Patients with acute heart failure (AHF) discharged directly from emergency departments (EDs) are at high risk for 30-day revisits, readmissions, and mortality. Most transitional care interventions have focused on inpatient settings, thereby excluding this vulnerable population. Our team developed a self-care coaching intervention called Get with the Guidelines in Emergency Department Patients with Heart Failure (GUIDED-HF) to address care transitions for patients with AHF discharged from EDs, aiming to improve patient self-management and clinical outcomes. We describe the implementation outcomes of a large hybrid type 2 study conducted across six EDs in two geographically diverse healthcare systems, guided by Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Care Transitions Intervention frameworks. We employed a multifaceted implementation strategy that included a best practice alert in the electronic health record, identification of local champions, educational meetings, and implementation of audit and feedback mechanisms. Data was collected through ED staff surveys, electronic health records, and monthly tracking sheets to assess implementation outcomes of reach, adoption, implementation, and maintenance. Clinical effectiveness is reported elsewhere. The study reached 37
Sustainment and sustainability of implemented complex evidence-based interventions in mental health settings remain an under-researched area of implementation science. Understanding what contributes to the ongoing use of evidence-based practices (EBPs) can inform all stages of implementation and help ensure effective treatment for patients. This study evaluated the sustainment of evidence-based practice for post-traumatic stress disorder in Norwegian mental healthcare 1, 2 or 3 years after the completion of a one-year implementation support provided to clinics between 2018 and 2022. The implementation support was based on the Leadership and Organizational Change for Implementation strategy (LOCI). We measured implementation climate immediately after the implementation support period ended, and sustainment and organizational capacity for sustainability 1, 2 or 3 years after. We examined the relationship between organizational capacity for sustainability and implementation climate in relation to sustainment using mixed-effect modelling. Eleven out of 43 clinics (25.6
Hospital-at-Home (HaH) delivers hospital-level acute care in patients’ homes, improving patient experience and cost-efficiency. Despite these advantages, scaling HaH remains challenging, and determinants of successful scale-up are poorly understood. The aim of this study is to examine contextual determinants and scaling strategies associated with the scale-up of a HaH service. A retrospective observational cohort study grounded in implementation theory was conducted from May 2022 to April 2025 to examine the planned scale-up of a HaH service in western Singapore, across three phases: “developing the scalable unit” (6–25 beds), “test of scale-up” (25–50 beds), and “go to full scale” (50–90 beds). Monthly outcomes mapped to the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation) were assessed alongside contextual factors and scaling strategies informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Linear and Poisson regression models examined associations between context, strategies and RE-AIM outcomes. Over 36 months, 3,908 patients were admitted (Phase 1 = 792; Phase 2 = 2,069, Phase 3 = 1,047). Reach, defined as proportion of virtual beds relative to the total bed capacity of referring hospitals rose from 0.6
The Implementation Research Logic Model (IRLM) was developed to help implementation researchers specify relationships among determinants, implementation strategies, mechanisms, and outcomes. Although the IRLM is intended to support planning, execution, reporting, and synthesis, it is often treated as a static product used for one purpose—most commonly for planning. Even when used across these purposes, a reporting gap may arise when strategies are adapted, bundled, discontinued, or implemented differently across sites. However, the IRLM can be used to execute and track the study or implementation effort. We describe a structured method for using the IRLM across three versions and outputs: (1) a protocol IRLM that represents the study’s theory-of-intent; (2) a tracked revision of the IRLM that documents changes, rationales, and evidence sources for adaptations and modifications; and (3) a final reconciled IRLM that represents the enacted theory-in-use. We illustrate the use of this methodology with the Apolipoprotein L1 (APOL1) Counseling and Testing Program, a hybrid type 2 effectiveness-implementation study using a two-site non-randomized trial of culturally competent APOL1 genetic testing, a conversational agent (chatbot), and nephrologist-delivered counseling for living kidney donor evaluation. Applying the versioned IRLM method to the APOL1 trial generated a strategy execution matrix and a revised set of context-strategy-mechanism-outcome linkages. The process made visible several forms of protocol-to-practice change including: discontinued electronic health record (EHR) integration strategies, adapted conversational agent and educational brochure delivery, site-specific task shifting, bundled stakeholder engagement strategies, and modifications to nephrologist training supports. Mechanism reassessment led to adding donor empowerment, separating communication from coordination, and removing an EHR-related complex mechanism that was no longer actionable. Treating the IRLM as a dynamic implementation product can improve transparency about what happened during implementation trials, why actions taken differed from the protocol, and how those differences alter hypothesized causal pathways and outcomes. This method complements longitudinal strategy tracking approaches and can support reporting, interpretability, replication, scale-up, and mechanism-focused implementation science.
Electronic audit and feedback is a widely used implementation strategy for improving clinician practice, yet interventions demonstrate variable effectiveness. Current approaches to electronic audit and feedback development rely heavily on subjective usability feedback and rarely include prospective optimisation prior to implementation. This may contribute to repeated redesign cycles when engagement barriers are only identified after deployment, representing an underexamined contributor to slower implementation pathways. We developed and tested a theory-informed methodology for prospectively evaluating engagement with electronic audit and feedback interventions. Central to the methodology was an a priori framework linking each element in the tool to its intended behavioural change technique (BCT), hypothesised behavioural mechanism, and required level of visual attention. To test the methodology, health professionals enrolled as investigators in an international multi-site penicillin allergy implementation study (international Network of Antibiotic Allergy Nations) reviewed their site-specific electronic audit and feedback report while wearing an eye-tracker and completing a subsequent think-aloud protocol. Gaze data and think-aloud data were independently analysed and then integrated to examine whether observed engagement aligned with the intervention’s intended behavioural design. Integration of gaze and think-aloud data identified convergence and divergence between intended and observed engagement with BCT-linked interface elements. Of 29 areas of interest, 14 were Convergent (intended and observed engagement aligned across both data streams); one Hidden Opportunity (visually attended as intended but BCT activation incomplete); seven Attentional Mismatch (fixation duration deviated from the intended level despite adequate processing); three Divergent (engagement failure across both data streams); and four Silent Engagement (no participant verbalised the element, so engagement could not be assessed from think-aloud data). Joint interpretation of the two data streams generated targeted redesign recommendations that would not have been identifiable using either method alone. This proof-of-concept study establishes the feasibility of a theory-informed methodology for prospectively evaluating engagement with electronic audit and feedback interventions prior to broader implementation. Integration of objective measures of overt visual attention with qualitative evidence of verbalised processing depth allows interface-level barriers to be identified before implementation at scale, rather than after. Specifying intended BCTs a priori was critical to interpreting engagement against the intervention’s behavioural design and identifying opportunities for optimisation. Prospective optimisation may help reduce avoidable redesign cycles and support more efficient pathways to implementation readiness.
