How implementation science helped us change practices How implementation science helped us change practices. The IRGLM’s experience with the Spinal Cord Injury Knowledge Mobilization Network   Marie-Thérèse Laramée, Caroline Joly, Isabelle Robidoux, Violette Jeune, Sonia Côté, Saagar Walia My name is Marie-Therese Laramee and I work here in Montreal at the CIUSSS Centre sud - Institut de réadaptation Gingras Lindsay ‘s site. I would like to acknowledge the work of my colleagues Caroline Joly, Isabelle Robidoux, Violette Jeune, Sonia Côté, Saagar Walia

Background What is Spinal Cord Injury Knowledge Mobilization network (SCI KMN) Community of practice formed in 2011 comprised of seven Canadian rehabilitation centres across 4 provinces. The goal of the SCI KMN To adopt and utilize the best available practices in spinal cord injury care to improve outcomes. To guide its work with evidence-informed implementation methodology adapted from the National Implementation Research Network (NIRN) frameworks The SCI KMN, formed in January 2011, is a spinal cord injury (SCI) rehabilitation community of practice funded by, and in collaborative partnership with, the Rick Hansen Institute (RHI), the Ontario Neurotrauma Foundation (ONF) and the Alberta Paraplegic Foundation (APF). It is comprised of 7 rehabilitation hospitals across 4 provinces in Canada, with a mission to improve health outcomes for persons with SCI with demonstrated economic impact through implementation science leading to innovations in clinical practice. The goal of the KMN is to adopt and utilize best practices to improve outcome. It is well known that a successful and sustainable implementation of a new practice is ensure by being based on implementation science. The SCI KMN established a partnership with the National Implementation Research Network (NIRN), an implementation science group whose theoretical frameworks and practical tools were designed for Best Practice implementation (BPI). Using implementation science, the SCI KMN community of practice systematically implemented best practices in Pressure Ulcer and pain assessment and management . The concept of adaptation and contextualization is imperative to the dynamic process of BPI. As such, the SCI KMN adapted the NIRN Active Implementation Frameworks and tools to meet the unique, evolving, and immediate needs of the network towards implementing best practices into active service in SCI healthcare, nationally.

Objectives Today’s presentation will describe: adapted NIRN’s integrated frameworks that guided our work level of completion of the two pressure ulcer prevention and two pain management practices impact on the clinicians and patients main facilitators and barriers to implementation that were encountered.

Methods Review evidence and reach consensus on the best practices to be implemented The best practices selected are recommendations from clinical practice guidelines. »The first thing that we have done was to review the evidence and reac

Our best practices PRESSURE ULCER PAIN Conduct comprehensive, systematic and consistent assessment of risk factors in individuals with SCI Provide structured education and provision of specific information. PAIN Use an interdisciplinary approach to assessment of pain and treatment planning. Address the person’s concerns and expectations when agreeing which treatments to use by discussing for example coping strategies for pain and for possible adverse effects of treatment. There are the practices chosen as described in the SCI Practice guidelines

Adapted NIRN frameworks Practice, program and systems change through… Multi-dimensional, Fully integrated Implementation Teams Implementation Drivers Implementation Stages Improvement Cycles How did we implement the practices? With the implementation science of NIRN’s adapted frameworks.

SCIKMN adapted Framework 1 : Teams Implementation Teams and Organizational Structure for Networks of Implementation Teams

SCIKMN adapted Framework 2: Stages Guidance using activities through four stages of implementation

SCIKMN adapted Framework 3: Drivers Assessment and analysis of implementation drivers

SCIKMN adapted Framework 4: Cycles PLAN Explore and prepare DO Engage as planned STUDY Evaluate effectiveness ACT Learn and improve   This is exactly what I did for this presentation . I analyse the collected data to address any improvement cycles that might be necessary Evaluation and Analysis of data collected to inform

SCIPUS at admission What has our improvement cycle analysis tell us: Our Risk factors tool completed by nursing staff at admission: From not having one in 2011, we are at more than 90% completion rates year after year. We are still working at having it completed within 72 hours of admission which has improved since our last analysis as shown by the 2015 data.

Education program As we thought that this practice was well installed and it is, this improvement cycles will need a more thorough analysis. We see that our attendance to group sessions tend to decrease each year. Few pistes de reflexion: We have had more incomplete lesions (79%) for whom attendance to group sessions is less appropriate. The lenght of stay has decreased and we give the group sessions every 6 weeks. Before, this was correct. With the lenght of stay decreasing, we will have to look at this carefully

Interprofessional team risk assessment We have worked on this a lot. We were doing quite poorly with a lot of incomplete interdisciplinary assessment. We have installed a new interdisciplinary discussion

Pain assessment at admission Our cycle has made it possible to improve the level of completion of the ISCI pain data set. Where we can see that our fully completed tool percentage has improved This is one of the disadvantage of inter professional tools. If one clinician does not fill its section, it is considered incomplete.

Concerns and expectations Same as the previous slide

Incidence of pressure ulcers Outcomes now Even if the percentage of our retropective PU is underrated we have passed from 11-12% incidence of PU developed during rehab at a mean of 7% and this year after year. We even had one year with a percentage

Incidence of pain The incidence of pain has to be looked at carefully since our retrospective group might not have been as

FACILITATORS OBSTACLES Multi level support by the organization Presence of dedicated coordinators Time allocated by managers Limited burden on clinicians Interactions between The limits of the tool Individual characteristics (resistance to change, individual knowledge, lack of motivation…) Tool characteristics (validity, reliability, value for clinicians…) Perception of added value Individual factors of the patients Challenge of having interdisciplinary best practices  Possibility of adapting the best practice Budget cutback and health network changes Presence of a culture on interdisciplinarity Staff turnover Financial support   Support from the SCI KMN central structure Implementation science and frameworks to guide the implementation

In summary SCIKMN has enabled the IRGLM’s team to develop implementation science capacity; • Four BPs have been successfully implemented since 2011. • PDSA cycles have allowed the teams to revisit the practices and improve the level of completion. IRGLM scaled this capacity to allow a better standardization of practices within the Montréal continuum of care following SCI Start of another multi-site implementation initiative for the use of electrical stimulation... Combined with standard wound care interventions with one rehabilitation centre and one acute hospital in the Montréal region.

Acknowledgements The patients involved in this project The clinicians of the SCI Program of IRGLM SCI KMN and the sponsors: Rick Hansen Institute Ontario Neuro Foundation Contact: marietherese.laramee.irglm@ssss.gouv.qc.ca