{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T18:43:24Z","timestamp":1785523404401,"version":"3.56.0"},"reference-count":78,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,6,15]],"date-time":"2021-06-15T00:00:00Z","timestamp":1623715200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,6,15]],"date-time":"2021-06-15T00:00:00Z","timestamp":1623715200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000050","name":"National Heart, Lung, and Blood Institute","doi-asserted-by":"publisher","award":["1R01HL153735"],"award-info":[{"award-number":["1R01HL153735"]}],"id":[{"id":"10.13039\/100000050","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Implementation Sci"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>The Handoffs and Transitions in Critical Care\u2014Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Discussion<\/jats:title>\n                <jats:p>The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Trial registration<\/jats:title>\n                <jats:p>ClinicalTrials.gov identifier: <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/ct2\/results?term=NCT04571749\">NCT04571749<\/jats:ext-link>. Date of registration: October 1, 2020.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s13012-021-01131-1","type":"journal-article","created":{"date-parts":[[2021,6,15]],"date-time":"2021-06-15T08:03:02Z","timestamp":1623744182000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":18,"title":["Handoffs and transitions in critical care\u2014understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial"],"prefix":"10.1186","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7050-0017","authenticated-orcid":false,"given":"Meghan B.","family":"Lane-Fall","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Athena","family":"Christakos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5590-3376","authenticated-orcid":false,"given":"Gina C.","family":"Russell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bat-Zion","family":"Hose","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth D.","family":"Dauer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5811-601X","authenticated-orcid":false,"given":"Philip E.","family":"Greilich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3057-2635","authenticated-orcid":false,"given":"Bommy","family":"Hong Mershon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1973-922X","authenticated-orcid":false,"given":"Christopher P.","family":"Potestio","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erin W.","family":"Pukenas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John R.","family":"Kimberly","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alisa J.","family":"Stephens-Shields","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebecca L.","family":"Trotta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rinad S.","family":"Beidas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7553-0004","authenticated-orcid":false,"given":"Ellen J.","family":"Bass","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,6,15]]},"reference":[{"issue":"11","key":"1131_CR1","doi-asserted-by":"publisher","first-page":"1223","DOI":"10.1111\/j.1553-2712.2000.tb00467.x","volume":"7","author":"P Croskerry","year":"2000","unstructured":"Croskerry P. The cognitive imperative: Thinking about how we think. Acad Emerg Med. 2000;7(11):1223\u201331. https:\/\/doi.org\/10.1111\/j.1553-2712.2000.tb00467.x.","journal-title":"Acad Emerg Med."},{"issue":"5","key":"1131_CR2","doi-asserted-by":"publisher","first-page":"398","DOI":"10.1097\/MCC.0000000000000446","volume":"23","author":"JM Kahn","year":"2017","unstructured":"Kahn JM. Bringing implementation science to the intensive care unit. Curr Opin Crit Care. 2017;23(5):398\u20139. https:\/\/doi.org\/10.1097\/MCC.0000000000000446.","journal-title":"Curr Opin Crit Care."},{"issue":"8","key":"1131_CR3","doi-asserted-by":"publisher","first-page":"1015","DOI":"10.1164\/rccm.201608-1690ST","volume":"194","author":"CH Weiss","year":"2016","unstructured":"Weiss CH, Krishnan JA, Au DH, Bender BG, Carson SS, Cattamanchi A, et al. An Official American Thoracic Society research statement: implementation science in pulmonary, critical care, and sleep medicine. Am J Respir Crit Care Med. 2016;194(8):1015\u201325. https:\/\/doi.org\/10.1164\/rccm.201608-1690ST.","journal-title":"Am J Respir Crit Care Med."},{"issue":"14","key":"1131_CR4","doi-asserted-by":"publisher","first-page":"1480","DOI":"10.1001\/jama.2016.0154","volume":"315","author":"AB Cavalcanti","year":"2016","unstructured":"Cavalcanti AB, Bozza FA, Machado FR, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016;315(14):1480\u201390.","journal-title":"JAMA."},{"issue":"7","key":"1131_CR5","doi-asserted-by":"publisher","first-page":"677","DOI":"10.1097\/PCC.0000000000000790","volume":"17","author":"LB Justice","year":"2016","unstructured":"Justice LB, Cooper DS, Henderson C, Brown J, Simon K, Clark L, et al. Improving communication during cardiac ICU multidisciplinary rounds through visual display of patient daily goals. Pediatr Crit Care Med. 2016;17(7):677\u201383. https:\/\/doi.org\/10.1097\/PCC.0000000000000790.","journal-title":"Pediatr Crit Care Med."},{"issue":"8","key":"1131_CR6","doi-asserted-by":"publisher","first-page":"2015","DOI":"10.1097\/CCM.0b013e31828a435f","volume":"41","author":"D Lane","year":"2013","unstructured":"Lane D, Ferri M, Lemaire J, McLaughlin K, Stelfox HT. A systematic review of evidence-informed practices for patient care rounds in the ICU*. Crit Care Med. 2013;41(8):2015\u201329. https:\/\/doi.org\/10.1097\/CCM.0b013e31828a435f.","journal-title":"Crit Care Med."},{"key":"1131_CR7","doi-asserted-by":"crossref","unstructured":"Cox ED, Jacobsohn GC, Rajamanickam VP, et al. A family-centered rounds checklist, family engagement, and patient safety: a randomized trial. Pediatrics. 2017;139(5):e20161688.","DOI":"10.1542\/peds.2016-1688"},{"issue":"2","key":"1131_CR8","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1016\/j.chest.2017.03.054","volume":"152","author":"DK Costa","year":"2017","unstructured":"Costa DK, White MR, Ginier E, Manojlovich M, Govindan S, Iwashyna TJ, et al. Identifying barriers to delivering the awakening and breathing coordination, delirium, and early exercise\/mobility bundle to minimize adverse outcomes for mechanically ventilated patients: a systematic review. Chest. 2017;152(2):304\u201311. https:\/\/doi.org\/10.1016\/j.chest.2017.03.054.","journal-title":"Chest."},{"issue":"9607","key":"1131_CR9","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1016\/S0140-6736(08)60105-1","volume":"371","author":"TD Girard","year":"2008","unstructured":"Girard TD, Kress JP, Fuchs BD, Thomason JWW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008;371(9607):126\u201334. https:\/\/doi.org\/10.1016\/S0140-6736(08)60105-1.","journal-title":"Lancet."},{"issue":"2","key":"1131_CR10","doi-asserted-by":"publisher","first-page":"459","DOI":"10.1378\/chest.118.2.459","volume":"118","author":"GP Marelich","year":"2000","unstructured":"Marelich GP, Murin S, Battistella F, Inciardi J, Vierra T, Roby M. Protocol weaning of mechanical ventilation in medical and surgical patients by respiratory care practitioners and nurses: effect on weaning time and incidence of ventilator-associated pneumonia. Chest. 2000;118(2):459\u201367. https:\/\/doi.org\/10.1378\/chest.118.2.459.","journal-title":"Chest."},{"key":"1131_CR11","doi-asserted-by":"crossref","unstructured":"Zjadewicz K, Deemer KS, Coulthard J, Doig CJ, Boiteau PJ. Identifying what is known about improving operating room to intensive care handovers: a scoping review. Am J Med Qual. 2018;33(5):540\u20138.","DOI":"10.1177\/1062860618754701"},{"issue":"2","key":"1131_CR12","doi-asserted-by":"publisher","first-page":"207","DOI":"10.1177\/1558689819844038","volume":"14","author":"A Ross Perfetti","year":"2019","unstructured":"Ross Perfetti A, Peifer H, Massa S, et al. Mixing beyond measure: integrating methods in a hybrid effectiveness\u2013implementation study of operating room to intensive care unit handoffs. J Mixed Methods Res. 2019;14(2):207\u201326.","journal-title":"J Mixed Methods Res."},{"issue":"9","key":"1131_CR13","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1016\/j.jcjq.2018.02.004","volume":"44","author":"MB Lane-Fall","year":"2018","unstructured":"Lane-Fall MB, Pascual JL, Massa S, Collard ML, Peifer HG, di Taranti LJ, et al. Developing a standard handoff process for operating room-to-ICU transitions: multidisciplinary clinician perspectives from the handoffs and transitions in critical care (HATRICC) Study. Jt Comm J Qual Patient Saf. 2018;44(9):514\u201325. https:\/\/doi.org\/10.1016\/j.jcjq.2018.02.004.","journal-title":"Jt Comm J Qual Patient Saf."},{"key":"1131_CR14","unstructured":"Lane-Fall M, Pascual J, Peifer H, et al. A partially-structured postoperative handoff protocol improves communication in two mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. Ann Surg. 2018;Electronically published ahead of print."},{"issue":"21","key":"1131_CR15","doi-asserted-by":"publisher","first-page":"2262","DOI":"10.1001\/jama.2013.281961","volume":"310","author":"AJ Starmer","year":"2013","unstructured":"Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262\u201370. https:\/\/doi.org\/10.1001\/jama.2013.281961.","journal-title":"JAMA."},{"issue":"19","key":"1131_CR16","doi-asserted-by":"publisher","first-page":"1803","DOI":"10.1056\/NEJMsa1405556","volume":"371","author":"AJ Starmer","year":"2014","unstructured":"Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. New Engl J Med. 2014;371(19):1803\u201312. https:\/\/doi.org\/10.1056\/NEJMsa1405556.","journal-title":"New Engl J Med."},{"issue":"9","key":"1131_CR17","doi-asserted-by":"publisher","first-page":"1472","DOI":"10.1097\/CCM.0000000000002578","volume":"45","author":"MB Lane-Fall","year":"2017","unstructured":"Lane-Fall MB, Ramaswamy TS, Brown SES, He X, Gutsche JT, Fleisher LA, et al. Structural, nursing, and physician characteristics and 30-day mortality for patients undergoing cardiac surgery in Pennsylvania. Crit Care Med. 2017;45(9):1472\u201380. https:\/\/doi.org\/10.1097\/CCM.0000000000002578.","journal-title":"Crit Care Med."},{"issue":"10","key":"1131_CR18","doi-asserted-by":"publisher","first-page":"2076","DOI":"10.1097\/CCM.0000000000001157","volume":"43","author":"JE Sevransky","year":"2015","unstructured":"Sevransky JE, Checkley W, Herrera P, Pickering BW, Barr J, Brown SM, et al. Protocols and hospital mortality in critically ill patients: the United States critical illness and injury trials group critical illness outcomes study. Crit Care Med. 2015;43(10):2076\u201384. https:\/\/doi.org\/10.1097\/CCM.0000000000001157.","journal-title":"Crit Care Med."},{"issue":"Suppl 3","key":"1131_CR19","doi-asserted-by":"publisher","first-page":"S116","DOI":"10.1086\/677832","volume":"35","author":"KJ Ali","year":"2014","unstructured":"Ali KJ, Farley DO, Speck K, Catanzaro M, Wicker KG, Berenholtz SM. Measurement of implementation components and contextual factors in a two-state healthcare quality initiative to reduce ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 2014;35(Suppl 3):S116\u201323. https:\/\/doi.org\/10.1086\/677832.","journal-title":"Infect Control Hosp Epidemiol."},{"key":"1131_CR20","doi-asserted-by":"crossref","unstructured":"Abraham J, Meng A, Tripathy S, Avidan MS, Kannampallil T. Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs. BMJ Qual Saf. 2021;30(6):513\u201324.","DOI":"10.1136\/bmjqs-2020-012474"},{"key":"1131_CR21","doi-asserted-by":"crossref","unstructured":"Massa S, Wu J, Wang C, Peifer H, Lane-Fall MB. Interprofessional training and communication practices among clinicians in the postoperative ICU handoff. Jt Comm J Qual Patient Saf. 2020;47(4):242\u20139.","DOI":"10.1016\/j.jcjq.2020.12.004"},{"issue":"4","key":"1131_CR22","doi-asserted-by":"publisher","first-page":"S43","DOI":"10.1016\/j.jamcollsurg.2015.07.088","volume":"221","author":"ME Barry","year":"2015","unstructured":"Barry ME, Hochman BR, Lane-Fall MB, Zappile DM, Holena DN, Allen SR, et al. Operating room-to-ICU handoffs captured on video: are transitions at night more dangerous? J Am Coll Surg. 2015;221(4):S43. https:\/\/doi.org\/10.1016\/j.jamcollsurg.2015.07.088.","journal-title":"J Am Coll Surg."},{"issue":"1","key":"1131_CR23","doi-asserted-by":"publisher","first-page":"96","DOI":"10.1186\/1471-2482-14-96","volume":"14","author":"MB Lane-Fall","year":"2014","unstructured":"Lane-Fall MB, Beidas RS, Pascual JL, Collard ML, Peifer HG, Chavez TJ, et al. Handoffs and transitions in critical care (HATRICC): protocol for a mixed methods study of operating room to intensive care unit handoffs. BMC Surg. 2014;14(1):96. https:\/\/doi.org\/10.1186\/1471-2482-14-96.","journal-title":"BMC Surg"},{"key":"1131_CR24","doi-asserted-by":"publisher","first-page":"i6795","DOI":"10.1136\/bmj.i6795","volume":"356","author":"H Pinnock","year":"2017","unstructured":"Pinnock H, Barwick M, Carpenter CR, et al. Standards for Reporting Implementation Studies (StaRI) Statement. BMJ. 2017;356:i6795.","journal-title":"BMJ."},{"issue":"3","key":"1131_CR25","doi-asserted-by":"publisher","first-page":"217","DOI":"10.1097\/MLR.0b013e3182408812","volume":"50","author":"GM Curran","year":"2012","unstructured":"Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217\u201326. https:\/\/doi.org\/10.1097\/MLR.0b013e3182408812.","journal-title":"Med Care."},{"issue":"1","key":"1131_CR26","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1007\/s10488-010-0314-z","volume":"38","author":"LA Palinkas","year":"2011","unstructured":"Palinkas LA, Aarons GA, Horwitz S, Chamberlain P, Hurlburt M, Landsverk J. Mixed method designs in implementation research. Adm Policy Ment Health. 2011;38(1):44\u201353. https:\/\/doi.org\/10.1007\/s10488-010-0314-z.","journal-title":"Adm Policy Ment Health."},{"issue":"1","key":"1131_CR27","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1146\/annurev-publhealth-040617-014128","volume":"39","author":"MA Handley","year":"2018","unstructured":"Handley MA, Lyles CR, McCulloch C, Cattamanchi A. Selecting and improving quasi-experimental designs in effectiveness and implementation research. Annu Rev Public Health. 2018;39(1):5\u201325. https:\/\/doi.org\/10.1146\/annurev-publhealth-040617-014128.","journal-title":"Annu Rev Public Health."},{"issue":"4","key":"1131_CR28","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1017\/cts.2019.394","volume":"3","author":"N Cobb","year":"2019","unstructured":"Cobb N, Witte E, Cervone M, Kirby A, MacFadden D, Nadler L, et al. The SMART IRB platform: A national resource for IRB review for multisite studies. J Clin Transl Sci. 2019;3(4):129\u201339. https:\/\/doi.org\/10.1017\/cts.2019.394.","journal-title":"J Clin Transl Sci."},{"issue":"1","key":"1131_CR29","doi-asserted-by":"publisher","first-page":"102","DOI":"10.1213\/ANE.0b013e318253af4b","volume":"115","author":"N Segall","year":"2012","unstructured":"Segall N, Bonifacio AS, Schroeder RA, Barbeito A, Rogers D, Thornlow DK, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg. 2012;115(1):102\u201315. https:\/\/doi.org\/10.1213\/ANE.0b013e318253af4b.","journal-title":"Anesth Analg."},{"issue":"3","key":"1131_CR30","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1097\/PCC.0b013e3181fe25a1","volume":"12","author":"BF Joy","year":"2011","unstructured":"Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12(3):304\u20138. https:\/\/doi.org\/10.1097\/PCC.0b013e3181fe25a1.","journal-title":"Pediatr Crit Care Med."},{"issue":"7","key":"1131_CR31","doi-asserted-by":"publisher","first-page":"2109","DOI":"10.1097\/CCM.0b013e3182514bab","volume":"40","author":"HS Agarwal","year":"2012","unstructured":"Agarwal HS, Saville BR, Slayton JM, Donahue BS, Daves S, Christian KG, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. Crit Care Med. 2012;40(7):2109\u201315. https:\/\/doi.org\/10.1097\/CCM.0b013e3182514bab.","journal-title":"Crit Care Med."},{"issue":"3","key":"1131_CR32","doi-asserted-by":"publisher","first-page":"256","DOI":"10.1097\/PCC.0000000000000343","volume":"16","author":"RK Breuer","year":"2015","unstructured":"Breuer RK, Taicher B, Turner DA, Cheifetz IM, Rehder KJ. Standardizing postoperative PICU handovers improves handover metrics and patient outcomes. Pediatr Crit Care Med. 2015;16(3):256\u201363. https:\/\/doi.org\/10.1097\/PCC.0000000000000343.","journal-title":"Pediatr Crit Care Med."},{"key":"1131_CR33","doi-asserted-by":"crossref","unstructured":"Kaufman J, Twite M, Barrett C, et al. A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period. Jt Comm J Qual Patient Saf. 2013;39(7):306\u201311.","DOI":"10.1016\/S1553-7250(13)39043-6"},{"issue":"10","key":"1131_CR34","doi-asserted-by":"publisher","first-page":"1139","DOI":"10.1161\/CIR.0b013e3182a38efa","volume":"128","author":"JA Wahr","year":"2013","unstructured":"Wahr JA, Prager RL, Abernathy JH 3rd, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation. 2013;128(10):1139\u201369. https:\/\/doi.org\/10.1161\/CIR.0b013e3182a38efa.","journal-title":"Circulation."},{"issue":"4","key":"1131_CR35","doi-asserted-by":"publisher","first-page":"629","DOI":"10.1016\/j.amjsurg.2015.05.008","volume":"210","author":"LM McElroy","year":"2015","unstructured":"McElroy LM, Macapagal KR, Collins KM, et al. Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study. Am J Surg. 2015;210(4):629\u201335. https:\/\/doi.org\/10.1016\/j.amjsurg.2015.05.008.","journal-title":"Am J Surg."},{"issue":"1","key":"1131_CR36","doi-asserted-by":"publisher","first-page":"53","DOI":"10.1186\/s13012-015-0242-0","volume":"10","author":"P Nilsen","year":"2015","unstructured":"Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(1):53. https:\/\/doi.org\/10.1186\/s13012-015-0242-0.","journal-title":"Implement Sci."},{"issue":"1","key":"1131_CR37","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1007\/s10488-010-0327-7","volume":"38","author":"GA Aarons","year":"2011","unstructured":"Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38(1):4\u201323. https:\/\/doi.org\/10.1007\/s10488-010-0327-7.","journal-title":"Adm Policy Ment Health."},{"issue":"1","key":"1131_CR38","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1186\/1748-5908-8-35","volume":"8","author":"SA Flottorp","year":"2013","unstructured":"Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci. 2013;8(1):35. https:\/\/doi.org\/10.1186\/1748-5908-8-35.","journal-title":"Implement Sci."},{"issue":"1","key":"1131_CR39","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1007\/s10488-008-0197-4","volume":"36","author":"EK Proctor","year":"2009","unstructured":"Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009;36(1):24\u201334. https:\/\/doi.org\/10.1007\/s10488-008-0197-4.","journal-title":"Adm Policy Ment Health."},{"issue":"4","key":"1131_CR40","doi-asserted-by":"publisher","first-page":"351","DOI":"10.1177\/109019818801500401","volume":"15","author":"KR McLeroy","year":"1988","unstructured":"McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351\u201377. https:\/\/doi.org\/10.1177\/109019818801500401.","journal-title":"Health Educ Q."},{"key":"1131_CR41","doi-asserted-by":"publisher","first-page":"103033","DOI":"10.1016\/j.apergo.2019.103033","volume":"84","author":"P Carayon","year":"2020","unstructured":"Carayon P, Wooldridge A, Hoonakker P, Hundt AS, Kelly MM. SEIPS 3.0: Human-centered design of the patient journey for patient safety. Appl Ergon. 2020;84:103033.","journal-title":"Appl Ergon"},{"key":"1131_CR42","doi-asserted-by":"publisher","first-page":"103059","DOI":"10.1016\/j.apergo.2020.103059","volume":"85","author":"AR Wooldridge","year":"2020","unstructured":"Wooldridge AR, Carayon P, Hoonakker P, Hose BZ, Eithun B, Brazelton T III, et al. Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. Appl Ergon. 2020;85:103059. https:\/\/doi.org\/10.1016\/j.apergo.2020.103059.","journal-title":"Appl Ergon."},{"issue":"3","key":"1131_CR43","doi-asserted-by":"publisher","first-page":"214","DOI":"10.1093\/intqhc\/mzp016","volume":"21","author":"GT Jun","year":"2009","unstructured":"Jun GT, Ward J, Morris Z, Clarkson J. Health care process modelling: which method when? Int J Qual Health C. 2009;21(3):214\u201324. https:\/\/doi.org\/10.1093\/intqhc\/mzp016.","journal-title":"Int J Qual Health C."},{"issue":"3","key":"1131_CR44","doi-asserted-by":"publisher","first-page":"369","DOI":"10.1111\/j.1442-2018.2010.00541.x","volume":"12","author":"GR Sadler","year":"2010","unstructured":"Sadler GR, Lee HC, Lim RS, Fullerton J. Recruitment of hard-to-reach population subgroups via adaptations of the snowball sampling strategy. Nurs Health Sci. 2010;12(3):369\u201374. https:\/\/doi.org\/10.1111\/j.1442-2018.2010.00541.x.","journal-title":"Nurs Health Sci."},{"key":"1131_CR45","doi-asserted-by":"crossref","unstructured":"Hart SG, Staveland LE. Development of NASA-TLX (Task Load Index): results of empirical and theoretical research. In: Hancock PA, Meshkati N, eds. Advances in Psychology. Vol 52. Amsterdam: North-Holland; 1988:139-183.","DOI":"10.1016\/S0166-4115(08)62386-9"},{"key":"1131_CR46","unstructured":"Schuler D, Namioka A. Participatory design: principles and practices: CRC Press, Taylor & Francis Group; 1993."},{"issue":"2","key":"1131_CR47","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1136\/jamia.1998.0050177","volume":"5","author":"C Sj\u00f6berg","year":"1998","unstructured":"Sj\u00f6berg C, Timpka T. Participatory design of information systems in health care. J Am Med Informatics Assoc. 1998;5(2):177\u201383. https:\/\/doi.org\/10.1136\/jamia.1998.0050177.","journal-title":"J Am Med Informatics Assoc."},{"issue":"Suppl 1","key":"1131_CR48","doi-asserted-by":"publisher","first-page":"S40","DOI":"10.2105\/AJPH.2009.184036","volume":"100","author":"N Wallerstein","year":"2010","unstructured":"Wallerstein N, Duran B. Community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. Am J Public Health. 2010;100(Suppl 1):S40\u20136.","journal-title":"Am J Public Health"},{"issue":"11","key":"1131_CR49","doi-asserted-by":"publisher","first-page":"e0186744","DOI":"10.1371\/journal.pone.0186744","volume":"12","author":"AN Bazzano","year":"2017","unstructured":"Bazzano AN, Martin J, Hicks E, Faughnan M, Murphy L. Human-centred design in global health: a scoping review of applications and contexts. Plos One. 2017;12(11):e0186744. https:\/\/doi.org\/10.1371\/journal.pone.0186744.","journal-title":"Plos One."},{"key":"1131_CR50","doi-asserted-by":"crossref","unstructured":"Finlay L. The Reflexive Journey: mapping multiple routes. In: Finlay L, Gough B, eds. Reflexivity: a practical guide for researchers in health and social sciences. New Jersey: Blackwell Science (Wiley); 2003:3-20.","DOI":"10.1002\/9780470776094.ch1"},{"key":"1131_CR51","doi-asserted-by":"crossref","unstructured":"Fernandez ME, ten Hoor GA, van Lieshout S, et al. Implementation mapping: using intervention mapping to develop implementation strategies. Front Public Health. 2019;7:158.","DOI":"10.3389\/fpubh.2019.00158"},{"issue":"1","key":"1131_CR52","doi-asserted-by":"publisher","first-page":"54","DOI":"10.1186\/1471-2288-6-54","volume":"6","author":"CA Brown","year":"2006","unstructured":"Brown CA, Lilford RJ. The stepped wedge trial design: a systematic review. BMC Med Res Methodol. 2006;6(1):54. https:\/\/doi.org\/10.1186\/1471-2288-6-54.","journal-title":"BMC Med Res Methodol."},{"key":"1131_CR53","unstructured":"Mathematica. Patient safety indicators (TM) v2019 ICD-10-CM\/PCS Benchmark Data Tables. Rockville: Mathematica; 2019.\u00a0Accessed 5\/31\/2021."},{"key":"1131_CR54","doi-asserted-by":"crossref","unstructured":"Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, Boynton MH, Halko H. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12:108.","DOI":"10.1186\/s13012-017-0635-3"},{"key":"1131_CR55","doi-asserted-by":"crossref","unstructured":"Hoeft TJ, Wilcox H, Hinton L, Un\u00fctzer J. Costs of implementing and sustaining enhanced collaborative care programs involving community partners. Implement Sci. 2019;14(1):37.","DOI":"10.1186\/s13012-019-0882-6"},{"key":"1131_CR56","unstructured":"Mathematica. Quality indicator user guide: Patient Safety Indicators (PSI) composite measures. Rockville, MD July 2019. https:\/\/www.qualityindicators.ahrq.gov\/Downloads\/Modules\/PSI\/V2019\/PSI_Composite_Development.pdf. Accessed 31 May 2021."},{"issue":"4","key":"1131_CR57","doi-asserted-by":"publisher","first-page":"695","DOI":"10.1097\/ALN.0000000000000401","volume":"121","author":"L Saager","year":"2014","unstructured":"Saager L, Hesler BD, You J, Turan A, Mascha EJ, Sessler DI, et al. Intraoperative transitions of anesthesia care and postoperative adverse outcomes. Anesthesiology. 2014;121(4):695\u2013706. https:\/\/doi.org\/10.1097\/ALN.0000000000000401.","journal-title":"Anesthesiology."},{"issue":"2","key":"1131_CR58","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1001\/jama.2017.20040","volume":"319","author":"PM Jones","year":"2018","unstructured":"Jones PM, Cherry RA, Allen BN, Jenkyn KMB, Shariff SZ, Flier S, et al. Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. JAMA. 2018;319(2):143\u201353. https:\/\/doi.org\/10.1001\/jama.2017.20040.","journal-title":"JAMA."},{"issue":"1","key":"1131_CR59","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1053\/j.jvca.2014.05.018","volume":"29","author":"CC Hudson","year":"2015","unstructured":"Hudson CC, McDonald B, Hudson JK, Tran D, Boodhwani M. Impact of anesthetic handover on mortality and morbidity in cardiac surgery: a cohort study. J Cardiothorac Vasc Anesth. 2015;29(1):11\u20136. https:\/\/doi.org\/10.1053\/j.jvca.2014.05.018.","journal-title":"J Cardiothorac Vasc Anesth."},{"issue":"1","key":"1131_CR60","doi-asserted-by":"publisher","first-page":"134","DOI":"10.1213\/ANE.0000000000000692","volume":"122","author":"JA Hyder","year":"2016","unstructured":"Hyder JA, Bohman JK, Kor DJ, Subramanian A, Bittner EA, Narr BJ, et al. Anesthesia care transitions and risk of postoperative complications. Anesth Analg. 2016;122(1):134\u201344. https:\/\/doi.org\/10.1213\/ANE.0000000000000692.","journal-title":"Anesth Analg."},{"issue":"4","key":"1131_CR61","doi-asserted-by":"publisher","first-page":"690","DOI":"10.1097\/ALN.0000000000001246","volume":"125","author":"MA Terekhov","year":"2016","unstructured":"Terekhov MA, Ehrenfeld JM, Dutton RP, Guillamondegui OD, Martin BJ, Wanderer JP. Intraoperative care transitions are not associated with postoperative adverse outcomes. Anesthesiology. 2016;125(4):690\u20139. https:\/\/doi.org\/10.1097\/ALN.0000000000001246.","journal-title":"Anesthesiology."},{"issue":"4","key":"1131_CR62","doi-asserted-by":"publisher","first-page":"239","DOI":"10.1017\/cts.2018.316","volume":"2","author":"AA Baumann","year":"2018","unstructured":"Baumann AA, Morshed AB, Tabak RG, Proctor EK. Toolkits for dissemination and implementation research: preliminary development. J Clin Transl Sci. 2018;2(4):239\u201344. https:\/\/doi.org\/10.1017\/cts.2018.316.","journal-title":"J Clin Transl Sci."},{"key":"1131_CR63","unstructured":"California Social Work Education Center. Implementation Toolkits: implementation in the human services. https:\/\/calswec.berkeley.edu\/toolkits\/implementation-toolkits. Published 2019. Accessed 9\/28\/2019."},{"issue":"1","key":"1131_CR64","doi-asserted-by":"publisher","first-page":"86","DOI":"10.1186\/s43058-020-00081-x","volume":"1","author":"K Thoele","year":"2020","unstructured":"Thoele K, Ferren M, Moffat L, Keen A, Newhouse R. Development and use of a toolkit to facilitate implementation of an evidence-based intervention: a descriptive case study. Implement Sci Commun. 2020;1(1):86. https:\/\/doi.org\/10.1186\/s43058-020-00081-x.","journal-title":"Implement Sci Commun."},{"key":"1131_CR65","doi-asserted-by":"crossref","unstructured":"Woods DD, Patterson ES, Corban JM, Watts JC. Bridging the gap between user-centered intentions and actual design practice. Paper presented at: Proceedings of the 1996 40th Annual Meeting of the Human Factors and Ergonomics Society1996; Santa Monica, CA, United States.","DOI":"10.1177\/154193129604001903"},{"issue":"4","key":"1131_CR66","doi-asserted-by":"publisher","first-page":"591","DOI":"10.1177\/1049732316665344","volume":"27","author":"MM Hennink","year":"2017","unstructured":"Hennink MM, Kaiser BN, Marconi VC. Code saturation versus meaning saturation: how many interviews are enough? Qual Health Res. 2017;27(4):591\u2013608. https:\/\/doi.org\/10.1177\/1049732316665344.","journal-title":"Qual Health Res."},{"issue":"4","key":"1131_CR67","doi-asserted-by":"publisher","first-page":"407","DOI":"10.1016\/0197-2456(89)90005-6","volume":"10","author":"R Jaeschke","year":"1989","unstructured":"Jaeschke R, Singer J, Guyatt GH. Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials. 1989;10(4):407\u201315. https:\/\/doi.org\/10.1016\/0197-2456(89)90005-6.","journal-title":"Control Clin Trials."},{"key":"1131_CR68","doi-asserted-by":"crossref","unstructured":"Guest G, MacQueen KM, Namey E, E. Applied Thematic Analysis. Thousand Oaks: Sage Publications; 2011.","DOI":"10.4135\/9781483384436"},{"key":"1131_CR69","first-page":"292","volume-title":"Qualitative Inquiry in Clinical and Educational Settings","author":"DG Hays","year":"2011","unstructured":"Hays DG, Singh AA. The basics of qualitative data management and analysis. In: Qualitative Inquiry in Clinical and Educational Settings. New York: Guilford Press; 2011. p. 292\u2013336."},{"key":"1131_CR70","doi-asserted-by":"crossref","unstructured":"Bolton M, Bass E. Using task analytic models to visualize model checker counterexamples. Paper presented at: IEEE International Conference on Systems, Man, and Cybernetics2010; Istanbul, Turkey.","DOI":"10.1109\/ICSMC.2010.5641711"},{"key":"1131_CR71","unstructured":"Sockolow P, Yang Y, Bass E, Bowles K, Holmberg A, Potashnik S. Data visualization of home care admission nurses\u2019 decision-making. Paper presented at: American Medical Informatics Association2017; Washington, DC."},{"key":"1131_CR72","unstructured":"Hammond K. Principles of organization in intuitive and analytical cognition. Center for Research on Judgment and Policy, Institute of Behavioral Science, University of Colorado.\u00a0Boulder;\u00a01981."},{"issue":"3","key":"1131_CR73","doi-asserted-by":"publisher","first-page":"456","DOI":"10.1518\/001872008X288385","volume":"50","author":"G Klein","year":"2008","unstructured":"Klein G. Naturalistic decision making. Hum Factors. 2008;50(3):456\u201360. https:\/\/doi.org\/10.1518\/001872008X288385.","journal-title":"Hum Factors."},{"issue":"1","key":"1131_CR74","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1186\/s12916-015-0488-z","volume":"13","author":"DJ Niven","year":"2015","unstructured":"Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, et al. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med. 2015;13(1):255. https:\/\/doi.org\/10.1186\/s12916-015-0488-z.","journal-title":"BMC Med."},{"issue":"5","key":"1131_CR75","doi-asserted-by":"publisher","first-page":"801","DOI":"10.1001\/jamainternmed.2015.0157","volume":"175","author":"DJ Niven","year":"2015","unstructured":"Niven DJ, Rubenfeld GD, Kramer AA, Stelfox HT. Effect of published scientific evidence on glycemic control in adult intensive care units. JAMA Intern Med. 2015;175(5):801\u20139. https:\/\/doi.org\/10.1001\/jamainternmed.2015.0157.","journal-title":"JAMA Intern Med."},{"issue":"10","key":"1131_CR76","doi-asserted-by":"publisher","first-page":"1443","DOI":"10.1007\/s00134-019-05694-y","volume":"45","author":"HT Stelfox","year":"2019","unstructured":"Stelfox HT, Bourgault AM, Niven DJ. De-implementing low value care in critically ill patients: a call for action-less is more. Intensive Care Med. 2019;45(10):1443\u20136. https:\/\/doi.org\/10.1007\/s00134-019-05694-y.","journal-title":"Intensive Care Med."},{"issue":"11","key":"1131_CR77","doi-asserted-by":"publisher","first-page":"2627","DOI":"10.1097\/CCM.0b013e3182982b03","volume":"41","author":"T Sinuff","year":"2013","unstructured":"Sinuff T, Muscedere J, Adhikari NK, Stelfox HT, Dodek P, Heyland DK, et al. Knowledge translation interventions for critically ill patients: a systematic review*. Crit Care Med. 2013;41(11):2627\u201340. https:\/\/doi.org\/10.1097\/CCM.0b013e3182982b03.","journal-title":"Crit Care Med."},{"issue":"1","key":"1131_CR78","doi-asserted-by":"publisher","first-page":"32","DOI":"10.1186\/1748-5908-7-32","volume":"7","author":"GA Aarons","year":"2012","unstructured":"Aarons GA, Green AE, Palinkas LA, Self-Brown S, Whitaker DJ, Lutzker JR, et al. Dynamic adaptation process to implement an evidence-based child maltreatment intervention. Implement Sci. 2012;7(1):32. https:\/\/doi.org\/10.1186\/1748-5908-7-32.","journal-title":"Implement Sci."}],"container-title":["Implementation Science"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13012-021-01131-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13012-021-01131-1\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13012-021-01131-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,6,15]],"date-time":"2021-06-15T08:04:48Z","timestamp":1623744288000},"score":1,"resource":{"primary":{"URL":"https:\/\/implementationscience.biomedcentral.com\/articles\/10.1186\/s13012-021-01131-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6,15]]},"references-count":78,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2021,12]]}},"alternative-id":["1131"],"URL":"https:\/\/doi.org\/10.1186\/s13012-021-01131-1","relation":{},"ISSN":["1748-5908"],"issn-type":[{"value":"1748-5908","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6,15]]},"assertion":[{"value":"12 May 2021","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"26 May 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 June 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was reviewed and approved by the institutional review board (IRB) at the University of Pennsylvania on November 9, 2020 (protocol #843670). In compliance with National Institutes of Health requirements, all participating sites have agreed to rely on a single IRB (sIRB); the University of Pennsylvania IRB is the designated sIRB. Reliance agreements were obtained from all participating sites.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"RSB receives royalties from Oxford University Press. She has served as a consultant to Camden Coalition of Healthcare Providers. She provides consultation to United Behavioral Health. She serves on the Clinical and Scientific Advisory Board for Optum Behavioral Health. The remaining authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"63"}}