Objectives: 1.To review the need for increased efforts to implement research evidence into bedside practice. 2.To review the need for measurement to identify gaps between best practice and actual practice. 3.To demonstrate why there is a need for increased knowledge translation efforts in critical care and how aCKTION Net proposes to fill this need. Click the link to view the video http://bit.ly/YpJWTC

1. “AC3KTION NET” KNOWLEDGE TRANSLATION
NETWORK
TRANSMISSION DES CONNAISSANCES
« AC3KTION NET »
Tuesday, February 12, 2013
Mardi 12 février 2013

2. Your Hosts & Presenters
Vos hôtes et présentateurs
Bruce Harries, Moderator
Ardis Eliason, Technical Host
John Muscedere, MD, FRCPC
Paule Bernier, DtP., M.Sc.
02/12/2013 2

3. Interacting in WebEx: Today’s Tools
Interagir dans Webex : outils à utiliser
Have you used WebEx before?
Avez-vous déjà utilisé WebEx?
 YES / OUI NO / NON 
Soyez prêts à
Be prepared to use:
utiliser les outils :
- Pointer - le pointeur
- Raise hand - lever la main
- CHAT - clavardage
- Text Tool - Outil textuel
Type your
“writing on the slide” pour « écrire sur la message
Select
- Shape Tools diapo » ‘send to’ & click
02/12/2013
- Outils de forme
3 ‘send’

4. Who’s Online?
Qui est en ligne?
POINTER
02/12/2013
4

5. POINTER What professions are represented?
Quelles professions sont représentées?
Nurse MD Infection
Control
Educator / Quality Administrator /
Improvement Senior Leader
Professional
Nutritionist
Other
Respiratory
Therapist
02/12/2013 5

6. Objectives
But de l’appel
 1. Revoir la nécessité d’accroître
 1. To review the need for les efforts pour intégrer les
increased efforts to implement données probantes émanant de la
recherche dans la pratique au
research evidence into bedside
chevet des patients.
practice.
 2. Revoir la nécessité d’instaurer
 2. To review the need for des mesures pour identifier les
measurement to identify gaps lacunes entre les pratiques
between best practice and actual exemplaires et les pratiques
practice. réelles.
 3. To demonstrate why there is a  3. Démontrer le besoin d’accroître
need for increased knowledge les efforts en matière d’application
translation efforts in critical care des connaissances dans le
domaine des soins critiques et la
and how aCKTION Net proposes
façon dont aCKTION Net propose
to fill this need. de combler ce besoin.
02/12/2013 6

7. “aC3KTion Net”
Dr. John Muscedere

8. a Canadian Critical Care
Knowledge Translation Network
“aC 3KTion Net”

9. Learning Objectives
• To understand the need for knowledge
translation (KT) in Critical Care
• To review the need for measurement as
a means to improve practice
• To demonstrate how the Canadian
Critical Care Knowledge Translation
Network (aC3KTion Net) can address the
KT needs identified for critical care.
02/12/2013 9

10. Need for Knowledge
Translation in Critical Care
• Lag between generation of research evidence and its
implementation into best practice
• Unknown penetration of new evidence into practice
• Few large scale KT initiatives thus far
– Patient safety
• Minimal resources to conduct KS activities
• Increasing focus on Quality
– Deriving best outcomes and best value from resources
expended.
02/12/2013 10

11. What is Knowledge Translation?
CIHR defines knowledge translation (KT) as:
“a dynamic and iterative process that includes
the synthesis, dissemination, exchange and
ethically-sound application of knowledge to
improve the health of Canadians, provide more
effective health services and products and
strengthen the healthcare system”
Canadian Institutes of Health Research.
www.cihr-irsc.gc.ca/e/39033.html.
02/12/2013 11

12. Why is there a need for KT efforts?
• Average of 17 years for new knowledge to have impact on
bedside standards of practice
• Reasons include:
– Slow diffusion of research evidence into practice
– Limited comparative effectiveness research to guide
implementation, investments and use of technologies
– Lack of health system policies across jurisdictions
– Research groups and clinical communities working in isolation
– Literature base is rapidly expanding such that it is difficult for
individual practitioners to remain current, assimilate and then
apply evidence into practice.
IOM. Crossing the quality chasm: A new
health system for the 21st century. 2001.
02/12/2013 12

13. Why is there a need for KT efforts?
• A large gulf remains between what we know and what we
practice.
• Variation in implementation is common internationally,
within countries, between regions and even between
hospitals.
• Even where guidelines exist, large gaps continue to exist
between best evidence and practice.
• Example- CV Medicine:
– 30% to 40% of patients fail to receive treatments of proven
effectiveness
– 20% to 25% of patients may receive care that is not needed or is
potentially harmful
Davis et al. BMJ 2003; 327: 33-35.
Tremblay et al, Can J Cardiol 2004; 20:1195-98.
02/12/2013 13

14. Variation in Quality Scores for
Pneumonia at Academic Medical
Centers (2004)
95.0
85.0
Percentage (%)
Percentage of 3 care
measures received:
75.0 1. Timely administration of
antibiotics
2. Measurement of SaO2
3. Immunization
65.0
55.0
45.0
John Wennberg, The Eisenberg Legacy Lecture
Stanford, California. Nov. 2, 2005.
02/12/2013 14

15. Why Focus KT efforts on
Critical Care?
• Patient Vulnerability:
– ICU patients experience high morbidity and mortality
– Ontario
• Level 3 pts- 20% mortality
• Level 2 pts- 10% mortality
• Patient Volume:
– ICU patients per year:
- Canada- 360,000 pts.
Globe and Mail, Nov. 24, 2011
02/12/2013 15

16. Why Focus KT efforts on
Critical Care?
• Access:
– 80% to 100% increase in the number of
critically ill patients over the next 20 years
– Demand will overwhelm capacity in the next
10 years
• Health Care Costs:
– In Canada (2004): ICU costs were estimated
to account for 15.9% of the $39 billion spent
on hospital services
– 0.5 – 1.0 % of GDP
02/12/2013 16

17. Best practices not uniformly
applied in critical care
• Wide variations documented in
application of commonly applied
therapies for critically ill patients
• Sepsis
• ARDS
• Sedation practices
• Transfusion practices
• Non-invasive ventilation
• Renal replacement therapy
• End of Life Care
• Etc.
02/12/2013 Hirshberg et al, Chest 2008; 133: 1335.
17

18. Uneven adoption of best
practices- VAP prevention
 Recent Survey (518 U.S. Hospitals)
 21% used ETTs with SSD
 40% use antimicrobial mouth rinses
 82% utilized semi-recumbent positioning
02/12/2013 Krein. Infect Control Hosp Epi.18
2008

19. Variance in the Application of
Best Practices
• Reasons include:
1. Lack of research evidence
• Can inform future research directions
2. Lack of awareness or lack of dispersion of best
practices
• Can be improved by knowledge synthesis or knowledge
translation activities
02/12/2013 19

20. Expanding Critical Care Literature Base: Number of
critical care RCTs published per year
600 560
550
500
2010
Modified from Kahn, CCM 2009; 37: S147

21. Challenge in delivery of Critical
Care from a KT perspective
• Team based care
– Need to reach RNs, RTs, Pharmacists, Dieticians, PTs etc.
• Physician challenges:
– Large amounts of critical care delivered by non-intensivists
– Critical care may only be a small proportion of their practice
– Differing backgrounds for MD entry into critical care
– Episodic care by physicians
• Institutional challenges
– Variability in available resources.
02/12/2013 21

22. Bridging the Gap
Evidence-Based
Best Practices
Clinical Practice
02/12/2013 22

23. HOW? KNOWLEDGE-TO-ACTION CYCLE
Two phases:
1. knowledge creation;
2. action cycle
Graham et al. 2006
02/12/2013 Graham et al. 2006

24. aC3KTion Net
• Network of ICUs (Networks) from across
Canada
• Academic
• Community
• Primary activity will be Knowledge Translation
and development of Critical Care Knowledge
Synthesis products
• Not KT Research
• Measurement of uptake/outcomes
02/12/2013 24

25. a Canadian Critical Care Knowledge Translation Network
aC3KTion Net
02/12/2013 25

26. aC3KTion Net Vision
To improve the care of critically ill through
the application of best practices as defined
by research evidence in a timely manner
thereby reducing the morbidity, mortality
and impact of critically patients on the
health care system.
02/12/2013 26

27. aC3KTion Net Scope
• All critical care units in Canada will be eligible and
encouraged to participate.
• Best practices that will be included in network
activities will be those pertaining to:
– clinical practice
– ICU organization
– administration and organization of critical care resources.
• We will include multi-professional representation to
encompass the multi-disciplinary nature of ICU
teams.
02/12/2013 27

28. aC3KTion Net Objectives
1. To bring together critical care researchers and
knowledge users (health care professionals, national
professional associations, and health care system
decision makers) to optimize resources and support
collaborative knowledge translation activities.
2. To survey practice at baseline and after implementation
efforts to guide knowledge translation activities and
measure the results of our efforts.
3. To conduct knowledge synthesis activities and develop
knowledge products to inform critical care best
practices.
02/12/2013 28

29. aC3KTion Net Objectives
Cont’d
4. To improve the care of critically ill patients through
the dissemination of best practices, as defined by
research evidence, into ICUs across Canada.
5. To improve critical care outcomes including
morbidity, mortality and the health care system
impact of critically ill patients.
02/12/2013 29

30. aC3KTion Net Partners/Decision Makers
BC Alberta
• Ministry of • Noel
Health CC Gibney, Manitoba
Working Alberta CC
Sask. • B.
Group clinical
Paunovic, Quebec
• Fraser
Network • Susan Winnipeg Maritimes
Shaw, Ontario • M. Légaré,
Health CC Head CC U of • W. Patrick,
Chair, SIQ
Manitoba • B. CC
Sask. Dalhousie U.
Lawless,
quality
CC
Council
Secretariat
1. Canadian Critical Care Society
2. Canadian Association of Critical Care Nurses
3. Canadian Society of Respiratory Therapists
4. Canadian Patient Safety Institute
5. Canadian ICU Collaborative

31. Network Activities
• Knowledge Sources: Canadian Critical Care Trials
Group (CCCTG), Literature, Other
• Knowledge Synthesis: Development of clinical
practice guidelines, evidence syntheses and
scoping reviews.
• Testing of Knowledge Products: Reviewed and
tested before implementation, to ensure
acceptability, ability to achieve intended purpose
and ascertain possible barriers
• Knowledge Implementation: Local teams will use
strategies/tools tailored to knowledge product.
– Education, protocols, checklists, order sets,
organizational changes and reminder systems
– PDSA cycles to track implementation activities
02/12/2013 31

32. Incubator Units
• Testing and modification of knowledge
products in a real world environment
– Involvement of all members of health care
team
– Knowledge products reviewed for:
• Acceptability
• Possible barriers to implementation
• Possible tools for implementation
• Implementation tools designed
– Academic hospitals, Community hospitals
02/12/2013 32

33. Measurement- Why?
 Even when motivated to change our behavior, we
cannot manage what we do not measure.
 Measurement can identify gaps in best practice.
 Measurement can illuminate the results of our
efforts at implementing best practice.
 Measurement can inform future research direction.
02/12/2013 33

34. Data Collection
• Modified point prevalence surveys
– Periodic data collection on cohorts of ICU patients
• 30 pts for large ICUs (> 15 beds)
• 20 pts for small ICUs (< 15 beds)
• eCRF with MDS that is scalable and modular
for new network initiatives as they are
developed
• Reports of performance for each ICU from
data collected
02/12/2013 34

35. CCCKTN Activity
Specific Specific Specific
Initiatives Initiatives Initiatives
Core Core
Core Core Core
Data Data
Data
Data Data
Set Set Set Set Set
KS/ KT Activity KS/ KT Activity KS/ KT Activity KS/ KT Activity
Data Elements
1. Core Data Set
Specific
2. Practice Data – specific practices Specific
Initiatives
Initiatives
KS/ KT Activity Core
Core Data
KS/ KT Activity Data
Set
Set
02/12/2013

36. KT Initiatives- how to
choose?
• Short term: Knowledge Products Ready for
Implementation after first data collection period
• E.g. guidelines
• VAP CPGs, Hypothermia Guidelines, Sepsis guidelines etc.
• Longer term: Initiatives based on demonstration
of practice variation
• To be based on data collected during baseline data
collection
• Will inform future KT activities/future Research activities
• What data to collect?
02/12/2013 36

37. Selection process for
initiatives
• Delphi technique
– Input from Steering/Scientific Committee
– Researchers, clinicians, knowledge users, decision
makers
Composition of Steering/Committee
Scientific Committee
31 Members Total (Overlap)
•21 MDs
•4 RNs
•1 Pharmacist
•1 RT
•9 Knowledge Users
•5 National organization members
(CCCS, CACCN, CSRT, CPSI, CICU)
02/12/2013 37

38. Top 5 CURRENT KT
Initiatives
1. Pain/Analgesia/Delirium Guidelines
2. Sepsis guidelines: new surviving sepsis
guidelines
3. Canadian Nutrition Guidelines in the
Critically Ill
4. Implementation of revised Ventilator
Associated Pneumonia Guidelines
5. Non-Invasive Ventilation Guidelines
02/12/2013 38

39. Top 10 Future KT
Initiatives
1. End of Life
2. Sedation/Analgesia
3. Sepsis (diagnosis/management)
4. Early Mobilization
5. Delirium (screening/treatment)
6. Communication in the ICU
7. Anti-Microbial Stewardship
8. Quality Improvement Initiatives
9. Fluid Therapy (resuscitation, maintenance)
10. Utilization of non-invasive mechanical
ventilation
02/12/2013 39

40. Recruitment of ICUs
• Main benefits of participation
– Access to KT activities
– Access to KS products
– Access to educational events/webinars
– Opportunity to participate in incubator units
– Ability to influence network activities
– Benchmarked reports of performance with national peers
– A vehicle to drive critical care quality improvement
• ICUs provide periodic data in return
02/12/2013 40

41. Recruitment of ICUs
• ICUs to be recruited through:
• Provincial networks, provincial registries of ICUs
• Advertisement through professional societies:
CCCS, CSRT, CACCN
• Partnerships with existing networks
• Any other recruitment strategies?
• Any other ways to incentivize ICUs to
participate in the network?
02/12/2013 41

42. Timelines/Future Activities
• aC3TION Net website
– Go Live, Feb 12, 2013
• Recruitment of participating ICUs
– Feb 12, 2013 on ward
• Outreach to provincial partners, stakeholders
– Spring, Summer 2013
• Café Scientifique (Town Hall meeting)
– Pilot in Kingston, ??? Other cities
• Projected start of first data collection period
– September 3, 2013
02/12/2013 42

43. Questions/Comments?
02/12/2013 43

44. QUESTIONS?
RAISE YOUR HAND / LEVEZ LA MAIN
OR/OU
CHAT TO “ALL PARTICIPANTS”

45. Canadian ICU Collaborative
Faculty
Chaim Bell; MD, PhD, Associate Professor of Medicine and Health Policy, Management, & Evaluation CIHR/CPSI Chair in Patient Safety & Continuity of
Care; University of Toronto; St. Michael's Hospital
Paule Bernier, P.Dt., Msc, Sir MB David Jewish General Hospital (McGill University), Montreal
Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary
Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre
Leanne Couves, Improvement Advisor, Improvement Associates Ltd.
Vanda DesRoches; RN BN, Prince County Hospital, PEI
Greg Duchscherer, RRT, FCSRT, Quality Improvement & Patient Safety Leader, Department of Critical Care Medicine, AHS (Calgary Zone)
Bruce Harries, Collaborative Director, Improvement Associates Ltd.
Gordon Krahn, BSc, RRT, Quality and Research Coordinator, BC Children’s Hospital
Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University
Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology, University of Western
Ontario; Chair/Chief of Critical Care Western
Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre;
Sherissa Microys MD, Assistant Professor, University of Ottawa; Intensivist, Ottawa Hospital; Major, Canadian Forces
John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital
Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium Guidelines, Society of
Critical Care Medline (SCCM)
02/12/2013 47

46. Reminders
Rappels
 Call is recorded  L'appel est enregistré
 Slides and links to  Les diapositives et liens
recordings will be vers les enregistrements
available on Safer seront disponibles sur Des
soins de santé plus
Healthcare Now!
sécuritaires maintenant!
Communities of Practice Communautés de pratique
 Additional resources are  Des ressources
available on the SHN supplémentaires sont
Website and disponibles sur le site Web
Communities of Practice SSPSM et Communautés
de Pratique
02/12/2013 48

47. National Call
Appel national
 "Learnings from the  « Apprendre de la
Delirium Collaboration sur le
Collaborative" delirium »
 Monday, February 25,  Lundi Février 25 2013
2013  Conférencier invité:
 Guest Speaker: Yoanna Skrobik, MD,
Yoanna Skrobik, MD, FRCPC, Intensiviste,
FRCPC, Intensivist, Hôpital Maisonneuve-
Hôpital Maisonneuve- Rosemont, Montréal
Rosemont, Montréal
02/12/2013 49

48. THANK YOU
MERCI

49. This National Call is hosted by:
Supported by:
02/12/2013
51