Innovative research approaches to improve evidence in global health
Qiebp research
1. +
Evidence Based
Practice, Research
and Quality:
Hedges (2006)
Distinctions, Synergies, and
Infrastructures to Optimize
Patient Outcomes
Clinical Fellows Graduation
TCU Lisa Hopp PhD, RN
Sept 21, 2011 ljhopp@purduecal.edu
2. First show of hands…
1 I am a staff nurse
2 I am a manager or
director
3 I am a fellow’s mentor
I am an advanced
4 practice nurse
5 I am an educator or
researcher
6 I am a nurse executive
I am having an identity
7 crisis
3. +
Why do I ask?-It matters to the:
Problems Questions
you identify you ask
Alternative
Solutions
solutions you
you choose
generate
4. Another show of hands:
Your primary focus:
1 Generating research
2 Using research
3 Using the best
available evidence
Improving process and
4 outcomes
5 Thinking in action,
taking care of patients
6 Other?
5. +
Think about the last innovation that you
have been involved in:
What did the process
look like?
Nice and neat?
Fits and starts?
Flexible and fluid?
6. +
Why are we here?
Compare and contrast 3 problem solving
processes: quality improvement (QI), evidence-
based practice (EBP) and clinical research
Identify
synergies and dependencies among them
that lead to optimal patient outcomes
Describeideal infrastructure characteristics that
promote high quality patient outcomes, evidence
uptake and clinical inquiry :
mentorship
leadership
organizational culture
evaluation processes
8. +
#
CAUTIs/10
Too Many 00 days
CAUTIs!
1st quarter
9. + What is the problem?
Whatis(are) the
cause(s)?
What is the right thing
to do?
Key Issues?
What is the right way
to do it?
What is the right cost
to do?
12. + Quality of Care in the US: 1998-2002
Overall, 54.9% of participants received
recommended care
Comparison % recommend care
Asch, SM, Kerr, EA, Keesey, J., et al
receiving-poor quality health care?
gender women: 56.6 men: 52.3
(2006). Who is at greatest risk for
age <31 yrs: 57.5 >64 yrs: 52.1
NEJM, 354, 1147-56
race black: 57.6 white: 54.1
hispanic: 57.5
income >$50K: 56.6 <15K: 53.1
13. Despite unprecedented advances in
+
biomedical knowledge and the
highest per capita health care
expenditures in the world, the
quality and outcomes of health care
for Americans vary dramatically
across the country. Improved
knowledge about which treatments
and procedures are effective could
lead to less regional differences,
stronger consensus on standards
and guidelines, and lower costs.
RWJ commissioned IOM to: IOM: Knowing
“Recommend a sustainable, What Works in
replicable approach to
identifying effective clinical
Healthcare (2008)
http://www.rwjf.org/pr/product.jsp?id=25351&c=EMC-CA142
services” or http://www.nap.edu/catalog.php?record_id=120388
14. Despite unprecedented advances in
+
biomedical knowledge and the
highest per capita health care
expenditures in the world, the
quality and outcomes of health care
for Americans vary dramatically
across the country. Improved
knowledge about which treatments
and procedures are effective could
lead to less regional differences,
stronger consensus on standards
and guidelines, and lower costs.
RWJ commissioned IOM to: IOM: Knowing
“Recommend a sustainable, What Works in
replicable approach to
identifying effective clinical
Healthcare (2008)
http://www.rwjf.org/pr/product.jsp?id=25351&c=EMC-CA142
services” or http://www.nap.edu/catalog.php?record_id=120388
15. +
Research Gaps,
Duplications and
Contradictions
IOM, 2008
16. +
10 Nurse-Hospital Acquired Conditions
High cost, high volume, higher payment
“could reasonably
and
have been
Paying prevented through
the application of
Attention? evidence based
guidelines”
19. +
IOM Roundtable on EBM’s goal:
By the year 2020, 90 percent of clinical decisions
will be supported by accurate, timely, and up-to-
date clinical information, and will reflect the best
available evidence.…the development of a
learning healthcare system designed to generate
and apply the best evidence for the collaborative
health care choices of each patient and provider,
to drive the process of discovery as a natural
outgrowth of patient care, and to ensure
innovation, quality, safety, and value in health
care.
20. + IOM Roundtable on EBM Goal:
By the year 2020, 90 percent of clinical decisions
will be supported by accurate, timely, and up-to-
date clinical information, and will reflect the best
available evidence.…the development of a
learning healthcare system designed to generate
and apply the best evidence for the collaborative
health care choices of each patient and provider,
to drive the process of discovery as a natural
outgrowth of patient care, and to ensure
innovation, quality, safety, and value in health
care.
21. “non-profit
+ organization to
assist patients,
clinicians, purchasers,
and policy- makers in
making informed health
2010 Affordable decisions by carrying out
Care Act
research projects that
provide quality, relevant
evidence on how diseases,
PCORI disorders, and other health
conditions can effectively
Patient-Centered and appropriately be
Outcomes prevented, diagnosed, treated,
Research Institute monitored, and managed.”
(GAO, 2010)
22. +
2010 Affordable
Care Act Increased emphasis on
systematic review as a
method to compare
PCORI effectiveness of
Patient-Centered treatments
Outcomes
Research Institute
23. +
ANA Social Policy Statement (2010)
“Human responses include any
observable need, concern, condition,
event, or fact of interest to nurses that
may be the target of evidence-based
practice” (p. 10)
First time that EBP is explicit
in the statement that defines
our social obligation to
patients
24. +
ANA Social Policy Statement (2010)
“Nursing actions are theoretically
derived, evidence-based, and
require well-developed intellectual
competencies” (p.11)
“Assurance of safe, quality, and
evidence-based practice” (p. 19)
25. +
Defining Characteristics of Nursing
Practice
Human Theory Nursing
Outcomes
Responses Application Actions
(effects)
(Phenomena) (Science) (EBP)
ANA, Social Policy
Statement (2010), p. 11
26. +
Magnet™ Recognition Infrastructure
Infrastructure Process
outcomes
Research,
EBP and
QI
27. +
IOM
CMS
AHRQ
JC
ANA
ANCC
EBP and Quality go hand-in-hand?
29. +
Clinical Research
Research means a systematic
investigation, including research
development, testing and evaluation,
designed to develop or contribute to
generalizable knowledge.
DHHS (2008) 45 CFR 46.102(d)
30. +
Key Questions
What is the effect…
What is the experience….
What is the relationship….
Etc…….
31. +
Steps of Research Process
Gap: Identify need and
purpose
Question: researchable
Design: aligns with question
and feasibility (ethics)
Collect: data via methods
Analyze and Report:
results and implications
32. +
Defining evidence-based nursing
practice:
“The process by which nurses make
clinical decisions using the best
available research evidence, their
clinical expertise, and patient
preferences in the context of available
resources”
DiCenso, Cullum and Ciliska (1998). Implementing evidence based
practice: Some misconceptions. Evidence Based Nursing, 1, 38-41.
33. +
Defining evidence-based nursing
practice:
“The process by which nurses make
clinical decisions using the best
available research evidence, their
clinical expertise, and patient
preferences in the context of available
resources”
DiCenso, Cullum and Ciliska (1998). Implementing evidence based
practice: Some misconceptions. Evidence Based Nursing, 1, 38-41.
34. +
Implications of the Definition
Clinical
• Best Expertise • Meaning of
• Available • Criteria experiences
• Externalized • Individualized
Patient
Evidence Preferences
35. +
Best Available
• Right • Sources • Accessible
Available
Best
Feasible
evidence • Technique • User-
for the friendly
question • Exhaustive
• Relevant
• Pre-
appraised
• Standard
Appraisal
Tools
36. + Shift toward pluralistic,
inclusive definitions of
The Nature of what evidence is, and
Evidence (1996) subsequently of what
evidence based
practice is..
(Pearson et al,
2005)
37. +
Reconceptualizing Evidence
From experience
From acknowledged experts
From learned/official bodies
From experimental research
Evidence
From any rigorous research
= studies
knowledge
About feasibility,
arising :
appropriateness,
meaningfulness and
effectiveness
38. +
Key Questions in EBP?
What works?
What is the right way to do what
works?
For whom does it work and when?
What works at the right cost?
Muir-Gray, 1997; Livesley
& Howarth, 2007
39. +
Essential Steps in EBP
Ask: Problem to Question
Acquire: Find best available
evidence
Appraise: validity and
applicability of the evidence
Apply: Implement in local
context
Assess: Evaluate the
outcomes
(Sackett & Haynes, 1995)
40. +
Quality Improvement
Systematic, data-driven process that teams
use to improve systems, processes and
outcomes
Generally conducted locally though maybe
organized at larger levels Newhouse, 2007
Lean methods aim to eliminate waste
Six Sigma aims to eliminate defects
“Obsessed with failure”
41. +
Key Questions in QI
Do you know how good you are?
Doyou know where you stand relative to the
best?
Do you know where the variation exists?
Doyou know your rate of improvement over
time?
Maureen Bisognano, CEO IHI
42. +
Essential Steps in QI à la Motorola
Define: Problem and goals
Measure: Collect data on
current practice
Analyze: Use data to verify
causes and all factors considered
Improve: Create and test new
solutions
Control: Ensure new state
persists
(Koning, 2006, J Healthcare Q)
44. + What is the effect of
nursing stop-orders vs.
usual physician orders on
reinsertion rates, catheter
How would days and incidence of
the story go CAUTIs in uncomplicated,
non-urinary surgical
if Amanda… patients with short term
indwelling catheters?
Conducted clinical
research?
45. + What is the effect of
nursing stop-orders vs.
usual physician orders on
reinsertion rates, catheter
How would days and incidence of
the story go CAUTIs in uncomplicated,
non-urinary surgical
if Amanda… patients with short term
indwelling catheters?
Was involved in an
evidence
implementation
project?
46. + Catheter days and
incidence of CAUTIs in
surgical patients with
short term indwelling
How would catheters are too high.
the story go
if Amanda…
Was involved in a
QI project?
47. +
How did these stories compare:
Key Differences?
Research EBP QI
Goal Grow knowledge Close gap Best patient
for better pt between know outcomes, best
outcomes and do for best cost, and
pt outcomes regulatory
compliance
Relationship Generate or Synthesize, Systematically
with confirm new translate and optimize how
knowledge knowledge use knowledge to process
knowledge
Time required Longest but Longer but Aim for rapid but
variable variable variable
Designs Quant to qual Before-after with Before-after with
process monitor process monitor
48. +
How did these stories compare:
Key Differences?
Research EBP QI
IRB required Yes Sometimes Not usually
Flexibility Dependent upon Dependent Generally fluid
design-varies upon and locally
from rigid to more approach, but driven
fluid generally fluid
Funding Often external Usually internal, Part of usual
maybe external operational
funding
Time to Long term Short term Short term to
Impact immediate
49. +
Empirically driven
Rigor varies amongst all; risk for
bias varies depending on
methods, skills, etc
Context varies from artificial to
realistic-emerging research
methods are far more naturalistic
Key Similarities Moving knowledge into practice is
a major concern
Aim to improve patient outcomes
New evidence can emerge from
all 3 processes though ability to
generalize varies
51. +
The
Intensive
Insulin
Therapy
Story
Target: 80-110 mg/dL
52. +
Intensive Insulin Tx
Leuven Trial-2001
Large RCT 1548 surg ICU pts blindly
allocated to conventional tx (IV insulin if glc >
215 mg/dL) and intensive (IV insulin to
maintain glc 80-110 mg/dL)
Findings: IIT reduced mortality, morbidity in
critically ill surgery patients
Van den Berghe, G. et al (2001). NEJM, 345, 1359-1367
55. +
Hold on-Meta-analysis (2010)
“Tightglycemic control is associated with a
high incidence of hypoglycemia and an
increased risk of death in patients who do
not receive parenteral nutrition”.
Marik, P.E. & Preiser, J. (2010). Chest, 137, (3)
57. + Hold on-Meta-analysis (2010)
Meta-regression revealed:
Relationship between proportion of parenteral
calories and 28-day mortality
Leuven trials tx effect related to parenteral feeding
Harm?
Mortalitylower in control (glc 150 mg/dl) OR=.9 [CI,
.81-.99] when Leuven trials removed
Noevidence to support IIT in general med-
surg ICU pts fed according to current
guidelines (ie, enteral) Marik, P.E. & Preiser, J. (2010).
Chest, 137, (3)
58. +
hwww.flickr.com/photos/are
Are there hazards when QI waits
on EBP?
namontanus/
59. What is the “ideal best” type of
research evidence?
Comparing Treatments Meta-analysis or
systematic review of
RCTs
Determining extent of risk, Systematic review of
DiCenso, Guyatt & Ciliska (2005)
predictive of future problem cohort, case-control
studies
Specificity/sensitivity of an Systematic review of
Craig & Smyth, (2002)
assessment/test blinded comparison of
test and reference
value
Perceptions/values/beliefs Meta-syntheses of
qualitative studies
61. + QI effort-implementing the evidence
from SRs and using evidence-based
strategies
12
CAUTIs Jan 08 - June 09
Pre-intervention
Rate at Audit 1:
10
5.9/1000 cath days
8
Rate at Audit 2:
6
2.8/1000 cath days
4
Title
Average
2
A/F 1
0
A/F 2
Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June
62. + How has QI been studied for its
effectiveness?
Researchmethods are “weak” and messy-
tremendous research challenges
38% were RCTs and more likely to find no effect
62% were observational and more likely to find an effect
Most studies could not be used beyond their local
setting:
Too short to make cause/effect claims
Inadequate monitoring of the intervention
Self-selection bias prevalent
Complex interventions
Alexander et al (2009) Med
Care Res and Rev, 66, 235-
63. +
Caveats
Mostof the hospital studies conducted in
university-based hospitals
Publication bias likely
Focused more on physician practice
30% used multiple-interventions
Alexander et al (2009) Med
Care Res and Rev, 66, 235-
64. + “All three approaches
have an important, yet
different, relationship
with knowledge:
What do you Research generates it
think of this EBP translates it
statement? QI incorporates it”
Shirey et al, 2011 J Cont Ed in
Nursing, 42(2)
65. + Embrace broader ideas about what
counts as evidence-including local
data but also embrace global
evidence(Harvey)
EBP should learn from QI and vice
versa to speed the spread and
enhance rigor (Harvey)
Toolsthat work for the common
Synergies? goal of evidence
translation, practice developed
evidence
Enhanced point of care KT, through
changes in evidence transfer
Evidence-based implementation
Harvey, G. (2005) Worldviews, second
quarter, 52-4
strategies
66. How about a shift in
paradigm:
+
Evidence-based Quality
Improvement
69. “Reliable knowledge has to be both
scientifically and socially robust.
Knowledge can no longer be
determined by narrowly defined
scientific communities but by wider
communities of knowledge
producers, disseminators, traders
and users.”
Kitson, A. & Bisby, M. (2008). Speeding the
spread. KT08
70. “Reliable knowledge has to be both
scientifically and socially robust.
Knowledge can no longer be
determined by narrowly defined
scientific communities but by wider
communities of knowledge
producers, disseminators, traders
and users.”
Kitson, A. & Bisby, M. (2008). Speeding the
spread. KT08
71. +
Themes for “how”
Shift in knowledge production: from
Mode 1 to Mode 2 research paradigms
to “speed the spread” of research
evidence
Theoretical
models related to “how” are
needed, some are evolving
Beyond barriers to Knowledge
Translation (KT)
72. + Researchers generate
research questions and
Mode 1 methods
Kitson & Bisby , 2008) www.kusp.ualberta.ca/KT08documents.cfm
Research
Researchers conduct
“Blue sky” data collection
Curiosity driven
Takes place in the
bench lab or clinical Researchers
lab
disseminate findings at
Traditional, linear the end of the study
End of grant transfer (amongst themselves?)
73. +
Mode 2
Kitson & Bisby , 2008) www.kusp.ualberta.ca/KT08documents.cfm
Researchers
Research
Socially distributed
knowledge
Negotiation/collaborati Users Multidisciplines
on driven
Takes place within
New
context of application
Methods
Transdisciplinary and
Reflexive, dialogue, ite quality
rative
74. +
Models are Emerging
Knowledge-to-Action PARIHS
Evidence
Context
Facilitation
SI = f (E, C, F)
Kitson & Bisby ( 2008)
www.kusp.ualberta.ca/KT08documents.cfm
www.cihr-irsc.gc.ca/e/29418.html
75. + Engagement
What are Transactional
common themes
Nonlinear
and
characteristics Iterative
among these
Fuzziness
models that can
guide Social
implementation
Contingent
science?
76. +
How do you do get
evidence into
practice?
Emerging Science:
Knowledge Translation
(KT)
Knowledge translation is a dynamic and iterative process
that includes 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 health care
system. http://www.cihr-irsc.gc.ca/e/29418.html
77. +
Beyond
Barriers:
Knowledge
Translation (KT)
Knowledge translation is a dynamic and iterative process
that includes 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 health care
system. http://www.cihr-irsc.gc.ca/e/29418.html
78. +
6 Opportunities for KT (CIHR, 2005)
Publications
KT3
KT1 KT2
Researchers
Questions & Research Global
Knowledge
Methods Findings Knowledge
Users
KT4
KT6
Contexualization
Impacts
of Knowledge
Application of
Knowledge
KT5
As cited in Sudsawad, P. (2007) http://www.ncddr.org/kt/products/ktintro/
79. +
6 Opportunities for KT (CIHR as cited in
Sudsawad, 2009)
1. Defining research questions/methods
2. Conducting participatory research
3. Publishing in plain language and accessible fashion
4. Putting findings in the context of other knowledge
5. Making decisions and taking action informed by
findings
6. Influencing subsequent research based on impact of
knowledge use
As cited in Sudsawad, P. (2007) http://www.ncddr.org/kt/products/ktintro/
80. +
KT in the US
T1-bench to clinical research
T2-clinical research to practice
82. +
Strategies that work better
Reminders, cues
Educational outreach
Interactive education
Didactic continuing education
meetings -small effect on profession
practice and less on patient outcome
Bero et al, BMJ, (1998); Grimshaw et al, Cochrane
Library(2005); Forsetland et al (2009) Cochrane Library;
Farmer et al., Cochrane Library (2008)
83. +
Strategies that work better
Multifaceted interventions (includes
two or more: audit and
feedback, reminders, local consensus
processes or marketing)
Interactive or combination
interventions had greater impact and
were more likely to affect complex
interventions
Bero et al, BMJ, (1998); Grimshaw et al, Cochrane Library(2005); Forsetland et al
(2009) Cochrane Library; Farmer et al., Cochrane Library (2008)
84. + Strategies that may not work
Passive distribution of
educational materials
Didactic educational meetings
Interventions targeted at
individual and organizational
barriers need further study
Bero, Grilli, Grimshaw, Harvey Haines and Donald, BMJ, 1998
Cheater et al, Cochrane Database of Reviews, 2005
86. +
Audit and Feedback on Compliance with
Recommended Practice
72 studies making 88 comparisons vs. no tx
Risk difference ranged from 16% decrease to
70% increase in compliance (dichotomous vars.)
10% decrease to 68% increase (continuous vars)
Low baseline compliance and higher intensity
feedback associated with greater effectiveness
Jamtvedt: The Cochrane Library, Vol.3. 2006 last update 5/06.
87. +
VA experience with A/F-Quality
Enhancement Research Initiative (QUERI)
Timely feedback
Individual
performance feedback rather than
aggregate
Non-punitive
Engage provider in process rather than as
passive recipient
Hysong et al, (2006). Audit and feedback and clinical
practice guideline adherence: Making feedback
actionable. Implementation Science, 1,9.
88. +
Other lessons learned from QUERI
Thedoing and study of implementation are
long-term investments
Significant resources must be devoted
Health
systems should take on both the
responsibility of doing best practices and
supporting implementation research
Graham and Tetroe (2009)
89. +
SR: Lean, Six Sigma, StuderGroup
Hardwiring
9 studies of Six Sigma; 9 Lean; 1 of StuderGroup
(you know the one)
Universally, all claimed the interventions were
effective
But--all had significant threats to validity including
weak designs, inappropriate or lack of statistical
reporting, and failure to rule out alternative
hypotheses including not analyzing control group
results, even though they used one!
Vest et al (2009) Implementation Science, 4:35
90. Tools and
+
Infrastructure
Human
Technological
Contextual
91. + IOM Roundtable on EBM Goal:
By the year 2020, 90 percent of clinical decisions
will be supported by accurate, timely, and up-to-
date clinical information, and will reflect the best
available evidence.…the development of a
learning healthcare system designed to generate
and apply the best evidence for the collaborative
health care choices of each patient and
provider, to drive the process of discovery as a
natural outgrowth of patient care, and to ensure
innovation, quality, safety, and value in health
care.
92. +
IOM’s goal based on:
Learning health system-evidence
generated and applied as a natural
product of the care process
Expanding comparative effectiveness
evidence capacity
IOM (2011)Learning What
Improve public understanding of the
Works,Infrastructure..
nature of evidence, the dynamic nature
of evidence development, and the
importance of insisting that care
reflects the best evidence
93. + IOM Themes on Infrastructure:
Planning builds to future
needs
Trained workforce for
Globalizing evidence evidence stewardship
and localizing
decisions
Infrastructure for
Learning Real-time data
analysis
Public-private
capacities fuel effort Learning beyond bridging the
research practice gap
Coordinating work
and ensuring HIT investment for
standards
real-time learning
94. +
Human
Facilitation
Mentors
Communities of practice
Communication
Relationship building
Organizational Culture
95. + •Transformational
leadership
Leadership •Clear roles, effective
team work
•Effective organizational
structure
•Democratic, enabling/e
mpowering approaches
•Traditional, command, contr
ol leadership
•Lack of role
clarity, teamwork
•Poor organizational
structure PARIHS model
Rycroft-Malone
•Autocratic decision-making (2004); Kitson et
al, (2008)
96. + •Clear values/beliefs
•Values
Culture individuals, consistency
•Emphasis on
relationships
•Resources allocated
•Unclear values & beliefs
•Task driven
•Low regard for individuals
•Lack of consistency PARIHS model
Rycroft-Malone
•Resources not allocated (2004); Kitson et
al, (2008)
97. + •Internal measures
used routinely
Evaluation •Audit and feedback
used routinely
•Peer review
•External measures
•Multiple methods
•Absence of:
•Audit and feedback
•Peer review
•External audit PARIHS model
Rycroft-Malone
•Narrow use of performance (2004); Kitson et
information sources al, (2008)
99. + Holistic- oriented
Enabling others
Purpose and Role •Sustained partnership
•Developmental
•Adult learning
approaches
•Internal/external
agents
•High intensity-limited
Task-centered coverage
Doing for others:
•Episodic contact
•Practical/technical help
•Didactic, traditional
approaches
•External agents PARIHS model
Rycroft-Malone
•Low intensity-extensive (2004); Kitson et
coverage al, (2008)
100. +
Skills and Attributes
Holistic/enabling
•Co-counseling
•Critical reflection
•Giving meaning
•Flexibility of role
•Authenticity
Task/doing for
•Project management skills
•Technical skills
•Marketing skills PARIHS model
•Subjective/ technical/clinical Rycroft-Malone
(2004); Kitson et
credibility al, (2008)
102. “In the 21st century, knowledge is
the key element to improving
health. In the same way that people
need clean, clear water, they have
a right to clean, clear knowledge”
Sir Muir Gray Chief Knowledge
Officer of NHS-UK
103. +
Knowledge Management
Aggregate: Put all your information
sources in one place, it auto-updates and
you can share it: NetVibes, iGoogle
104. +
Knowledge Transfer
http://plus.mcmaster.ca/np/Default.aspx
http://www.tropika.net/svc/specials/KT-
Toolkit/pages/KT-Toolkit
105. Where do you go first
+ to find the best
available evidence?
How do you usually
seek the evidence?
Acquire Doyou have Internet
access at the POC?
What kinds of
evidence are available
at the POC?
106. + Currently, EB Clinical Guidelines
in the US:
Highly decentralized:
National Clearinghouse - 360 different
organizations
http://www.nap.edu/catalog.php?re
http://www.rwjf.org/pr/product.jsp?i
471 guidelines related to HTN
d=25351&c=EMC-CA142 or
276 guidelines related to stroke
But little guidance on other topics
cord_id=120388
107. + Recommend single entity:
Buildfoundation for knowing what works in
health care
Set priorities
Open
Transparent
http://www.nap.edu/catalog.php?re
http://www.rwjf.org/pr/product.jsp?i
Establish
methodologic standards for
d=25351&c=EMC-CA142 or
systematic reviews
Develop clinical practice guidelines
cord_id=120388
Transparency
Minimize bias
108. IOM’s Framework
Research Studies
Systematic Review:
ID & assess studies
Appraise body of evidence
http://www.nap.edu/catalog.php?re
http://www.rwjf.org/pr/product.jsp?i
Synthesize
d=25351&c=EMC-CA142 or
cord_id=120388
Clinical Guidelines and Recommendations
109. + What works needed for policy
to:
Constrain cost
Decrease geographic variations
http://www.nap.edu/catalog.php?record_id=
http://www.rwjf.org/pr/product.jsp?id=25351
Increase quality
Consumer directed health care
&c=EMC-CA142 or
Making coverage decisions
120388
111. +
Quick Action from 2008-11
AHRQ
SR as method to
Standardized
compare IOM
Systematic
effectiveness of
Review
treatments
Methods
2008 2009 2011
112. +
Systematic reviews should:
Identify
gap between what we know
and what we need to know
Concise and transparent
http://www.nap.edu/catalog.php?re
http://www.rwjf.org/pr/product.jsp?i
d=25351&c=EMC-CA142 or
Contradictory findings
Provide narrative summary or pooled
cord_id=120388
statistical analysis
113. + “An important barrier to
the implementation of
Patient CPG
Preferences recommendations is
and their inability to
Implementation reconcile patient
Science preferences and
values as well as
social norms”
Legare et al, 2009
Implementation
Science, 4, 30
114. +
How do you integrate pt preferences?
Examine the source of information for
public/consumer involvement in its development
Develop/adopt plain language information for
patients/family
Engage a consumer in policy development
Consider patient satisfaction scores in policy
refinement
Offer patient choice at POC
No systematic approach
Other?
115. + Lisa’s top picks for implementation
resources
Cochrane Library: Guidelines International
Effective Practice and Network
Organisation of Care www.g-i-n.net/
Group (EPOC)
www.cochrane.org RNAO’s toolkit for
guideline implementation
CIHR funded KT
Clearinghouse www.rnao.org
http://ktclearinghouse.ca/ JBI
Global Learning
cebm Centre
http://www.globallearningc
entre.joannabriggs.edu.au
/
My name is Amanda, I’m a senior staff nurse on a general surgical unit. During the first quarter of this year, the adult medical surgical and critical care units at my hospital had consistently higher rates of catheter associated urinary tract infections. Of course, a CAUTI can be catastrophic for patients, particularly some of our more frail patients. But since October 2008, CAUITs also pose a financial hardship to the hospital’s bottom line if they are acquired in the hospital. I am working with our quality improvement nurse, a unit performance improvement team and the evidence based practice council to improve our outcomes and come up with a plan that the rest of the hospital can adopt or adapt to. I’m going to think out loud about this. All we know know is that we have too many infections and we are losing money-about $50,000 this quarter because two of these infections required significantly more non-reimbursed care. I hope that the quality improvement nurse will be able to help us understand the problem, its causes and how to improve our methods and how to measure our outcomes. I think I’ll need to work with the EBP council to identify the best way to prevent CAUTIs from happening. But wait, I think the quality improvement nurse will need to know not just the local data but also the evidence to be able to help us look at the causes. For example, what if the cause of the increase in infections is something about our insertion techniques-won’t we need to know what “ought” to be done in order to know if it there is something we aren’t doing or doing against the evidence? Maybe the evidence shows we should be using a different way to care for the daily hygiene but how are we going to know if that is a problem, if we don’t know the evidence first? At least I’m sure that the quality improvement nurse will be able to help us figure out how to change behavior if we need to fix our process of care. Well, maybe we will need some evidence about that too-how to translate what the evidence says into action. Once we figure out what to do about this, I think it would be a good idea to show others what we did if we come up some good strategies. I wonder if we have to go through IRB? Would gathering data and then disseminating that be research? Hmmmmmm
12 metropolitan areas (Boston; Cleveland; Green- ville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Newark, N.J.; Orange County, Calif.; Phoenix, Ariz.; Seattle; and Syracuse, N.Y.), using random-digit-dial telephone surveys, the CTS delib- erately recruited enough participants to assess how development of indicators of quality The indicators of quality used in the study were de- rived from RAND’s Quality Assessment Tools sys- tem. 25 RAND staff members selected acute and chronic conditions that represented the leading causes of illness, death, and utilization of health The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportu- nities to improve care.
Our team worked with a faculty member at our local university, infectious disease staff, and clinical nurse specialist to set up a clinical study to determine if using nursing stop orders would effect the catheter days, rate of CAUTIs and be safe –(measured as reinsertion rates). The stop order was a nursing prompt to discontinue the catheter on the surgical or first post-operative day. Our faculty partner recommended that we randomly assign units to one treatment or the other. We obtained IRB approval, and consented patients pre-operatively. We were careful to exclude patients with urinary surgery or obstructions, urinary retention, if they were receiving fluid challenges or any other treatment requiring accurate hourly outputs or if they had sacral wounds and incontinence. We used blind allocation to groups but of course we couldn’t blind the nurses who managed the catheters. We conducted the study for 12 months in order to reach our sample size of 700 – our faculty partner used a power analysis to determine the sample size. That meant we needed to first teach nurses on all the participating units so they knew the protocol. We used CDC criteria to determine the incidence of UTIs (we used our hospital’s usual procedures as we had very little funding to culture every patient), the EMR to count catheter days and we made judgments on unnecessary catheter days based on the criteria we provided nurses to discontinue the catheter. Data collection was challenging-our Quality Improvement nurse helped us since she follows CAUTIs anyway. She also helped us with the metric so we accounted for fluctuating census. The faculty partner helped us with the data analysis and helped us prepare a manuscript and abstract submission to present our findings at a national meeting on safety.(1:45)
Our team worked with the EBP council, librarian, infectious disease staff, clinical nurse specialist and faculty facilitator to help us reduce our CAUTI rates and catheter days. Our QI nurse fed back the first quarter data-not good, we had to do something. To make a long story short—the data told us that we needed to do something about our catheter days. The librarian took our PICO question, searched and found only a randomized controlled study about stop orders. We used journal club to appraise it and it was a very solid study that showed no impact on CAUTIs but the catheter days were decreased by just over 1.5 days on the average. The design, measurement and analysis supported the validity of the study. In addition, the librarian found several practice guidelines that recommended discontinuing the catheter as soon as possible after surgery with level 1 evidence (that means based on a systematic review with precise results). We proposed a policy and protocol change and received permission to pilot the project on 2 surgical units as long as we reported monthly to the medical and quality committees. Our EBP team, knowing this was a very high priority for our hospital and on top of our QI nurse’s list, brainstormed how we could implement the stop-orders. Again, the librarian helped us uncover systematic reviews about how to enhance evidence uptake. We found clinical prompts and audit and feedback worked better. We checked with the hospital’s IRB to determine if our proposal to measure and even disseminate what we did required IRB approval. The IRB said it sounded more like a quality improvement project and gave us the green light. We worked with our QI nurse to make sure we could audit what we were doing and feedback to the staff. We needed to negotiate with the IT staff to add a pop-up prompt to nurses to consider discontinuing the catheter and to obtain accurate catheter days. Our QI nurse (now a very good friend) analyzed the data and helped us feedback the monthly catheter days. We decided to go for broke and kept a running catheter day average and CAUTI counts in our pilot unit conference rooms, competing among us to keep it under 1.5 days and 0 CAUTIs. We took the project to most adult units in the hospital andpresented our project at the local, regional and national meetings.(2:20)
Our QI nurse fed back the first quarter data on CAUTIs and catheter days-not good, we had to do something. He is a black belt in Lean Six Sigma. He led us through a problem defining process where we identified contributing factors using brainstorming and a cause-effect diagram. We did a high level process map where we worked backwards from discontinuing a urinary catheter to its insertion on our unit. We wondered if the lack of autonomy to make a decision to discontinue and having to wait for a physician’s order was a main contributor to the problem. The QI nurse reviewed 10 patients’ data and created a Pareto chart. It verified that the largest delay in discontinuing catheters came from the lack of physician order. Again, we analyzed the causes of the lack of an order. We hypothesized that physicians and nurses remembering was a key issue. With the QI nurse’s help, we designed a small experiment, based on the experiences of some of the local hospitals who used nursing stop orders. After negotiating with the surgeons, and manager, we piloted the stop orders on our unit and compared the catheter days and CAUTIs over the next quarter. We were pleased to see a drop in catheter days; the QI nurse helped other units implement the stop orders and continued to follow catheter days and CAUTI rates
Current guideline dissemination and implementation strategies can lead to improvements in care within the context of rigorous evaluative studies. However, there is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgment about how best to use the limited resources they have for quality improvement activities.
What if Amanda combined her efforts: using the best available evidence to inform both the what and how of the improvement process, using more rigor to prospectively and systematically measure and compare the effects? Attended to sustainability of the effort?
Gibbons: finding boundary objects-ie, the thing that begins the discussion and the negotiation, overcoming the awkwardness of the usual interactions/distances to find shared space, the “trading zone”-negotiation of meaning. Gibbons: Boundary objects command the allegiance of diverse interests and engender willingness among participants not to compromise, but to improviseCanada: 1996-97, 95% of the research budget was investigator-driven, curiosity-driven; 2007-8, dropped to 70% with 30% targeted toward specific programs and goals.
10 year project that is beginning to reap the benefits:This approach to quality improvement has merit; systematic change especially when it involves bringing about change nationally, takes leadership, time and persistence and much patience.
a first-order priority for effectiveness research is the establishment of infrastructure for a more dynamic, real-time approach to learning. Efforts under way to better engage health delivery organization, practitioners, patients, and the community in research prioritization, conduct, and results dis- semination should be supported and expanded.there is a need to ensure that these developing opportunities are matched by the skills of the work- force. This includes training and education in the methodologies of research design, the translation of research, guideline development, and the maintenance and mining of clinical records. But it alsoincludes giving attention to reorienting the education of frontline caregivers around their emerging responsibilities for access, inter- pretation, and discussion with patients of a dynamic evidence base, as well as helping to ensure the availability and integrity of the clinical data that shape conclusions on evidence.Reference was made throughout the meeting to work going on elsewhere in the world and, in particular, to work at the National Institute for Health and Clinical Excellence in the United Kingdom. This brought clearly into play the need to ensure that, where possible, common work to assess an intervention’s clinical effectiveness