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Translating Evidence into Practice
Sean M. Berenholtz, MD MHS FCCM Johns Hopkins University
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Questions: What comes to mind when you think about translating evidence into Practice? Who’s role is it at your institution to translate evidence into practice? How often do you work with the quality improvement folks? Did you receive quality care during your last doctor visit? Survey the audience to give you a better understanding of who is present. You can ask how many people are quality, cme, administrators, etc. Create a connection so that people can understand? Pre-select 2 people to respond; having people engaged
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Objectives: Identify the multi-level approaches to improve translating evidence into practice Discuss different strategies to improve patient care Review a model for large scale knowledge translation Identify gaps between best evidence and practice Applying the 4Es to creating reliable health care
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RAND Study Confirms Continued Quality Gap
10.5 Alcohol dependence 22.8 Hip fracture 40.7 Urinary tract infection 45.2 Headaches 45.4 Diabetes mellitus 48.6 Hyperlipidemia 53.0 Benign prostatic hyperplasia 53.5 Asthma 53.9 Colorectal cancer 57.2 Orthopedic conditions 57.7 Depression 64.7 Hypertension 68.0 Coronary artery disease 68.5 Low back pain Percentage of Recommended Care Received Condition Quality gap – many different; patients not getting the quality they should get; translating evidence, efficient, timely. McGlynn et al, NEJM 2003; 348(26):
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Approaches to Improve TRiP
Assumptions Evidence-based medicine, Clinical practice guidelines, Decision aids Provision of best evidence and convincing information leads to optimal decision making and optimal care Professional education and development Self-regulation, Recertification Bottom-up learning based on experiences in practice and individual learning needs leads to performance change Assessment and accountability Feedback, Accreditation, Public reporting Providing feedback on performance relative to peers, and public reporting of performance data motivates change in performance Patient-centered care, Patient involvement, Shared decision making Patient autonomy and control over disease and care processes lead to better care and outcomes Total quality management and continuous quality improvement, Restructuring processes, Quality systems, Breakthrough projects Improving care comes from changing the systems, not from changes in individuals Many different models, different approaches; many multilevel approaches Adopted from Grol R. JAMA 2001;286:
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Grol R. JAMA 2001;286:
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BMJ 2008;337:
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Translating evidence into practice: A model for large scale knowledge translation
Summarize the evidence Identify local barriers to implementation Measure performance Ensure all patient receive the intervention BMJ 2008;337:
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Generalizable Central Line Associated Blood Stream Infection (CLABSI)
Infect Control Hosp Epidemiol 2014;35(1):56-62. Ventilator Associated Pneumonia (VAP) Infect Control Hosp Epid. 2011;32(4): Venous Thromboembolism (VTE) Arch Surg. 2012;147(10): Colorectal Surgical Site Infections (SSI) J Am Coll Surg. 2012;215(2):
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Central Line Associated Blood Stream Infections
> 2 million central venous catheters placed in U.S. ICUs annually 16,000 CLABSI in U.S. ICUs annually Mortality: 18% (0-35%) Annual deaths: ,000 Cost per episode: $28,690-$56,000 Annual cost: $60 - $460 million CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001
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Gap Between Best Evidence and Practice
Knowledge awareness or familiarity (n=77) Attitudes agreement (n=33) self-efficacy (n=19) outcome expectancy (n=8) inertia of previous practice (n=14) Behavior external barriers (n=34) Always some gap, knowledge gap, attitude or behavior Cabana et al. JAMA 1999 11
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Central Line Associated Blood Stream Infection (CLABSI) Prevention
Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines 5 things to target
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Standardize Care Make it easier, go to
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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Creating Reliable Health Care Executive Leaders Team Leaders Staff
Engage How Does This Make the World a Better Place? Educate What Do We Need to Do? Execute How can we do it with my resources and culture? Evaluate How Do We Know We Made a Difference? Health Services Research 2006
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CLABSI Rate for All ICUS at JHH: 1998 - Q2 2012
Crit Care Med 2004;32(10):2014
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Michigan Keystone ICU CLABSI Rate: 2004-2012
N Engl J Med 2006;355: ; BMJ 2010;340:c309.
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National Efforts On the CUSP:Stop BSI Program
1,071 ICUs in 45 states 43% CLABSI reduction Number of ICUs that achieved CLABSI rate of ZERO, more than doubled Infect Control Hosp Epidemiol 2014 Jan;35(1):56-62.
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Lessons Learned Harm is preventable
Many complications, including HAIs, are preventable Should be viewed as defect Focus on systems -- Not individuals Far more complex than a checklist Engage frontline staff to identify and fix local defects ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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Key Concepts: Technical and Adaptive Work
Sweet Spot Evidence-based interventions Local culture
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How Will We Get There? TECHNICAL WORK ADAPTIVE WORK
Work that we know we should do, like appropriate antibiotic dosing and skin preparation The intangible components of work, like ensuring team members speak up with concerns and hold each other accountable Work that lends itself to standardization (e.g., checklists and protocols) Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they should Evidence-based interventions Safety culture, including teamwork
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Learning, Development, and Capacity
3 Target: People aiming for a career in safety- quality work Graduate degrees Career development awards Safety-quality experts Education 2 safety-quality education Role tailored Target: Healthcare leaders /managers with responsibility for improving safety-quality - Patient Safety Certificate Safety fellows 1 Basic safety-quality Education Target: All healthcare professionals - Medical, nursing , and other healthcare professions’ students - Residents , fellows
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AI Patient Safety Training
Online Patient Safety Certificate Patient Safety Fellowship 13 modules, 18 hours 6 months, didactic, mentorship Patient Safety Certificate Program Analytics Leadership in Patient Safety 24 modules, 5 consecutive days 12 months, didactic, mentorship For more, visit ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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Comprehensive Unit-based Safety Program (CUSP)
A practical approach to tap into the wisdom of frontline staff and improve teamwork and safety culture
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CUSP Pre-work Comprehensive Unit-based Safety Program
Start in one unit and then spread Imperative for frontline staff to be involved Build strong partnerships: Infection prevention staff Hospital quality and safety leaders Nurse educators Physician leaders ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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CUSP Objectives Comprehensive Unit-based Safety Program
Educate staff on science of safety Identify defects Partner with a senior executive Learn from defects Improve teamwork and communication Jt Comm J Qual Patient Saf 2010;36:252-60 Resources:
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Statewide Michigan CUSP ICU Results "Needs Improvement”
Needs Improvement: Less than 60% of respondents reporting good safety or teamwork climate Statewide in % needed improvement, down to % in 2007 J Critical Care 2008;23: Crit Care Med 2011;39(5):1-6 26
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Best Way Forward Harm is preventable Informed by science
Many complications, including HAIs, are preventable; Should be viewed as defect Informed by science Technical and adaptive teamwork Led by clinicians and supported by management Tap into wisdom of frontline staff Need to build capacity ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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Engagement: Small group discussions from pre-work
Results from discussions with quality improvement folks at your institution Ask: What quality driven organizational projects are being addressed? Are there financial implications for these projects? (High level projects could be aligned with your organization’s strategic priorities, mission, vision, and external reporting requirements for quality measures.) What quality metrics are being used? Think about how you can CME/CPD get involved? Ask the organizational leaders is there a way they can envision how they think the CME/CPD office can get involved.
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