translating evidence into practice sean m. berenholtz, md mhs fccm johns hopkins university 1
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Translating Evidence into Practice
Sean M. Berenholtz, MD MHS FCCMJohns 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?
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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
10.5Alcohol dependence
22.8Hip fracture
40.7Urinary tract infection
45.2Headaches
45.4Diabetes mellitus
48.6Hyperlipidemia
53.0Benign prostatic hyperplasia
53.5Asthma
53.9Colorectal cancer
57.2Orthopedic conditions
57.7Depression
64.7Hypertension
68.0Coronary artery disease
68.5Low back pain
Percentage of
Recommended Care Received
Condition
McGlynn et al, NEJM 2003; 348(26):2635-2645
Approaches to Improve TRiP
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Approach 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 developmentSelf-regulation, Recertification
Bottom-up learning based on experiences in practice and individual learning needs leads to performance change
Assessment and accountabilityFeedback, 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
Adopted from Grol R. JAMA 2001;286:2578-2585.
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6Grol R. JAMA 2001;286:2578-2585
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BMJ 2008;337:963-965.
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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;337:963-965.
Generalizable
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• 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):305-314.
• Venous Thromboembolism (VTE)– Arch Surg. 2012;147(10):901-907.
• Colorectal Surgical Site Infections (SSI)– J Am Coll Surg. 2012;215(2):193-200.
Central Line Associated Blood Stream Infections
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• > 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: 500 - 4,000• Cost per episode: $28,690-$56,000 • Annual cost: $60 - $460 million
CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001
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)
11Cabana et al. JAMA 1999
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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
www.cdc.gov
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Standardize
Care
• 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
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
All ICUs
11.8244288986566
7.50932921651543
6.85717995538852
7.90467201510146
4.2403464453266
2.52707670416558
2.25318262045139
2.32853513971211
2.73326727937408
1.67229458112237
1.33986928104575
1.2243056897996
1.58810609900321
0.88034368617508
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0.89624267493967
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0.50
1.50
2.50
3.50
4.50
5.50
6.50
7.50
8.50
9.50
10.50
11.50
12.50
CL
A-B
SI
Rat
e P
er 1
,000
CL
. D
ays
Crit Care Med 2004;32(10):2014
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Michigan Keystone ICUCLABSI Rate: 2004-2012
Q1 '04 Q1 '05 Q1 '06 Q1 '07 Q1 '08 Q1 '09 Q1 '10 Q1 '11 Q1 '12
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
3.2
3.4
CLABSI rate per 1,000 central-line days
2.46
0.00
2.55
0.79
Average CLABSI rate
Median CLABSI rate
MHA Keystone: ICU CLABSI rates per 1,000 central-line days for Q2 2004 - Q2 2012
N Engl J Med 2006;355:2725-32; 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
TechnicalWork
Adaptive Work
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
Basic
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Educ
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Role
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Educ
ation
Target: All healthcare professionals- Medical, nursing , and other healthcare professions’ students
- Residents , fellows
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Target: Healthcare leaders /managerswith responsibility for improving safety-quality
- Patient Safety Certificate- Safety fellows
Target: People aiming
for a career in safety- quality work- Graduate degrees
- Career development awards
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Learning, Development, and Capacity
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AI Patient Safety Training
• Online Patient Safety Certificate– 13 modules, 18 hours
• Patient Safety Certificate Program– 24 modules, 5
consecutive days
• Patient Safety Fellowship– 6 months, didactic,
mentorship
• Analytics Leadership in Patient Safety– 12 months, didactic,
mentorship
For more, visit http://www.hopkinsmedicine.org/armstrong_institute/
programs/
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
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A practical approach to tap into the wisdom of frontline staff and improve teamwork and safety culture
COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP)
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CUSP Pre-workComprehensive 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 ObjectivesComprehensive Unit-based Safety Program
Jt Comm J Qual Patient Saf 2010;36:252-60
Resources: http://www.ahrq.gov/cusptoolkit/
1. Educate staff on science of safety
2. Identify defects
3. Partner with a senior executive
4. Learn from defects
5. Improve teamwork and communication
Safety Climate Teamwork Climate0
10
20
30
40
50
60
70
80
90
100
84% 82%
23% 22%
Before After
Statewide Michigan CUSP ICU Results"Needs Improvement”
26J Critical Care 2008;23:207-221Crit Care Med 2011;39(5):1-6
• Needs Improvement: Less than 60% of respondents reporting good safety or teamwork climate
• Statewide in 2004 82-84% needed improvement, down to 22-23% in 2007
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Best Way Forward
• Harm is preventable– 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
Engagement: Small group discussions from pre-work
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• 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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