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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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Welcome
• Q&A session
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• We will answer as many Qs as time permits
• Perry Kim, Manager of Research and IP, will be hosting Q&A session
2017-06-28
Carol Barrie,Executive Director
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2017-06-28
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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 CFN Interdisciplinary Fellowship Program
• Full application packages were due June 2, 2017 and the review process is near completion. Will be contacting those individuals selected to move on in the selection process mid-July.
• Please visit our website for more details: http://www.cfn-nce.ca/training/interdisciplinary-fellowship-program/2017-cfn-interdisciplinary-fellowship-program/
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/
2017-06-28
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Stayed Tuned - New Competition
• New competition expected to be launched late summer, details of the competition will be communicated
2017-06-28
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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
www.cfn-nce.ca
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
