EVIDENCE-BASED EVIDENCE-BASED CARECARE

PROGRAMPROGRAM©2004-2010 Grey Bruce Health Network©2004-2010 Grey Bruce Health Network

www.gbhs.cawww.gbhs.ca

GBHNGBHN

Program began in 2001 and now consists of 11 Program began in 2001 and now consists of 11 hospital sites, partnering 3 corporations in Grey hospital sites, partnering 3 corporations in Grey and Bruce with Open Source Order Setsand Bruce with Open Source Order Sets

The corporations are unified in providing The corporations are unified in providing consistent care according to evidence based consistent care according to evidence based standards and expert practice recommendationsstandards and expert practice recommendations

All clinical practices are evidence / expert basedAll clinical practices are evidence / expert based Together we form a collective mind in the Together we form a collective mind in the

pursuit of better patient outcomespursuit of better patient outcomes

Evidenced Based CareEvidenced Based Care

This program coordinates, educates This program coordinates, educates and evaluates the development and and evaluates the development and implementation of clinical pathways, implementation of clinical pathways, order sets and other evidence-based order sets and other evidence-based care tools.care tools.

The program is based on current The program is based on current evidence and clinical practice evidence and clinical practice guidelines, as well as addressing guidelines, as well as addressing workflow issues and the needs of workflow issues and the needs of rural healthcarerural healthcare

What is a Clinical Pathway? A mapping of a patients condition that

organizes, sequences and times the major interventions of nursing staff, physicians and other departments for a particular case type, subset or condition

Research shows this mapping improves patient outcomes and reduces length of stay

All pathways are generalized and must be critiqued to the individual

Pathways are nursing tools, are initiated by nursing and DO NOT require a Physician order

What is an Order Set?

Order sets replace “Preprinted orders” that were traditionally individual physician specific

Order sets can be implemented ONLY by the physician when signed by them or delegate

Order sets are diagnosis specific and based on published guidelines and research

Order sets are initiated for MOST RESPONSIBLE diagnosis for admission

Order sets are generalized in approach and critiqued to the individual and their comorbidities

Where does the Where does the evidence come from?evidence come from?

The ideal evidence-based system would have The ideal evidence-based system would have automatic links summarizing all relevant and automatic links summarizing all relevant and important research evidence about all clinical important research evidence about all clinical problems, and update you whenever a patients problems, and update you whenever a patients chart was accessed, based on their diagnosis and chart was accessed, based on their diagnosis and co-morbidities.co-morbidities.

Critical thinking of the practitioner is still the vital Critical thinking of the practitioner is still the vital link to successful patient outcomeslink to successful patient outcomes

Research dataThe Development Teams and Annual Review Teams review the Research Data found to create and update our Clinical Pathways

How do we find the How do we find the evidence?evidence?

Review published guidelines for various Review published guidelines for various diagnosis and organizationsdiagnosis and organizations

The EBC Program chairs an expert based The EBC Program chairs an expert based multidisciplinary team who is responsible for multidisciplinary team who is responsible for up to date practice guidelinesup to date practice guidelines

Being a member of Open Source Order Sets Being a member of Open Source Order Sets grants access to expert advice and practices grants access to expert advice and practices from across Canadafrom across Canada

Workflow and resource considerations from Workflow and resource considerations from front line stafffront line staff

What if there is no What if there is no evidence?evidence?

Personal experiencePersonal experience

Expert opinionExpert opinion

ComparisonComparison of of

Expert-Based Care Expert-Based Care

and and

Evidence-based CareEvidence-based Care

Expert-based CareExpert-based Care

Expert opinionExpert opinion Experts or publication by experts Experts or publication by experts

essentialessential Hierarchical approachHierarchical approach Expert-to-pupil relationship Expert-to-pupil relationship High value of cliniciansHigh value of clinicians

Evidence-based CareEvidence-based Care

Critical analysis by interested readerCritical analysis by interested reader Electronic access essential Electronic access essential Democratic approachDemocratic approach More egalitarian relationship More egalitarian relationship Increased scrutiny of technology for Increased scrutiny of technology for

proven benefit before adoptionproven benefit before adoption High value of statisticians as well as High value of statisticians as well as

cliniciansclinicians

Clinical Pathways aim Clinical Pathways aim to have… to have… The right people The right people Doing the right thingsDoing the right things At the right timeAt the right time In the right placeIn the right place With the right outcome With the right outcome All with attention to the patient All with attention to the patient

experienceexperience And to compare planned care with And to compare planned care with

care actually givencare actually given

Who is Impacted by Who is Impacted by Pathways and Order Pathways and Order

Sets?Sets?

Corporate LevelCorporate Level

Improved financial outcomes Improved financial outcomes resulting in a ‘snowball’ reaction resulting in a ‘snowball’ reaction across the networkacross the network

Enables acute care institutions to Enables acute care institutions to serve mandated populations by serve mandated populations by decreasing ALC volumesdecreasing ALC volumes

Caregiver and ClientCaregiver and Client

-Improved quality and coordination of care-Improved quality and coordination of care

-Improved clinical outcomes-Improved clinical outcomes

-Reduced practice variations-Reduced practice variations

-Increased use of Best Practice-Increased use of Best Practice

-Improved communication and information -Improved communication and information transfer across multi-disciplinary teams transfer across multi-disciplinary teams and organizationsand organizations

-Provide consistent patient education -Provide consistent patient education across the networkacross the network

Responsibilities of Responsibilities of Allied Health Allied Health ProfessionalsProfessionals

Participate Participate - at the corporate level- at the corporate level

ParticipateParticipate – at the caregiver level – at the caregiver level

ParticipateParticipate – at the patient level – at the patient level

Clinical Pathway Clinical Pathway PackagesPackages

Preprinted orders/order setsPreprinted orders/order sets Clinical pathway/expected outcomesClinical pathway/expected outcomes Teaching checklistTeaching checklist Patient pathwayPatient pathway Discharge checklistDischarge checklist Patient education materialsPatient education materials Associated links (smoking cessation Associated links (smoking cessation

support; CHF/Stroke clinicssupport; CHF/Stroke clinics

Available Pathways Available Pathways Include Include (but not limited to)(but not limited to)

General MedicineGeneral Medicine– Eg. Community Acquired Pneumonia (CAP)Eg. Community Acquired Pneumonia (CAP)

Medical OncologyMedical Oncology– Eg. Febrile Neutropenia Eg. Febrile Neutropenia

General SurgeryGeneral Surgery– Eg. Total Hip Replacement Eg. Total Hip Replacement

Labour and DeliveryLabour and Delivery– Eg. Vaginal BirthEg. Vaginal Birth

Available Order Sets Available Order Sets Include Include (but not limited to)(but not limited to)

Adult Subcutaneous Insulin Order SetAdult Subcutaneous Insulin Order Set C-Diff Treatment Order SetC-Diff Treatment Order Set Newborn Circumcision Order SetNewborn Circumcision Order Set ACS Thrombolytic Therapy Order SetACS Thrombolytic Therapy Order Set Cellulitis Admission Order Set Cellulitis Admission Order Set Many more developed and being Many more developed and being

developeddeveloped

Available Clinical Available Clinical Protocols IncludeProtocols Include (but not (but not

limited to)limited to)

Bowel Care Clinical ProtocolBowel Care Clinical Protocol Hypoglycemic Clinical ProtocolHypoglycemic Clinical Protocol Hyperkalemia Clinical ProtocolHyperkalemia Clinical Protocol ALC Clinical ProtocolALC Clinical Protocol DVT Treatment Clinical ProtocolDVT Treatment Clinical Protocol And many more developed and And many more developed and

being developedbeing developed

Additional Linked Additional Linked Information Information

Associated Documents are linked to the Associated Documents are linked to the order set by clicking on the plus sign order set by clicking on the plus sign beside each order setbeside each order set

These (AD) include referral forms, These (AD) include referral forms, external associated educational external associated educational workshops infoworkshops info

Clinical Protocols (CP) that are listed Clinical Protocols (CP) that are listed within the associated order set also have within the associated order set also have an additional link here for viewing and an additional link here for viewing and printingprinting

How to use order sets?How to use order sets?

Order sets are used in the same fashion as hand written Order sets are used in the same fashion as hand written Physician ordersPhysician orders

Order sets are printed from source on demand – copies Order sets are printed from source on demand – copies are NOT to be kept on hand unless otherwise specified are NOT to be kept on hand unless otherwise specified by EBC programby EBC program

indicates mandatory order unless crossed out by indicates mandatory order unless crossed out by physician.physician.

Open Box indicates optional order, activated when Open Box indicates optional order, activated when

checked checked .. (Note: pre checked medication routes DO NOT (Note: pre checked medication routes DO NOT

authorize the use of the drug unless drug itself selected)authorize the use of the drug unless drug itself selected)

Reference to additional information, policies, protocols Reference to additional information, policies, protocols are provided for guidelines and decision making supportare provided for guidelines and decision making support

Next StepsNext Steps

Document in plan is an electronic Document in plan is an electronic version of the traditional paper pathway; version of the traditional paper pathway; 2 currently released are Acute 2 currently released are Acute Coronary Syndrome and Community Coronary Syndrome and Community Acquired PneumoniaAcquired Pneumonia

Linkage of evidence electronicallyLinkage of evidence electronically

CPOE (Computer Physician Order Entry)CPOE (Computer Physician Order Entry)

DataData

Nurses and Health Care Professionals Nurses and Health Care Professionals are now being heard from the bedsideare now being heard from the bedside

Data can be tracked requiring best Data can be tracked requiring best practice standards shown to be metpractice standards shown to be met

Careplans (document in plan) will be Careplans (document in plan) will be used more effectively and consistentlyused more effectively and consistently

Contact Information Contact Information for for Suggestions/CommentSuggestions/Commentss Open forum on order set repository links Open forum on order set repository links

directly to the programdirectly to the program

Contact information on web site Contact information on web site

Andrea Rawn Andrea Rawn EBC Program Co OrdinatorEBC Program Co Ordinator Education/Utilization CoordinatorEducation/Utilization Coordinator Evidence Based Care ProgramEvidence Based Care Program arawn@gbhs.on.ca