ICN Victoria presents Dr Dashiell Gantner, research fellow at the Monash University in Melbourne. Here he talks about translating ICU research into clinical practice.

1. Do we translate research into practice?
Dr Dashiell Gantner
Research Fellow, Centre of Excellence in
Traumatic Brain Injury Research
PhD Scholar, Australian and New Zealand
Intensive Care Research Centre
Monash University
Victorian ICN, May 9 2013

2. “The extent to which beliefs are based upon evidence is
very much less than believers suppose.”
Bertrand Russell

3. How much of what we do in ICU is
‘evidence-based’?
• At a single centre reviewed treatments received by 100
consecutive patients
• Identified 261 different treatments designed to influence a
patient centered end-point (predominantly survival or
neurological outcome)
• Total of 2152 treatments received
• Evidence level categorised

5. Much of what we do is not supported
by high quality evidence
Evidence level for 2152 treatments for 100
56 34 26
2036
2500
2000
1500
1000
500
0
Level A Level B Level C Level D or
E
patients
Number of patients
treated

6. What are we discussing?
• Translational research involves moving knowledge
and discovery gained from the basic sciences to its
application in clinical settings
– Aka Translation of Research Into Practice Studies (TRIPS)
• This concept is often summarised by the phrases
“bench to bedside” (T1) and “bedside to community”
(T2) research
• The gap between clinical evidence and practice is
called the “evidence-practice gap” or “know-do gap”

8. T1 Research T2 Research
Basic science Clinical research Clinical Practice

9. Lost in Translation
“One of the most consistent findings
from clinical and health services
research is the failure to translate
research into practice and policy.”
Grimshaw et al Implementation Science 2012
“The most cost-effective opportunity to
improve patient outcomes will likely
come not from discovering new
therapies but from discovering how to
deliver therapies that are known to be
effective.”
Berenholtz & Pronovost, Current Opin Crit Care 2003

10. The problem in medicine
• Overall patients received only
55% of recommended care

11. The problem in medicine
• “Knowledge-Practice gaps” exist in all specialties
– 20-30% of patients may receive unnecessary or
potentially harmful care 1
– Only 14% of clinical discoveries are incorporated
into routine clinical practice
> takes average of 17 years to occur 2
1 Shuster et al, Milbank Q 1998
2 Balas et al 2000

12. The problem in ICU
• German SepNet 1
– 214 ICUs, 152 patients with
ARDS in Germany
– ICU directors perceived
adherence to ARDSnet: 79.9%
– Observed tidal volumes:
> ≤6ml/kg in 2.6%
> >8ml/kg in 80.3%
1 Brunkhorst et al, CCM 2008
2 Finfer et al, CCM 2010

13. SAFE TRIPS
• 391 ICUs, 25 countries
• Marked international
variation in choice of fluids
– Persistent use of colloids
despite lack of evidence
– “Practice... is guided more
by local practice than by
reliable research
evidence.”

14. The problem in trauma & TBI
• Aus NZ (2001): Adherence to BTF guidelines in as few as
44.5% of severe TBI patients1
• USA (2006): “Good adherence” to BTF guidelines in only
50% of 413 trauma centres2
• USA (2006-2008): Compliance with TBI-specific processes
of care highly variable in Level 1 Trauma Centre3
– 10% increase in compliance associated with 14%
decrease in mortality
1 Myburgh et al, J Trauma 2008
2 Hesdorffer et al, J Trauma 2007
3 Shafi J Trauma 2012

15. The goal of research is improved health,
not just new knowledge
T2 Translation
Everything to
publication

16. Benefits of active implementation
• Compliance with guidelines improves after “active”
implementation

17. • Projected impact of improved
compliance with BTF
guidelines
Faul et al, J Trauma 2007
Economics of translation

18. Access Economics estimate:
• Implementation of SAFE TBI
findings would save $700-800
million

19. Do we translate research into
practice?
Dr Dashiell Gantner
Research Fellow, National Trauma Research
Institute
PhD Scholar, Australian and New Zealand
Intensive Care Research Centre
Monash University
Victorian ICN, May 9 2013
How

20. Knowledge Translation
• Start at the end: Improve outcomes
• The beginning:
> Identify best practice
> Measure practice
> Understand practice
> Improve practice

21. Knowledge Translation - methods
• No “gold standard” method of knowledge translation
– Dependent on barriers specific to the disease, clinicians,
therapy and institution
• Key principles of KT:
1. Knowledge and acceptance of the evidence
2. Knowledge and understanding of existing practice
3. Knowledge of barriers and facilitators to improving practice

22. 1. Confirm and disseminate best evidence
• Synthesis of global evidence
– Up-to-date systematic reviews
> Cochrane
– Evidence-based guidelines
> Brain Trauma Foundation
– (Evidence-based) Consensus statements
> ESICM, ATS, ANZICS, CICM
• Ideally readily accessible and easily interpretable

23. 2. Confirm evidence-practice gap
• SepNet ARDS, SAFE TRIPS exemplify measurement of
practice
• Registry data
– ANZICS APD
– Trauma registries
• Regular local audits
– E.g. VAP care bundles

24. 3. Understand practice
• Identify barriers and facilitators to implementation of research findings
– Structured interviews
– Surveys of stakeholders:
> Intensivists, nurses, other specialists, hospital admin, government

25. 4. Implementation – Change Practice
• Behavioural change theory
– Theoretical Domains Framework
Michie Implementation Sci 2011

26. Barriers to implementation
• Intervention characteristics:
– High cost
– Intensive time demands
– High level of staff expertise required
– Highly specific to particular setting
• Research design
– Not relevant or representative sample of patients or settings
– Failure to evaluate cost
– Failure to assess implementation
– Failure to evaluate sustainability

27. Barriers to implementation
• Implementation characteristics:
– Competing demands
– Limited resources, organizational support
– Prevailing practices work against innovation
– Perverse incentives or regulations e.g. free albumin

28. Implementation strategies
• Must be tailored to specific settings and target groups
• Multi-faceted interventions often more effective than
individual interventions
• Examples include clinical guidelines, local opinion
leaders, audit and feedback, computerized reminders,
educational meetings, economic analyses to inform
policy makers

29. Keystone Initiatives
• Reducing morbidity of mechanical ventilation1
– Sought to ensure that for 90% of ventilator days, patients received:
– HOB elevation ≥30º
– Ulcer prophylaxis
– DVT prophylaxis
– Daily sedation holiday
– Interventions:
> Questionnaire to identify barriers to compliance with ventilator
processes
> Implementing an educational intervention to improve compliance with
the ventilator processes
> Implementing a checklist to be completed daily during ICU rounds to
ask providers whether patients were receiving these therapies
• Percentage of ventilator days where all 4 processes received:
30 -> 90%

31. That’s how you get a Genius grant!

32. Our very own genius: Dr Nadia Chaves
Barriers and enablers of optimal prescribing
Barriers Enablers
Organisational No incentive for the
organisation to change
Potentially money saving
Accreditation is coming
ICU Consultant Time management
“Others” prescribe
inappropriately
Can’t change things because
someone else has started
them
We do need to improve
things
We are willing to help
We would like a role
ICU pharmacist
ICU Registrar/
resident
ICU Nurse
ICU Team
Political/
Contextual
Current NHMRC TRIP Fellow

33. Plan: Medication record sticker
Start date / /
Stop/review date / /
Indication

34. Observe: Results post-sticker
93
83
61
90
62
89
58
16
72
13
0 10 20 30 40 50 60 70 80 90 100
All min standards
Start date
Stop/Review date
Indication medication chart
Indication
Percentage
Pre-intervention
Post-intervention

35. What made the sticker work?
 Most common reasons for inappropriate prescription:1
 Complacency, fear (intrinsic)
 Time management (extrinsic)
 A simple sticker allowed CAPABILITY, OPPORTUNITY
AND MOTIVATION2
 The ICU chose what they thought would work
1. Rodrigues In J Antimicrob Agents 2013
2. Michie Implemen Sci 2011

36. ANZ ICU TRIPS activities
• ANZICS CTG TRIPS Working Group (Established 2011)
– TBI TRIPS
– Fluid TRIPS
– QUality of Evidence in Standard Therapies (QUEST) – ICU
• Funding opportunities – NHMRC, NIH, CIHR, ISCRR

37. Conclusions
• Hardly any therapies in ICU are supported by Level I
evidence
• The few that are, are not implemented
• Implementation science is a growing, cross-disciplinary
field
• Active implementation works to reduce evidence-practice
gaps
• Washing your hands and ticking boxes can earn you
$500,000!