Marita Titler 8/2/2015. Models for EBP and Translation Science

Transcription

1 Models for EBP and Translation Science Marita G. Titler, PhD, RN, FAAN Rhetaugh Dumas Endowed Chair Department Chair Systems, Populations and Leadership University of Michigan School of Nursing August 5, 2015 Objectives Use the Iowa Model as a guide to implement EBPs to improve patient outcomes Translation Research Model - identify the myths and realities implementing EBPs. Identify applications to your practice setting. 1

2 Funded Projects Translation Science Evidence-Based Practice: From Book to Bedside (PI: Titler, R01 HS10482; AHRQ) Book to Bedside: Sustaining Evidence-Based Practices in Elders (PI: Titler, R02 HS10482) Cancer Pain In Elders: Promoting EBPS in Hospices (PI: Herr; Co-PI Titler; R01CA115363) Advancing Quality Care Through Translation Research (PI: Titler R13 HS014141). Funded Projects Translation Science Moving Beyond Fall Risk Scores: Implementing fall prevention interventions that target patient specific fall risk factors (Titler and Conlon RWJ INQRI 68266) Implementing FOCUS (psychoeducational intervention for adults with cancer and their caregivers) in Cancer Support Communities Ohio, California (Titler, CTSA pilot). 2

3 The Iowa Model of Evidence Based Practice to Promote Quality Care Problem Focused Triggers 1. Risk Management Data 2. Process Improvement Data 3. Internal/External Benchmarking Data 4. Financial Data 5. Identification of Clinical Problem Knowledge Focused Triggers 1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee Consider Other Triggers No Is this Topic a Priority For the Organization? Yes Form a Team = a decision Point Problem and Knowledge Focused Triggers Is there a better method of clinical practice? Encouragement of questions from direct care givers Sources Quality data EBP guidelines and systematic reviews (e.g. AHRQ; ONS) 3

4 Examples Symptom Management Pain Fatigue Mobility and exercise Pain assessment/treatment chemotherapy induced neuropathic pain Prevention of CAUTI Delirium prevention & screening Oral care Restricted visiting of patients in ICUs - every 2 hours; 10 minute visits; immediate family members; no children Flexible visiting practices Family presence (Cohen et al, 1998; Halm et al, 1990; Titler, 1999; Titler et al, 1995; Titler 1995; Titler & Walsh, 1992; Titler et al, 1991) 4

5 Family Presence in Care Delivery Settings Standard of care Is an EB for this practice Enhances communication Informs our practice family member s knowledge of their loved one We can make this happen every day The Topic Matters 5

6 The Iowa Model of Evidence Based Practice to Promote Quality Care Problem Focused Triggers 1. Risk Management Data 2. Process Improvement Data 3. Internal/External Benchmarking Data 4. Financial Data 5. Identification of Clinical Problem Knowledge Focused Triggers 1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee Consider Other Triggers No Is this Topic a Priority For the Organization? Yes Form a Team = a decision Point Criteria to Consider When Selecting A Topic Priority for the organization Cultural values Priority for the department Staff interest and commitment Magnitude of the problem Likelihood to contain costs and improve outcomes Applicability Multidisciplinary 6

7 EBP: A Team Sport = a decision Point Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Yes Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design EBP Recommendations 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify Practice Recommendations Is There a Sufficient Research Base? No Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory Conduct Research 7

8 P.I.C.O. Model for Clinical Questions Patient, Population, or Problem Intervention or Treatment (caution EB review of the science) Comparison Intervention or Treatment Outcome Building the Question Using P.I.C.O. Patient or Problem Intervention Comparison Intervention Outcomes Tips for Building Example How would I describe a group of patients similar to mine? Patients discharged to home following surgery for laryngeal cancer Which main intervention am I considering? Based on evidence Pharmacological treatment. Discharge planning telephone f/u What is the main alternative to compare with the intervention? Conventional Therapy Usual Care What can I hope to accomplish? Improved pain control at home (post discharge) 8

9 Examples Purpose of this EBP project is to decrease pain experienced at home (post-discharge) following surgery for laryngeal cancer by improving pharmacological treatment and discharge planning. Clinical question how do we improve pain management of home-going patients following surgery for laryngeal cancer? Evidence sources Research AHRQ.gov EBCs Technology reports Systematic reviews Specialty organizations (AHA, ONS etc.) Get with the guidelines programs (CAD, Stroke, HF and more) 9

10 Critique Evidence Evidence tables many examples Learn to critique research, systematic reviews, CPGs, technology reports. Scottish Intercollegiate Guidelines Network Summary recommendations for practice A Note About RCTs as Only Evidence Source Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of RCTs Smith & Pell (2003) BMJ 10

11 Hints Have a well formulated clinical question or purpose statement - is not a research question, is a clinical question. Be specific enough to make the project manageable Purpose/question must be informed by the evidence. E.g. Intervention component will need to be decided upon and refined following critique of the evidence. Revise the purpose statement based on critique of the evidence and application to your patient population = a decision Point Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Yes Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design EBP Recommendations 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify Practice Recommendations Is There a Sufficient Research Base? No Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory Conduct Research 11

12 Making Difficult Decisions: Is There a Sufficient Research Base? Relevance of research findings for practice Consistency, quality & quantity of findings Volume of studies with sample characteristics similar to patient population Consistency of the evidence across sources Feasibility for practice The risk/benefit ratio Writing an EBP standard/policy/procedure Incorporate essential elements from the evidence tables and evidence sources in the standards of practice. What do clinicians at the point of care need to know and need to document. Electronic health record 12

13 Dietary Restrictions for Neutropenic Oncology Patients Project Director Linda Moeller, RN, BSN Team Deb Bohlken, RN, BSN, OCN Laura Suchanek, RN, MA, AOCN Linda Abbott, RN, MSN, AOCN Purpose and Rationale To determine the evidence for restricting patient s intake of fresh fruits and vegetables to prevent infection Restricted food choices for cancer patients impact their quality of life, performance status and treatment outcomes 13

14 Synthesis of Evidence Myelosuppressive chemotherapy is the gold standard for treating oncology patients Neutropenia is an anticipated consequence of this treatment Neutropenia precautions are often implemented to protect patients Synthesis of Evidence One component of neutropenic precautions has been restriction of patient s intake of fresh fruits and vegetables. Diet not directly linked to blood stream infections. Safe food handling and preparation are more likely to reduce food-borne infection than restrictions of fresh fruits and vegetables. 14

15 Practice Change Elimination of fresh fruit and vegetable restriction, with restriction of only select foods (unpasteurized food/beverages, blue veined cheeses) Education of patients and families about safe food handling and preparation Patient education brochure Modification of neutropenia precautions policy = a decision Point Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Yes Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice Recommendations 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Recommendations Is There a Sufficient Research Base? No Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory Conduct Research 15

16 Purpose of Evaluation To collect and analyze data in the natural clinical setting related to both the PROCESS and the OUTCOMES Satisfaction with Adult Inpatient Services To use data for decision making Basic Concepts for Evaluation Measure both the processes and outcomes Align the metrics (i.e. process and outcome measures) with the phenomenon of interest and the evidence. To make improvement in outcomes, focus on the processes!!!! Watch for trends and do not overreact to one or two data points. Integrate with QI Program Data sources Pick the most reliable Try and use what is already being collected 16

17 No change in blood stream infection rates before and after the practice change Evaluation Continue to Evaluate Quality of Care and New Knowledge No Is Change Appropriate for Adoption in Practice? Yes Institute the Change in Practice Disseminate Results Monitor and Analyze Structure, Process, and Outcome Data - Environment - Staff - Cost - Patient and Family = a decision Point 17

18 Instituting the EBP More Widely Attention to implementation steps and strategies Education and competencies of staff Include key stakeholders Unit/clinic based change champions Ongoing evaluation as part of your QI program Why Listen to Bowel Sounds? Diane Madsen, RN (see December 2005 AJN) 18

19 Literature Summary Auscultation of bowel sounds first proposed in 1905 (Cannon - reported in Nachlas, Younis, Roda, et al, 1972) Motility involves electrical activity coordinated with motor/muscle contraction leading to propulsion (Livingston & Passaro, 1990) Return of motility: small intestine, stomach, colon (Hotokezaka, et al, 1996; Livingston & Passaro, 1990; Schippers, et al, 1991) Literature Summary Return of bowel sounds likely represents early uncoordinated motor activity in small intestine and not coordinated propulsion in colon (Boghaert, et al, 1987; Nachlas, et al 1972 ; Rothnie, et al, 1963; Benson, et al, 1994; Morris, et al, 1983) Ability to tolerate feeding is limited by stomach and colonic motility (Cali, et al, 2000; Hotokezaka, et al, 1996; Nachlas, et al, 1972) Monitoring bowel sounds does not serve to indicate recovery of motility s/p abdominal surgery patients (Huge, et al, 2000) 19

20 Why Listen to Bowel Sounds? TRADITION EBP Standard Primary markers of return of GI motility (Bauer et al, 1985): First flatus First BM Additional markers of return of GI motility: Return of appetite Benign abdomen or absence of other symptoms Monitoring for complications 20

21 Excerpts from an Evidence-Based Practice Policy and Procedure GI assessment after abdominal surgery in adults: Assess for: Flatus within the last 8 hours R1, R6, R12, L3 Bowel movement, within last hours R12, L3 R1, R6, Precautions, Observations, General Considerations: Auscultation does not serve to monitor recovery of post-op motility R7, R7, R9 Myths and Realities of Implementation Implementation is a process 21

22 Model to Guide Selection of Strategies for Implementation (Rogers, 1995, 2003; Titler and Everett, 2001) Social System Characteristics of the EBP Communication Process Communication Rate & Extent of Adoption Users of Innovation Multifaceted strategies are necessary to translate research into Practice (Greenhalgh et al, 2005) Implementation Model Social System Characteristics of the EBP Communication Process Communication Rate & Extent of Adoption Users of the EBP (Rogers, 2003; Titler and Everett, 2001) 22

23 Myths Dissemination of trustworthy practice guidelines promotes use of EBPs. The evidence is strong, thus clinicians will change their practice we just have to show them the evidence. An EBP standard will change practice Characteristics of EBP that influence adoption Complexity of EBP (simple versus complex) Relative advantage of EBP effectiveness, relevance to the task, social prestige Compatibility with values, norms, work flow and perceived needs of end-users: clinicians, patients and families Strength of the evidence needs to have an evidence-base. Leader/facilitator as well as clinicians needs to have an understanding about the evidence-base 23

24 Important Principle Attributes of the EBP topic as perceived by users and stakeholders (e.g. ease of use, valued part of practice) are neither stable features nor sure determinants of their use. Rather it is the interaction among the characteristics of the EBP topic, the intended users, and a particular context of practice that determines the rate and extent of adoption. Strategies for adoption related to characteristics of the EBP topic Practitioner review and use of the EBPs to fit the local context - localization. Use of quick reference guides and decision aides Use of clinical reminders CDS; electronic reminders. (Balas et al, 2004; Berwick, 2003; Bradley et al, 2004; Fung et al, 2004; Grimshaw et al, 2006; Guihan et al, 2004;Wensing, et al, 2006) 24

25 TRF- Fall Prevention Bundle Focus on interventions that reduce or modify individual risk factors. Studies with sustained reductions in falls have focused on identifying individual fall risk factors (rather than ticking boxes to get a score), put in place interventions to address each risk factor, use a fall as a learning opportunity to improve care, 25

26 Implementation Model Social System Characteristics of the Innovation Communication Process Communication Rate & Extent of Adoption Users of Innovation 26

27 Myths Clinicians stay abreast of the latest evidence in their specialty. Clinicians learn about new evidence from We just need to educate them about the EBP didactic presentation preferred. Communication factors that influence adoption Interpersonal communication channels Methods of communication Social networks of users Interdisciplinary, trans-disciplinary perspective. Who will be influenced by the EBP? Who will be users of the EBPs? Stakeholders 27

28 Communication The Stickiness Factor: There is a simple way to package information that, under the right circumstances, can be irresistible. Memorable ideas spur us to action. (Gladwell, 200) 28

29 Strategies for adoption r/t communication Education is necessary but not sufficient to change practice. Interactive education is more effective than didactic education alone. Knowledge and skills to carry-out the EBPs. Key messages at the site of care 29

30 Strategies for adoption r/t communication Opinion leaders Change champions Educational outreach/academic detailing 30

31 Opinion Leader Practitioner within a specific discipline (nurse, physician, administrator) Viewed as an important and respected source of influence amongst peer group Role expectations: Organizational leadership Experts in practice Promote needed changes in organizational infrastructure (e.g., documentation systems) to support evidence-based practice (Greenhalgh et al 2005, Irwin & Ozer 2004, Redfern & Christian 2003, O Brien et al 1999, Berner et al 2001, Cullen 2005, Locock et al 2001) Change Champions Expert clinicians Informal leaders Positive working relationship Committed to providing quality care (Rogers 2003a, Titler 2004a, Titler et al 2006b, Harvey et al 2002, Rogers 2003b, Shively et al 1997, Titler & Mentes, 1999b, Titler 1998a) 31

32 Role of Change Champion Imparts information about evidence-based practice to peers Encourages staff to align their practice with the best evidence Teaches and demonstrates skills necessary to carryout evidence-based practice (1:1; small group) Orientation of new personnel Models practice Recognizes/rewards staff Educational Outreach Educated person who meets with practitioners in their setting to provide information about the EBPs, address questions, positive comments about aligning practice with the evidence. Feedback on provider performance Consultation on issues Who does this? Opinion leader Consistent person/consistent message Greenhalgh et al 2005, Feldman et al 2005, Horbar et al 2004, Jones et al 2004, Loeb et al 2004, McDonald et al 2005, Murtaugh et al 2005, Titler et al 2006b, O Brien et al 1997, Hendryx et al

33 Outreach visits What I was thinking is her site visits. was very inspirational to the staff. is very inspiriting and it really motivated people to think outside the box, or "How can we be better at this?" And after she rounded on the units, we would meet in a room and talk more about our audits that we would provide her and looking at our risk factors and our interventions and how we were doing with those. That was useful for the team. Implementation Social System Characteristics of the Innovation Communication Process Communication Rate & Extent of Adoption Users of Innovation 33

34 Who are/will be the Users of the Evidence-Based Practice Nurses Physicians Respiratory Therapists Physical Therapists Pharmacists Others Because implementation of a new practice almost invariably requires changing how things are done, it affects multiple individuals from multiple specialties and their interrelationships (Lucian Leape, 2005) 34

35 Myths Clinicians will adopt EBPs at about the same pace I just have to get those resistors on board. Focus on the resistors first and others will follow If I build it, they will come AKA: If I tell them, they will do it! Diffusion Diffusion is the process by which (1) an Innovation (2) is communicated through certain channels (3) over time (4) among the members of a social system Percent of Adoption 100% 90% 80% 70% 60% 50% 40% 30% Innovation I Take-Off Innovation II Later Adopters Innovation III 20% 10% 0% Early ADOPTERs Time Rogers, E.M. (1995). Diffusion of Innovations (4th Ed.). New York, NY: The Free Press. 35

36 Strategies r/t users of the EBP Identify users of the EBPs Performance gap assessment beginning of the change; indicators related to EBP topic. Audit and feedback during the practice change. Discussion forums rather than passive reports Trying the practice plan as part of the implementation process. Performance Gap Assessment Recommended practice compared to current practice Key indicators - do not try to assess all performance measures. Do early in process/beginning Get the data to those providing care/discussion Positive effect on changing practitioner behavior (Baskerville et al, 2001; Davis et al 1995; Flore et al, 1996; Hobar et al, 2004; McCartney et al, 1997; Titler et al, in review) 36

37 Performance Gap Assessment Pain Management ATC analgesia Pain intensity <3 Demeraol use PCA Benchmark Hospital A Hospital B Audit and Feedback Effective Strategy; during implementation Keep feedback actionable Link with organizational quality improvement structure and processes Data perceived by the clinician as important and valid. Timely, individualized, non-punitive feedback Bradly, et al, 2004; BootsMiller, et al., 2004; Dranitsaris, et al., 2001; Dulko, D. 2007; Hysong, et al., 2006; Morrison, et al., 2006; Pineros, et al., 2004; Won, et al., 2004; Wright, et al.,

38 % of Patients with Every 4 Hour Pain Assessment during first 48 hrs. Postop surgery *** ***Change begun Audit Feedback Example Fall Rate Fictitious data 38

39 Implementation Model Social System Characteristics of the Innovation Communication Process Communication Rate & Extent of Adoption Users of Innovation Titler & Everett,

40 Myths One size fits all Practice cultures are the same or similar in our organization. Changing practice is the NM s responsibility Context matters 40

41 Organizational factors that affect adoption Learning culture Leadership Capacity to evaluate the impact of the EBP during and following implementation Effective implementation needs both a receptive climate and a good fit with intended users needs and values (IOM 2001, McGlynn et al 2003, Stetler 2003, Rogers 2003a, Bradley et al 2004a, Ciliska et al 1999, Morin et al 1999, Fraser 2004a, 2004b, Vaughn et al 2002, Anderson et al 2003, Anderson et al 2004, Anderson et al 2005, Batalden et al 2003, Denis et al 2002, Fleuren et al 2004, Kochevar & Yano 2006, Litaker et al 2006, Cullen et al 2005a Redman 2004, Scott-Findlay & Golden-Biddle 2005) Organizational Strategies to Promote Adoption of EBPs Professional roles expect EBP in each role Performance criteria aligned with use of EBP; Career ladder programs Multidisciplinary teams Policies/procedures/documentation Technology for knowledge management to support patient care 41

42 Institutionalize EBP as a Normal Part of Work (Stetler et al, 2009) Role model site: Deliberately and strategically building the capacity to implement and institutionalize EBP over a period of 5 years. Why/motivation for EBP clear How or methods of strategic EBP change What including infrastructures (governance) for EBP Beginner site: EBP rarely seen as an ongoing explicit priority or vision. Role model site: Context to create and sustain EBP Management Creating and sustaining a clear vision Role modeling Developing supportive relationships Mentoring Leadership Beyond isolated projects Fabric of organization Building structures Provision of resources Monitoring progress Providing feedback Changing formal leaders who did not fit with the strategic vision. 42

43 Clinical Context for Evidence-Based Practice Bridie Kent and Brendan McCormick Implementation Model Social System Characteristics of the Innovation Communication Process Communication Extent of Adoption Users of Innovation 43

44 Myths Evaluation is not that important I can inform others verbally Stories tell the impact Results A 22% reduction in fall rates (outcome) Significantly improved use of fall prevention interventions targeted to patient specific risk factors (e.g. mobility from 33/100 patient days to 88/100 patient days). (process) 44

45 Transformative We've really transformed the culture I think as a system, we're so much better now I think this has created a teamwork that I've not seen before. But I personally feel we've made a much safer place for our patients, because we've made people aware for multiple different... you know all of the different disciplines that work with the patient are now much more aware of the fall risk of the patient. Hawaii State Center for Nursing Hawaii Nurses Shaping Healthcare: A State-Wide Evidence-Based Practice Initiative Legislative mandate to for EBP and quality outcomes Debra D. Mark, RN, PhD Nurse Researcher, Hawai i State Center for Nursing debramar@hawaii.edu 45

46 Outcomes to Date Increasing EBP capacity across the state Trained 39 teams 8 Health care systems Institutionalizing EBP Papers and conference presentations 46

47 Questions/Discussion 47