UNDERSTANDING THE MECHANISMS OF PROTOCOL IMPLEMENTATION FOR THE EARLY RECOGNITION AND TREATMENT OF PROBABLE SEPSIS

Abstract

The purpose of this research was to construct a program theory that identifies and describes the salient contexts and mechanisms that can lead to successful implementation of a sepsis screening intervention. Successful implementation of evidence-based clinical practice is governed by human and environmental factors that can differ between local settings (Sales, Smith, Curran, & Kochevar, 2006). Failed or partial implementation of clinical practices is common (Davies, Walker, & Grimshaw, 2010) impacting negatively on patient safety, patient outcomes, and systemic inefficiencies. A theory-based approach to implementation provides a structure that can allow local teams the ability to move away from ad hoc or intuitive planning (Eccles, Grimshaw, Walker, Johnston, & Pitts, 2002). A customized Rapid Realist Review was used to identify the hypothetical implementation resources, context, and mechanisms that are salient in causing successful implementation of sepsis screening interventions. This process included a rapid review of the literature using a realist analytical lens and multi-phase refinement of the theoretical propositions with 15 physicians and nurses. The final program theory included multiple outcomes that must be reached in order to achieve successful implementation. Successful implementation was defined as achieving fidelity and sustainability of the intervention. Salient implementation resources and context were identified that trigger three middle-range promoting mechanisms and two inhibiting mechanisms. Within each of these mechanisms there are multiple lower level mechanisms operating that are salient for all clinicians and professional sub-groups. The final program theory hypothesized the salient features of a complex reality that can be applied or adapted for the implementation of a sepsis screening intervention in other local contexts or for the implementation of other similar small-scale interventions.