Translating Evidence into Practice Sean M. Berenholtz, MD MHS FCCM Johns Hopkins University 1

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

• Click to edit Master text styles– Second level

• Third level– Fourth level

» Fifth level

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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.



» Fifth level

6Grol R. JAMA 2001;286:2578-2585



» Fifth level

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



» Fifth level

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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

6

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



» Fifth level

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

safe

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ualit

y

Educ

ation

Role

tailo

red

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y edu

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perts

Educ

ation

Target: All healthcare professionals- Medical, nursing , and other healthcare professions’ students

- Residents , fellows

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2

3

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/


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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


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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


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.

Documents

Translating Evidence into Practice Sean M. Berenholtz, MD MHS FCCM Johns Hopkins University 1