Translating Science into Better Patient Care in the ICU · Translating Science into Better Patient...

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Translating Science into Better Patient Care in the ICU

Tom Stelfox, BMSc, MD, PhDUniversity of Calgary

Webinar SeriesJune 28, 2017

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• Q&A session

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2017-06-28

Carol Barrie,Executive Director

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Reminder: Upcoming Webinars

Register at:http://www.cfn-nce.ca/news-and-events-overview/webinars/

• Wednesday, July 12, 2017 at 12 noon ETImplementing a Risk Screening Tool in Primary Care for Older Frail Adults – CFN-funded Implementation Grant Program – Paul Stolee and Jacobi Elliott, University of Waterloo

• Wednesday, July 26, 2017 at 12 noon ETiGAP‐ Improving General Practice Advance Care – CFN-funded Core Research Grant Program –Michelle Howard, McMaster University

• Wednesday, August 9, 2017 at 12 noon ETInnovation for toilet relocation to ease access for frail elderly at home & Wearable Caregiver Posture Coaching Feedback System – CFN-funded Health Technology Innovation Grant Program – Tilak Dutta, University Health Network

2017-06-28

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2017 Knowledge Translation Competition

• Designed to advance previously funded CFN research evidence into practice

• Intent to apply is due July 24, 2017 at 5 p.m. ET

• Please visit our website for more details: http://www.cfn-nce.ca/research-evidence/2017-knowledge-translation-grants-for-cfn-funded-research/

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• New competition expected to be launched late summer, details of the competition will be communicated

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Presenter

• Associate Professor of Critical Care Medicine, Medicine and Community Health Sciences at the University of Calgary

• Scientific Director of Alberta Health Services Critical Care Strategic Clinical Network

• Received his PhD in Health Care Policy from Harvard University and his MD from the University of Alberta

• Research program focuses on the application of health services research methods to evaluate and improve the quality of health care delivery to critically ill patients

2017-06-28

Translating Science into Better Patient Care in the ICU

Tom Stelfox,BMSc, MD, PhD

Translating Science into Better Patient Care in the ICU

Canadian Frailty Network – June 28, 2017

No disclosures or conflicts of interest

Many acknowledgements

Objective – Tell You a Story of Knowledge Translation

Patient case to ground us in clinical reality

Review knowledge translation – why, where, when, how

Illustrate one applied example

Personal Reminder Why Knowledge Translation is Important

April 15, 2014

Help

What a Great New Drug

FDA Safety CommunicationJune 11, 2013

Increased Mortality Severe Kidney Injury Risk of Bleeding

What is the plan?

All is Well That Ends Well?

We don’t always get it right…

Improvement Opportunities?

We don’t always get it right…

Improvement Opportunities? Recognize & respond to

illness

De-adopt harmful practices / adopt beneficial practices

Implement Patient & Family-Centred Care

We don’t always get it right…

Improvement Opportunities? Recognize & respond to

illness

De-adopt harmful practices / adopt beneficial practices

Implement Patient & Family-Centred Care

Review of Knowledge TranslationWhy, Where, When, How?

Research Should Inform Clinical Practice

ClinicalPractice

New Practicee.g., Lytics for STEMI

Practice Updatee.g., new lytics

De-adopt Existing Practice

e.g., Flecainide MI

Discover

Replace

Reverse

Research

Evidence-Based Medicine

Conscientious, explicit, and

judicious use of current best evidence in

making decisions

David Sackett 1934-2015

Evidence-Based Medicine

Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough...

Without clinical expertise, practice risks becoming tyrannised by evidence…

Without current best evidence, practice risks becoming rapidly out of date…

Translating Science into Better Care

Potential

Patient Care

Discovery

Clinical

Implementation

Sustainability

Knowledge Translation Facilitates Research Use

Graham J Con Ed Health Prof 2006

Under Use

When science shows an intervention is effective, but it is not used

E.g., strong evidence to support prophylaxis to prevent venous thromboembolism (VTE) 15% of Canadian ICU patients do not receive VTE

prophylaxis 75% do not receive the most effective form

More is better

Over Use

When science shows an intervention is ineffective or harmful, but it is used

E.g., Hydroxyethyl starch in critically ill patients is not helpful, may be harmful & yet it is still prescribed

Less is better than more

Misuse

When science shows an intervention is effective, but it isused for the wrong patients, wrong reason or wrong time

E.g., albumin is an effective therapy for select patients with liver disease, ineffective for most patients & harmful for some Many ICU patients receive albumin while many liver disease

patients do not

More for some and less for others (right treatment for right patient)

17 Year Journey: Research to Clinical Practice

Limited knowledge how to implement science

Inefficient dissemination methods

Science & clinical communities operating in isolation

Inadequate assessment of cost, societal values & personal preferences

JAMA Intern Med 2015; 175: 801-09

The Tale of Tight Glycemic Control

Leuven I (2001)

NICE-SUGAR (2009)

Single center RCT

N = 1,548

NNT = 29 (survival)

Multi-center RCT

N = 6,104

NNH = 38 (death)

What happened to patient glycemic

control?

Tight Glycemic Control

Most Common Adoption Strategies

0

10

20

30

40

50

60

70

80

90

No.

Stu

dies

Sinuff Crit Care Med 2013

Most Effective Adoption Strategies

0

10

20

30

40

50

60

70

80

90

No.

Stu

dies

Sinuff Crit Care Med 2013

Observations of Interventions from Other Areas

Passive education – limited impact Professional interventions (e.g., reminders) ~10% ∆

Closer to point of care larger impact

Financial interventions - volume of care Patient or family directed – ?quality of care? Multifaceted not better than single component Tailored not better than non-tailored

Impact modest & variable

Clinical Practice & Science Evolve

Using Science to Improve Care:A Local Experiment

Critical Care in Alberta

Which Practices to Focus on?

Inconsistent Scientific Findings

1. Ioannidis JAMA 2005, Prasad et al. Arch Int Med 2011, 3. Prasad et al. Mayo Clinic Proc. 2013, 4. Niven et al.

44%

46%

38%

Reproducibility of Scientific Evidence in Critical Care

47%

Patient, Provider, Decision-Maker, Researcher Perspectives

AUDIT

TOP 5 PRIORITIES

Reconciliation Panel3 Patients/Family Members3 Providers3 Decision-Makers

Frontline Providers1,103 providers, 16 ICUs

Patients & Families32 participants, 13 ICUs

Network Committee32 Decision-Makers

9 Priorities9 Priorities

13 Priorities

Stelfox et al. 2015Gill et al. 2016McKenzie et al. 2017

Opportunities for Improvement

0

10

20

30

40

50

60

70

% O

ppor

tuni

ty fo

r Im

prov

emen

t

Why VTE Prophylaxis?

Simple Routine Strong scientific basis

PROTECT & ePROTECT

Clinical impact – LMWH vs. UFH DVT PE HIT Major Bleeding Costs

Patient #1Right Radial Arterial Catheter Site

Patient #1Left Radial Arterial Catheter Site

Patient #2Right Radial Arterial Catheter Site

What Are These Lesions?

Stelfox et al. Intensive Care Med 2012

Barriers to VTE Prophylaxis

0 5 10 15 20 25 30 35

ICU culture

No support from MDs

No support from RNs

No support from pharmacists

Leaders with strong preferences

No clinical guidelines

Guidelines don’t recommend LMWH

Insufficient knowledge

Percentage of RespondentsSauro et al. 2017

Strategies for Improving VTE Prophylaxis

0 10 20 30 40 50 60 70 80

Education

Verbal reminders

Web-based reminders

Pre-set orders

Daily goals checklist

Audit & feedback

QI team

Clinical champion

Percentage of RespondentsSauro et al. 2017

Intervention

Interventions

Interventions

Guideline – update

Computerized order set

Education

Point-of-care reminders by pharmacists

Audit & feedback

Updated Guideline

YES NO

High Bleeding Risk?

Pharmacological Prophylaxis

Mechanical ProphylaxisReassess Daily

Medical-Surgical PatientDalteparin 5000 units Q24Enoxaparin 40 mg Q24

Trauma PatientEnoxaparin 30 mg Q12h

RIGHT PATIENT | RIGHT AGENT | RIGHT DOSE

Mechanical prophylaxis only if

patient ineligible for chemoprophylaxis

Adjusted dosing for

patients with renal failure

Adjusted dosing for

BMI Extremes

Education

Point-of-Care Reminders

PrescribersText messages during rounds

PharmacistsMedication review

NursesVTE prophylaxis

Can we use LMWH for this patient?

61%

86%

70%82%

8%

3%4%29%

12%

24%4%

7%7%

12%14%

0%

20%

40%

60%

80%

100%

120%

ICU A ICU B ICU C ICU D

LMWH UFH Mechanical No prophylaxis

November 2016 ThromboprophylaxisAre all these

patients at low risk for VTE?

Is LMWH contraindicated due

to bleeding risks, HIT, or surgery in all

these patients?

RIGHT PATIENT | RIGHT AGENT | RIGHT DOSE Calculated on inpatients after 24h of admission

Prizes

VTE Prophylaxis Data to Date

Process Evaluation

Is the intervention reaching the target audiences?

How is the intervention being received?

What modifications can we make to improve?

Renal Insufficiency

0

10

20

30

40

50

60

70

80

90

100

Pre Post Pre Post

% P

atie

nt D

ays

UFH LMWH

GFR > 30 mL/min GFR < 30 mL/min

Next Steps

Assess outcomes & costs – fall 2017

Look for unintended consequences

Evaluate sustainability

Determine if we can automate

Lessons Learned

Research impacts practice through discovery, replacement and reversal

Patients, families, providers & decision-makers are keen to participate in practice change

Focus on technologies/practices with reproducible evidence

Persistent Questions

When should we adopt or de-adopt a patient care practice?Magnitude of benefit/harm?Nature of the science?Cost?

Return to Our Case

Improving Care

Family initiated rescue

De-adopt harmful & low value practices

Partnering with patients & their families

Bedtime Reading

Acknowledgements

Mentors Sharon Straus

Collaborators Sean Bagshaw Chip Doig Kirsten Fiest Barry Kushner Dan Niven Jeanna Parsons Leigh Karolina Zjadewicz Dan Zuege Dave Zygun

Trainees Kea Archibold Kyla Brown Chloe de Grood Hasham Kamran

Research Team Jamie Boyd Rebecca Brundin-Mather Andrea Soo

Funding Agencies CFN Alberta Innovates CIHR

Thank You

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Post-webinar surveySurvey will pop up on your screen after webinar

• Feedback on how to improve webinar series

Register at:http://www.cfn-nce.ca/news-and-events-overview/webinars/

• Wednesday, July 12, 2017 at 12 noon ETImplementing a Risk Screening Tool in Primary Care for Older Frail Adults – CFN-funded Implementation Grant Program – Paul Stolee and Jacobi Elliott, University of Waterloo

• Wednesday, July 26, 2017 at 12 noon ETiGAP‐ Improving General Practice Advance Care – CFN-funded Core Research Grant Program –Michelle Howard, McMaster University

2017-06-28

Upcoming webinars