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Closing the Gap Between Research and Practice: A Multidisciplinary Approach. Marita G. Titler, PhD, RN, FAAN Rhetaugh Dumas Endowed Chair - PowerPoint PPT Presentation
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Closing the Gap Between Research and Practice: A Multidisciplinary Approach
Marita G. Titler, PhD, RN, FAANRhetaugh Dumas Endowed Chair
Associate Dean for Practice Development and ScholarshipDivision Chair Health Systems and Effectiveness Science
University of Michigan School of Nursing
August 2014
Overview
• Describe interdisciplinary research in implementation science with examples (science of translation)
• Identify examples of application of evidence in practice with clinicians (doing of EBP in healthcare)
• Lessons Learned • Reflections on the future
Implementation Science
• Testing implementation interventions to improve uptake and use of evidence to improve patient outcomes and population health.
• Explicating what implementation strategies work for whom, in what settings, and why.
Program of Research: Implementation Science
• Evidence-Based Practice: From Book to Bedside (PI: Titler, R01 HS10482; AHRQ, 1.5 million)
• Book to Bedside: Sustaining Evidence-Based Practices in Elders (PI: Titler, R02 HS10482; 0.5 million)
• Cancer Pain In Elders: Promoting EBPS in Hospices (PI: Herr; Co-PI Titler; R01CA115363; 2.8 million; )
• Advancing Quality Care Through Translation Research (PI: Titler R13 HS014141; $50,000).
• Moving Beyond Fall Risk Scores: Implementing fall prevention interventions that target patient specific fall risk factors (Titler and Conlon RWJ INQRI 68266; $300,000)
Funded Projects Co-Investigator• Dissemination of Tobacco Tactics versus 1-800-
QUIT-NOW for Hospitalized Smokers. 1U01HL105218-01.PI: S. Duffy. 2010-2014.
• Effectiveness of Smoking Cessation Guidelines in the ED. 1R21 DA021607 PI: D. Katz, 2008 - 2011.
• Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans. VA IIR, D. Katz. 2008 – 2011.
• Statewide Implementation of Guidelines to Control MRSA. CDC. PI: L. Herwaldt, 2007-2010.
Model to Guide Implementation(Rogers, 1995, 2003; Titler and Everett, 2001; Titler, 2008)
Communication Process
Rate & Extentof Adoption
Characteristics of the EBP
SocialSystem
Users ofInnovation
Com
mun
icat
ion
Multifaceted strategies are necessary to translate research into Practice (Greenhalgh et al, 2005)
InvestigatorsPI: Marita G. Titler, PhD, RN, FAAN
John Brooks, PhDKathleen C. Buckwalter, PhD, RN, FAAN
William Clarke, PhDLinda Everett, PhD, RN
Keela Herr, PhD, RN, FAAN J. Lawrence Marsh, MD
Margo Schilling, MDBernard Sorofman, PhD
Toni Tripp-Reimer, PhD, RN, FAANXianjin Xie, MS
Funded by AHRQ RO1 HS10482
TRIP Intervention Saves Healthcare Dollars and Improves Quality of Care
Aim 1: To test the effect of the TRIP intervention on nurse and physician adoption of evidence-based acute pain management practices in elders.
Aim 2: To test the effect of the TRIP intervention on decreasing barriers to use of evidence-based acute pain management practices.
Aim 3: To determine the cost effectiveness of the TRIP intervention.
Specific Aims
Design • Cluster randomized trial
• Implementation model to guide the multifaceted implementation intervention.
• Implementation intervention had components aimed at organizational and individual level
• 12 hospitals (randomized 6 to experimental; 6 to comparison arm) in the Midwest United States
Findings: Improved Acute Pain Management
• Improved pain assessment (OR=7.5)• More around-the-clock opioid administration
(OR=6.6)• Less administration of Demerol (OR=.35)• Higher summative index of quality care for acute
pain management (overall adoption score. 0-18) (p<.0001).
• Less pain intensity (1.5 on a 0-10 scale)
(Titler et al, 2008 HSR)
Findings on Cost
• Total costs per patient were $1,495.89 less in the E group than the C group (p <0.0001)
• For each one-unit increase in the Summative Index, total costs decreased by $1,598.75 (p = 0.002)
• A net savings to the hospital of more than $131,000 per 100 patients, even after implementation costs are taken into account.
(Brooks et al, 2008 HSR)
Cancer Pain in Elders: Promoting EBPs in Home Hospice Settings
Funded by NCI R01 CA115363
Investigators
PI: K. Herr, PhD, RNCo-PI: M. Titler, PhD, RN
P.G. Fine, MDS. Sanders, PhD, MSW
J. Cavanaugh, PhD
Moving Beyond Fall Risk Scores: Implementing an Evidence-Based Targeted
Risk Factor Fall Prevention Bundle Marita G. Titler, PhD, RN, FAAN
University of Michigan School of Nursing
Paul Conlon, PharmD, JDSenior Vice-President for Clinical Quality and Patient Safety
Trinity Health System, Novi, Michigan
Alex Tsodikov, PhD
Biostats, SPH, University of Michigan
Margaret Reynolds, PhD, RN
Trinity Health System, Novi, Michigan
Funded by RWJ foundation INQRI program
Study Aims
Aim 1: Compare fall rates, fall injury rates, and types of injuries from falls prior to, during and following implementation of the
“targeted risk factor fall prevention bundle”
Aim 2: Evaluate level of adoption of the evidence-based “targeted risk factor fall prevention bundle” at baseline and following
implementation
Aim 3: Explore, using qualitative methods, components of the implementation intervention and the “targeted risk factor fall prevention bundle”
Design • Prospective pre post implementation
design 3 community hospitals (13 adult noncritical care units) in the THS
• Funded for 18 months• Sites
– Hospital A = 471 bed teaching hospital– Hospital B = 243 bed community hospital – Hospital C = 90 bed rural community hospital
Fall Prevention Bundle • Focus on interventions that
reduce or modify individual risk factors.
• Studies with sustained reductions in falls have – focused on identifying
individual fall risk factors (rather than ticking boxes to get a score),
– put in place interventions to address each risk factor,
– used a fall as a learning opportunity to improve care,
Implementation Model & Intervention
EBP Practices – Risk Specific
Intervention: • QRGs • Posters• Key messages
Intervention: • Opinion Leaders (OL)• Staff education• Change Champions (CC)• Outreach visits• Train-the-trainer program
Intervention:• Senior administrator support• Education program for senior leaders and nurse managers• Meetings with pharmacists
Intervention:• Performance gap assessment • Audit and feedback• Teleconferences
Users
Adoption of EBPs
Co
mm
un
icat
ion
Social System
Characteristics of the Innovation Communication Process
Hospital; Patient Care Unit
Nurses, Pharmacists
Outcomes & Processes
Measures:• Fall rates• Fall injuries• Use of risk
specific fall prevention interventions
Results
• A 22% reduction in fall rates• Significantly improved use of fall prevention interventions
targeted to patient specific risk factors (e.g. mobility from 33/100 patient days to 88/100 patient days).
Results
Before Intervention Midpoint After Intervention0
10
20
30
40
50
60
70
80
90
100
74%83%
89%
15%11%
7%
11% 6% 4%
Falls Injury Type
Minor InjuryModerate InjuryMajor Injury
Perc
enta
ge
Fall Prevention Interventions
N=1638 total patient days before intervention; N=1606 total patient days after intervention
* Patient days are the number of days of labeled risk (denominator)
** Number of times intervention(s) was received per 100 patient days (example: Received mobility intervention 88 times per 100 patient days)
*** Sum of correct decisions based on risk profile; got one of the interventions that correspond to the risk profile (removes overlaps)
Before Intervention After InterventionRisk specific interventions*** Patient
Days*Rate per
100 patient days**
Patient Days
Rate per 100 patient
days
pValue
Mobility 1285 31 1333 88 <.001
Toileting/Elimination 853.7 50 917.7 66 <.001
Medication 1525 0.11 1562 0.1 0.981
Mental/Cognitive Status 769 2.3 531 77 <.001
Risk for injury 1142 66 1285 88 <.001
Focus Group Findings: Prior to Implementation
“It’s like we had a blanket fall prevention program and it excludes very few people … and so the nurses are more worried about the tasks of the flag and arm band and not honing in why this patient is a fall risk.”
Focus Group Findings: After
• “It is promoting more awareness … ‘what should we be doing for this patient?’”
• “You know all of the different disciplines that work with the patient are now much more aware of the fall risk for the patient.”
• “We take each patient and we look at specific fall risk. We are much more in depth into looking at the patient themselves compared to what we were before the falls study. It really did allow us to concentrate on “ok what are his needs.””
Collaboration
• That's one thing that I've noticed is that it's more of a team effort, between not just among staff but families and the patients are definitely more aware.
• I think this has created a teamwork that I've not seen before.
• the fact that physical therapy and occupational therapy were aboard. And working with our patients twice a day instead of once a day -- educating our CNA's on walking patients that prevent falls was very large.
QRGs and Posters
– I think the standardized interventions [QRGs] on specific interventions. That was nice to have that in a document that we can hand out in the units.
– we've had posters. And our fall champion's really good with putting out a lot of information on the falls.
– [QRGs] useful for a quick reference. You know, easy to read and bullets, and quick.
Challenges & Opportunities of INQRI PIs – Implementation Studies
• Telephone interviews – taped and transcribed
• Interview guide– Types and perceptions about implementation
strategies used– Successes, challenges and lessons
learned– Steps taken for sustainability
Titler et al, Medical Care 2013
Implementation Topics and Design
• Four Clinical Topics– Pain– Delirium – Fall prevention– Substance abuse- screening, brief intervention and
referral
• One professional development of nurse managers • Four were multi-site studies• Prospective pre post design
Challenges• IRB Approval
– Multi-site studies– IRBs not set-up for reviewing these types of studies
• Time frame for actual implementation (18 months of funding) – Most 4 to 6 months– “I am very worried we did not give units enough time to
make changes”
• Study specific challenges– Implementation tools/strategies not being used– Key stakeholders not being engaged early enough
Lessons Learned• Context
– “So in implementation science, it seems that context is so important. You know…Obviously this is a big lesson”
• Complexity of implementation– “Implementation is a complex process that takes time.
… Changing practitioner behavior is hard.”
• Communication– “One of the lessons learned is to use multiple
communication strategies with the sites to keep them engaged.”
Medical Care Volume 51, Number 4 Suppl 2, April 2013
Current Studies
• FOCUS: An Innovation in Care for Cancer Patients and Family Caregivers in the Cancer Support Community Network. PI: Titler. Co-I Dockham, MSW, Northouse, PhD, Ronis, PhD
Current Studies
• U01AG048270 NIA/PCORI. Clinical Trial of a Multifactorial Fall Injury Prevention Strategy in Older Persons. 30 million. PI: Shalender Bhasin; Joint PIs: Thomas Gill; David Reuben. Titler: Co-I and Lead for Patient Engagement. Other CO-Is – physical therapy, informatics, statistics.
Structure • National Patient and Stakeholder Council • Local Patient and Stakeholder Council at
each of the 10 clinical trial sites
Evidence-Based Practice• Integration of best research evidence with
clinical expertise and patient values (Sackett et al, 2000)
• Synthesis and use of evidence from scientific investigations (e.g. observational studies) and other types of knowledge (e.g. case reports; expert opinion) (Cook, 1998)
• Process not an event
Critical Care Nursing Clinics of North America, December 2001
Hawaii State Center for Nursing• Hawaii Nurses Shaping Healthcare: A
State-Wide Evidence-Based Practice Initiative
Debra D. Mark, RN, PhDNurse Researcher, Hawai’i State Center for [email protected]
Outcomes to Date • Increasing EBP capacity across the state• Trained 39 teams• 8 Health care systems• Institutionalizing practice change• Papers and conference presentations
Dietary Restrictions for Neutropenic Oncology Patients
Project DirectorLinda Moeller, RN, BSN
TeamDeb Bohlken, RN, BSN, OCN
Laura Suchanek, RN, MA, AOCN Linda Abbott, RN, MSN, AOCN
Purpose and Rationale
• To determine the evidence for restricting patient’s intake of fresh fruits and vegetables to prevent infection
• Restricted food choices for cancer patients impact their quality of life, performance status and treatment outcomes
Practice Change• Elimination of fresh fruit and vegetable
restriction, with restriction of only select foods (unpasteurized food/beverages, blue veined cheeses)
• Education of patients and families about safe food handling and preparation– Patient education brochure
• Modification of neutropenia precautions policy
Evaluation• No change in
blood stream infection rates before and after the practice change
Lessons Learned
• Partnerships• Implementation strategies
– Complexity of the clinical topic– Context – Communication – Key stakeholders
Implementation Science and EBP Requires Partnerships
and Collaboration
Principles of Partnerships: Research and EBP
• Nurturing of relationships over time• Inclusion in all phases of research• Sustaining partnerships
– Identifying assets and strengths– Develop capacity for research – Develop capacity for EBP
Implementation Strategies• Complexity of the clinical topic
– Quick reference guides and decision aides– Length of time for implementation– Key messages
• Communication– Education – necessary but not sufficient to change
practice; interactive; ongoing; new staff– Opinion leaders and change champions – specific to
discipline – Outreach to clinical practice sites (conversations; sense
making; “site visits” )
Implementation Strategies
• Identify clinicians who will be using the EBPs– Engagement early and often– Performance gap assessment – beginning to
discuss current state• Audit and feedback – actionable, discussion,
not passive dissemination of reports; Data perceived by the clinician as important and valid.; Timely, individualized, non-punitive feedback
“Because implementation of a new practice almost invariably requires changing how things are done, it affects multiple individuals from multiple specialties and their interrelationships”
(Lucian Leape, 2005)
Reality
Context matters
Context factors that affect adoption• Learning culture• Leadership (involve them from the beginning)• Managers of clinical sites• Capacity to evaluate the impact of the EBP during
and following implementation• Effective implementation needs both a receptive
climate and a good fit with intended users needs and values
(IOM 2001, McGlynn et al 2003, Stetler 2003, Rogers 2003a, Bradley et al 2004a, Ciliska et al 1999, Morin et al 1999, Fraser 2004a, 2004b, Vaughn et al 2002, Anderson et al 2003, Anderson et al 2004, Anderson et al 2005, Batalden et al 2003, Denis et al 2002, Fleuren et al 2004, Kochevar & Yano 2006, Litaker et al 2006, Cullen et al 2005a Redman 2004, Scott-Findlay & Golden-Biddle 2005)
Views through various disciplinary lenses
• Listen to various perspectives• Value of unique disciplinary perspectives• More horizontal integration across
disciplines
Reflections for the Future • PhD education: course work balanced with
mentorship – how much course work is enough
• Trans-disciplinary PhD education • Hillman scholars program – BSN to PhD
Reflections for the Future
• Plan efficacy studies with the end in mind – how will or can the findings from this study be used in practice
• Partner with communities of practice and the public early on in designing the study – traditionally have examined the state of the science from research – is this topic important to people?
Resources• Education
– Newsletters– 14 Podcasts– How to start a journal club– EBP references– Eye on Evidence– Webinars – lunch and
learn; journal clubs
• Research– Network of sites for
research– Process for investigators
to access NNPN organizations for research
– Organization context measurement instruments
• Culture• Climate• Interactive human
relationships
WE ALL HaveContributions to make
WISHING YOU THE SPIRIT of COLLABORATION IN YOUR DISCOVERY AND APPLICATION OF EVIDENCE IN PRACTICE
Questions/Discussion