agreement by the two independent reviewers. The Joanna Briggs Institute Critical Appraisal MASTARI Instrument for Randomized Controlled trials/ Experimental studies, and The Joanna Briggs Institute data extraction tools were used to critically appraise, and extract data from the ten included randomized controlled trials. The two reviewers who performed the critical appraisal were qualified critical care professional nurses and experts in research methodology. These reviewers conducted the critical appraisal independently to ensure the objectivity of the process. Appropriate ethical considerations were maintained throughout the process of the research study. The results indicated that 80 percent of the included studies were conducted in adult intensive care units while 20 percent were conducted in the neonatal intensive care units. Furthermore, 60 percent of the studies were conducted in the United States of America, 10 percent in France, a further 10 percent in Taiwan, another 10 percent in England and yet another 10 percfent was conducted in Australia and Newzealand. The included studies utilized more than one (multifaceted) implementation strategies to implement clinical practice guidelines in the intensive care units. The first most utilized were: printed educational materials; Information/ educational sessions/meetings; audit and feedback and champion/local opinion leaders; seconded by educational outreach visits; and computer or internet usage. Third most used were active/passive reminders; systems support; academic detailing/ one-on-one sessions teleconferences/videoconferences and workshops/in services. Fourth most used were ollaboration/interdisciplinary teams; slide shows, teleconferences/videoconferences and discussions. Fifth most used were practical training; monitoring visits and grand rounds. However all the strategies were of equal importance. Conclusively, the included studies utilized multifaceted implementation strategies. However, no study indicated the use of a guideline for the implementation strategies in the process of clinical practice guidelines implementation. The systematic review developed a draft guideline for clinical practice guideline implementation strategies in the intensive care units. The guideline will enhance effective implementation of clinical practice guidelines in such a complex environment