Translating Evidence into Practice Sean M. Berenholtz, MD MHS FCCM Johns Hopkins University 1 Questions: What comes to mind when you think about translating evidence into Practice? Whos 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? 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 3
RAND Study Confirms Continued Quality Gap Condition Percentage of Recommended Care Received Click edit Master text styles Low backto pain 68.5 artery disease Coronary Second level 68.0 Third level Depression 57.7
48.6 Diabetes mellitus 45.4 Headaches 45.2 Urinary tract infection 40.7 Hip fracture 22.8 Alcohol dependence 10.5 McGlynn et al, NEJM 2003; 348(26):2635-26454 Approaches to Improve TRiP
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 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 Adopted from Grol R. JAMA 2001;286:2578-2585. 5 Click to edit Master text styles Second level Third level Fourth level Fifth level Grol R. JAMA 2001;286:2578-2585
6 Click to edit Master text styles Second level Third level Fourth level Fifth level BMJ 2008;337:963-965. 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. 8 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):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. 9 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: 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 10 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) Cabana et al. JAMA 1999 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 12 Standardize Care ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 13 Creating Reliable Health Care Executive Leaders
Team Leaders Staff Click to edit Master text styles Engage How Does This Make the World a Better Place? Second level Third level Educate Fourth level What Fifth level 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 14 C L A -B S I R a te P e r 1 , 0 0 0 C L . D a y s CLABSI Rate for All ICUS at JHH: 1998 - Q2 2012 13.00 12.00 11.00 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00
Q1 '06 Q1 '07 Q1 '08 Q1 '09 Q1 '10 Q1 '11 Q1 '12 N Engl J Med 2006;355:2725-32; BMJ 2010;340:c309. 16 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. 17 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 18 Key Concepts:
Technical and Adaptive Work Sweet Spot Evidence-based interventions Local culture How Will We Get There? TECHNICAL WORK ADAPTIVE WORK Click to edit Master text styles Work that we know level we should do, Second like appropriate antibiotic dosing Third level and skin preparation Fourth level Fifth level
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 rts Learning, Development, and Capacity Ro
sa le t fet ail y-q ore ua d lit y ed uc 2 ati o n Sa Ed fety uc -qu ati al on ity ex pe 3
Ba Ed sic s uc afe ati ty on - q ua lity 1 - Target: People aiming for a career in safety- quality work - Graduate degrees Career development awards Target: Healthcare leaders /managers with responsibility for improving safety-quality - Patient Safety Certificate - Safety fellows
Target: All healthcare professionals - Medical, nursing , and other healthcare professions students - Residents , fellows 21 AI Patient Safety Training Online Patient Safety Certificate 13 modules, 18 hours Patient Safety Fellowship 6 months, didactic, mentorship Patient Safety Certificate Analytics Leadership in Program Patient Safety 24 modules, 5 consecutive days 12 months, didactic, mentorship
For more, visit http://www.hopkinsmedicine.org/armstrong_institute/ programs/ ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY 22 COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP) A practical approach to tap into the wisdom of frontline staff and improve teamwork and safety culture 23 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 24 CUSP Objectives Comprehensive Unit-based Safety Program 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 Jt Comm J Qual Patient Saf 2010;36:252-60 Resources: http://www.ahrq.gov/cusptoolkit/ 25 Statewide Michigan CUSP ICU Results "Needs Improvement 100 Needs Improvement: Less than 60% of respondents reporting good safety or teamwork
climate Statewide in 2004 8284% needed improvement, down to 22-23% in 2007 90 80 84% 82% 70 60 50 40 30 20 23% 22% 10 0
Safety Climate Before Teamwork Climate After J Critical Care 2008;23:207-221 Crit Care Med 2011;39(5):1-6 26 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 27 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 organizations 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.
Maximal Heart Rate 220 - Age, S.E.E. = 10-12 beats/min Has no relationship to fitness Produces obligatory reduction in aerobic fitness as you age Max CO = Max HR x Max SV Total Calories Expended Minimal goal is 1000 kcals...
b) An example of Müllerian mimicry, where both ecologically sympatric pairs are distasteful, and both have warning coloration. Life-cycle of monarch Adult monarch butterflies are protected from birds and other predators by the toxins in their tissues. These toxins are...
Lemniscus. This term is used for some ascending (sensory) nerve tracts in the upper part of the medulla, pons and midbrain. Spinal lemniscus. combination of spinothalamic, spinotectal tracts. Medial lemniscus. crossed posterior column fibers. Lateral lemniscus. 3rd neuron of auditory...
About us. State Aid for Local Transportation (SALT) was established in 1957. The purpose of the state aid program is to provide resources, from the Highway Users Tax Distribution Fund (HUTDF), to assist local governments with the construction and maintenance...
WAVE MECHANICS (Schrödinger, 1926) The currently accepted version of quantum mechanics which takes into account the wave nature of matter and the uncertainty principle. * The state of an electron is described by a function y, called the "wave function"....
Least squares means comparisons to the commercial mix using the Dunnett's method at α = 0.05 (*). (SPAD only) Note: None of the HydraFiber mixes were different from the commercial mix based on Dunnett's test. (SPAD only)
Outline: Morphology. Morphemic segmentation. un + beat + able. Phonology ("morphonology") and orthography. bab. y + s = bab. ie. s. Inflectional vs. derivational morphology. Morphological analysis: word form lemma + morphosyntactic features (tag) Tagging (context-aware disambiguation) Unsupervised affix detection...
Ready to download the document? Go ahead and hit continue!