How many doctors does it take to change a light bulb? Steve Doherty October 2006

A History of change James Lancaster East India company 1591 and 1601

An orange a day keeps the doctor away James Lind Experiments on scurvy in 1747

Well maybe not … Results published in 1754 Not used by Royal nave for over 40 years

Louis and Leeches

But that ’ s all ancient history … “ Failure to translate research evidence into clinical practice is one of the two major barriers preventing benefit from the biomedical sciences. ” Sung et al. Central challenges facing the national clinical research enterprise. JAMA 2003;289:

Overview History of knowledge translation Change is difficult Change is needed Effects of our attempts …

The History of Knowledge Translation

Guidelines An important component in summarising evidence from research. Developed by many different organisations. Many different formats.

Guideline Implementation Time and money spent on developing guidelines Guidelines don ’ t implement themselves

Guideline Implementation Guideline dissemination strategies generally involve little money, little time, little effort and little expertise.

Guideline Implementation CEC pilot study.

The challenge of change > new trials on medline each year Traditional approaches – mail outs, conferences, review articles will only produce limited change. Grol,and Grimshaw Lancet 2003;362:

So how do we effect change in our department! Busy ED ~ pa Many challenges / barriers.

Challenges Department with relatively few senior medical staff Rotating junior staff High numbers of short term locums Night locums Inability to allocate nursing staff for all beds

Challenges No formal orientation for locum staff hence guideline awareness “ hit and miss ” Increasingly high nursing staff turn over and hence loss of continuity. No formal nursing education program / meetings.

Challenges No dedicated (to the ED) quality improvement or data collection staff. EDIS, via keywords, unable to generate guidelines or remind staff to use them The likelihood, that these changes will not be sustained.

Does “ the evidence ” help? Grimshaw et al Systematic review of 235 evaluations of guideline dissemination 86% showed improvement with compliance Overall improvement was 10%

Attempted change Most effective strategies Reminders How do you implement a reminder What form? Education Audit and feedback. By who and how often

Evidence also exists for … Focusing on the organization and processes rather than just the individual clinician Opinion leaders Characteristics of the guideline Clear planning Identification of evidence-practice gaps Identification of barriers Involvement of targeted group Clear expression of desired behaviour

Guideline characteristics Good evidence Simple, decreases workload Common, important or acute disease Accessible, usable Local champion Available in the front of the medical record

Evidence-based Implementation There is sufficient “ evidence ” to guide attempts at changing clinical practice. Our strategy was to appraise this evidence and to apply it to our department.

EBM Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ”

Evidence-based Implementation An analagous triad Best available evidence (on implementing change in practice) Judiciously used (by the implementation team) Applied to an individual department, service etc.

Change Is Needed

Sore Throat Rate of bacterial infection causing sore throat varies with age 3-13 years 30-40% Other age groups 5-15% BEACH study 4% of all GP presentations (sore throat) prescribing rates of 88% (Australian GP 2001)

Sore Throat Clinical Indicators

Otitis Media Australia has one of the highest rates of antibiotic prescribing in the world (>90%) The Netherlands the lowest (< 5%) For the same outcomes

Asthma 7 clinical indicators across area Assessment of severity Spirometry Spacer use Steroid use STAMPs Ipratropium overuse Antibiotic overuse

Assessment of Severity

Spirometry

Spacer use

Steroid use

STAMP use

Atrovent - Mild

Antibiotics

7 Clinical Indicators combined

Other projects Same strategy has been used for gastro, bronchiolitis, croup, head injury. Some adult equivalents Ottawa rules Applied in small rural district hospitals Future plans Mental health

Summary Changing behaviour in a complex organisation is difficult. Evidence exists for some strategies. Addressing “ individuals ” is not the answer – whole systems need to be addressed.

The End!