Adaptation and Implementation of SBIRT for Adolescents With Chronic Medical Conditions Hospitalized in Pediatric Inpatient Units

APPROACH Overview. This study has three specific aims. Aim 1a involves observations of the inpatient units' clinical workflows to conduct mixed-methods assessments focused on integration of SBIRT into EHR documentation procedures. Aim 1b involves HCD/ECD methodology, including Partner Steering Committee (PSC) assembly and ideation sessions. These sessions will focus on iterative co-creation of SBIRT adaption to the inpatient setting and pediatric population, and two interactive rounds of initial implementation field testing with end users in one inpatient unit. Aim 2 includes a partner-driven method to collaboratively identify, select, and prioritize SBIRT implementation strategies to test in a pilot trial. Aim 3 is a single arm pilot hybrid type III SBIRT effectiveness-implementation trial in which two inpatient units will receive the optimized strategies to integrate SBIRT into their treatment workflow.

Specific Aims 1a and 1b: Months 1-18 Aim1a: Observations of Inpatient Workflows (Aim 1a: Months 1-6). The research team and I will complete 4 months of observations on two inpatient units (i.e., Division of Pulmonary and Sleep Medicine and Division of Nephrology) that identified as units of high need for SBIRT during my K12 project. Understanding clinical workflows is a crucial first step to improve the quality, safety, and efficiency of patient care delivery. Observations of clinical workflows enable quality improvement processes, provide a basis to compare and quantify workflow improvements through mixed-methods analysis, and promote a LHS by assessing a variety of clinical and real-world data. Under the guidance of Dr. Franklin, my research team and I will observe current clinical procedures for recording AOD screening data in the EHR to determine areas where SBIRT can be integrated into standard EHR documentation procedures.

The research team and I will use the Clinical Workflow Analysis Tool (CWAT) during workflow observation. CWAT interfaces with the EHR by identifying workflow patterns, bottlenecks, and context of current AOD use screening. The investigators will access the CWAT through a department issued tablet to maintain logs of qualitative and quantitative data such as the timing, location, and duration of AOD use screening, clinicians providing the screening (attending physicians, nurse practitioners, social workers, physician assistants, or residents) and type of information logged in the EHR. The research team and I will also use components of the Health Equity Implementation Framework (HEIF) as an observation guide focusing on interactions between patients and clinicians (clinical encounters), current AOD use screening questions (current intervention) and the setting (context) to identify areas to strengthen accessibility and inclusion in the clinical workflow. Four trained research assistants will observe daily clinical procedures and meetings (e.g., patient intakes, rounds, history & physical exams, case conferences etc.) in pairs for 5 hours three times weekly during high peak times in the units (9 - 2pm or 2pm - 7pm) for 16 weeks (240 hours per unit for a total of 480 hours).

During months 4 and 5 Dr. Danny Wu and I will use the CWAT to take these data and generate interactive visualizations to help identify and interpret workflow patterns. The visualization design will follow Munzner's nested model53 and generate four visual analytic components, including task analysis, sequential pattern analysis, location analysis, and task-location analysis. This aim will culminate in a visual workflow map and narrative of key observations to inform discussion with the PSC in Aim 1b.

Aim 1b: Collaborate with hospital partners using HCD/ECD methods to optimize SBIRT's fit for the inpatient setting (Aim 1b; Months 7-18). Building upon Aim1a, I will employ HCD/ECD methods to ensure fit between the intervention, population, and system (e.g., workflow processes and clinical context) in which SBIRT will be delivered (). This optimization process consists of two steps that will take 12 months. Step 1 involves assembling an interdisciplinary Partner Steering Committee (PSC, months 7-8) and step 2 includes ideation sessions (months 9-18) with the PSC. Each month, PSC members will meet for two hours.