This issue of Medicina Intensiva presents two interesting observational studies describing current practices in mechanical ventilation (MV). We will focus on how these types of studies offer insight into current practices and how they serve to understand how we adopt evidence-based practices (EBP).

Frutos-Vivar et al.1 describe the practice of MV discontinuation in Spain across 18 years (4 cohorts, last in 2016). Amongst the findings, we see the expected disappearance of synchronized intermittent mandatory ventilation as a method to wean.2 However, we see the preferred methods to test readiness to liberate from MV are T-piece and a gradual decrease of pressure support (PS). This is in contrast with current recommendations of using a PS of 5–8cmH2O.3 Plotnikow et al.4 describe the process of MV in Argentina in a large multicentric 3-month observational study. This report shows evidence of widespread adoption of lung-protective strategies for all patients and through the ventilation timeline. The majority of patients spent their time on volume control continuous mandatory ventilation, and most had plateau pressure measurements (90%), more than in other recent cohorts.5 Similar to the Spanish cohort, the strategy chosen to test readiness to liberate from MV (T-piece) was discordant with the most recent MV liberation guidelines.3

In both studies, we see adoption and divergence from EBPs. These studies provide a view into how evidence, literature, and trends permeate into practice. Why is this relevant? From the academic standpoint, the ultimate goal of research is to improve patient care. However, knowledge of an EBP does not guarantee it will reach the patient. It is estimated that it takes 17 years for an EBP to become incorporated into routine clinical practice and only a fraction of EBPs reach widespread clinical use.6 Some interventions can be adopted rapidly7 while others remain underutilized.5 Why do we adopt some evidence and diverge from others? The emerging field of implementation science (IS) provides tools to investigate this question. One of these tools is the Consolidated Framework for Implementation Research (CFIR)8 (Table 1), a conceptual framework consisting of 37 constructs within 5 domains designed to aid in the implementation of EBPs.8 The CFIR can be used pre-implementation to guide a formative evaluation to identify barriers and facilitators, during implementation to monitor progress, and post-implementation to explore what factors impacted the use of an EBP.8 The use of a framework allows both implementation researchers and individuals responsible for quality improvement in healthcare to understand the context in which an EBP is being underutilized. Depending on the context, certain barriers to implementation may be more frequent.

We often think of two CFIR domains as the main drivers of implementation: IndividualsInvolved (e.g. clinician knowledge) and Inner Setting (e.g. ICU structure, resources).9 We often focus our academic discussions on the strength of the evidence and recommendations (CFIR construct: Evidence Strength and Quality). In the case of PS or T-piece for MV liberation, this is a conditional recommendation with moderate certainty in evidence3; a salient point, as this may impact the degree of personal belief about an intervention, which often serves as a precursor of behavior (Construct: Knowledge and beliefs about the Intervention). Frutos-Vivar et al. highlight the fit between intervention and workflow (Construct: Compatibility), where the use of modes that favor synchrony (such as PS) may be a reason why the practice migrated towards a decreasing PS maneuver.

Using an IS framework prompts systematic consideration of other domains which may impact the implementation of EBPs. For example, the Outer Setting (e.g. economic, political), Plotnikow et al hypothesize that a nationwide limitation of resources could have contributed to their results. Or in the case of Frutos-Vivar et al. where they found geographic heterogeneity in implementation of liberation practices; that is, regardless of having identical patient characteristics, no patient would get the same liberation strategy. These findings need further examination as they have relevance for patient care at a national level. Not only do conceptual frameworks aid to uncover barriers and facilitators systemically, but this knowledge also serves to inform intervention design and selection of implementation strategies10 to increase the use of EBPs.9

How should the principles and methods of IS be operationalized to improve the care of the studied patients? With over 100 conceptual models to help understand barriers and facilitators,11 the implementation process, and aid in the evaluation of implementation, there is no single model or framework that will fit all EBP evaluations. Working knowledge of several widely used frameworks will help determine which framework is best for a specific evaluation and/or context. While a recent review of IS studies in critical care settings found the most commonly reported strategies used were educational meetings, auditing and feedback, development of tools, and input from local opinion leaders,12 implementation strategies should be selected to target local barriers and facilitators. Implementing and sustaining change in any practice is not simple. Many of the resources and organizational structures may not be present at all institutions. However, familiarization with IS frameworks, implementation strategies, and implementation outcomes13 offers a pathway to improve the efficiency and chances of implementation success. Studies just as these1,4 help us understand our practice and map out interventions to implement interventions that will hopefully improve the lives of our patients and caregivers.