version twoA model for EBP and Translation Science · Models for EBP and Translation Science Marita G. Titler, PhD, RN, ... – EBCs – Technology ... 1995, 2003; Titler and Everett,

Marita Titler 8/2/2015

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Models for EBP and Translation Science

Marita G. Titler, PhD, RN, FAANRhetaugh Dumas Endowed Chair

Department Chair Systems, Populations and LeadershipUniversity of Michigan School of Nursing

August 5, 2015

Objectives

• Use the Iowa Model as a guide to implement EBPs to improve patient outcomes

• Translation Research Model - identify the myths and realities implementing EBPs.

• Identify applications to your practice setting.


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Funded Projects – Translation Science

• Evidence-Based Practice: From Book to Bedside (PI: Titler, R01 HS10482; AHRQ)

• Book to Bedside: Sustaining Evidence-Based Practices in Elders (PI: Titler, R02 HS10482)

• Cancer Pain In Elders: Promoting EBPS in Hospices (PI: Herr; Co-PI Titler; R01CA115363)

• Advancing Quality Care Through Translation Research (PI: Titler R13 HS014141).

Funded Projects – Translation Science

• Moving Beyond Fall Risk Scores: Implementing fall prevention interventions that target patient specific fall risk factors (Titler and Conlon RWJ INQRI 68266)

• Implementing FOCUS (psycho-educational intervention for adults with cancer and their caregivers) in Cancer Support Communities – Ohio, California (Titler, CTSA pilot).


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The Iowa Model of Evidence Based Practice to Promote Quality Care

Problem Focused Triggers1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data5. Identification of Clinical Problem

Knowledge Focused Triggers1. New Research or Other Literature2. National Agencies or Organizational

Standards & Guidelines3. Philosophies of Care4. Questions from Institutional

Standards Committee

ConsiderOther

Triggers

Is this Topica PriorityFor the

Organization?

Form a Team

Yes

No

= a decision Point

Problem and Knowledge Focused Triggers

• Is there a better method of clinical practice?

• Encouragement of questions from direct care givers

• Sources– Quality data– EBP guidelines and

systematic reviews (e.g. AHRQ; ONS)


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Examples• Symptom Management

– Pain– Fatigue

• Mobility and exercise• Pain assessment/treatment

chemotherapy induced neuropathic pain• Prevention of CAUTI• Delirium prevention & screening• Oral care

Restricted visiting of patients in ICUs -every 2 hours; 10 minute visits; immediate family members; no children

Flexible visiting practices Family presence

(Cohen et al, 1998; Halm et al, 1990; Titler, 1999; Titler et al, 1995; Titler 1995; Titler & Walsh, 1992; Titler et al, 1991)


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Family Presence in Care Delivery Settings

• Standard of care

• Is an EB for this practice

• Enhances communication

• Informs our practice – family member’s knowledge of their loved one

• We can make this happen every day

The Topic Matters


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The Iowa Model of Evidence Based Practice to Promote Quality Care

Problem Focused Triggers1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data5. Identification of Clinical Problem

Knowledge Focused Triggers1. New Research or Other Literature2. National Agencies or Organizational

Standards & Guidelines3. Philosophies of Care4. Questions from Institutional

Standards Committee

ConsiderOther

Triggers

Is this Topica PriorityFor the

Organization?

Form a Team

Yes

No

= a decision Point

Criteria to Consider When Selecting A Topic

Priority for the organization Cultural values Priority for the department Staff interest and

commitment Magnitude of the problem Likelihood to contain costs

and improve outcomes Applicability Multidisciplinary


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EBP: A “Team Sport”

Is Therea SufficientResearch

Base?

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design EBP Recommendations4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify Practice Recommendations

Base Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory

Conduct Research

Yes No

= a decision Point


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P.I.C.O. Model for Clinical Questions

• Patient, Population, or Problem

• Intervention or Treatment (caution

EB – review of the science)

• Comparison Intervention or Treatment

• Outcome

Building the Question Using P.I.C.O.

Patient or Problem

Intervention Comparison Intervention

Outcomes

Tips for Building

How would I describe a group of patients similar to mine?

Which main intervention am I considering?

Based on evidence

What is the main alternative to compare with the intervention?

What can I hope to accomplish?

Example Patients discharged to home following surgery for laryngeal cancer

Pharmacological treatment.

Discharge planning –telephone f/u

Conventional Therapy

Usual Care

Improved pain control at home (post discharge)


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Examples

• Purpose of this EBP project is to decrease pain experienced at home (post-discharge) following surgery for laryngeal cancer by improving pharmacological treatment and discharge planning.

• Clinical question – how do we improve pain management of home-going patients following surgery for laryngeal cancer?

Evidence sources

• Research • AHRQ.gov

– EBCs– Technology reports– Systematic reviews

• Specialty organizations (AHA, ONS etc.)• Get with the guidelines programs (CAD,

Stroke, HF and more)


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Critique Evidence

• Evidence tables – many examples

• Learn to critique research, systematic reviews, CPGs, technology reports.

• http://www.sign.ac.uk/ Scottish Intercollegiate Guidelines Network

• Summary recommendations for practice

www.agreecollaboration.org/)

A Note About RCTs as Only Evidence Source

• “Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of RCTs”

– Smith & Pell (2003) BMJ


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Hints • Have a well formulated clinical question or purpose

statement - is not a research question, is a clinical question. Be specific enough to make the project manageable

• Purpose/question must be informed by the evidence. E.g. Intervention component will need to be decided upon and refined following critique of the evidence.

• Revise the purpose statement based on critique of the evidence and application to your patient population


Base?



Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design EBP Recommendations4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify Practice Recommendations


Conduct Research

Yes No

= a decision Point


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Making Difficult Decisions:Is There a Sufficient Research Base?

• Relevance of research findings for practice

• Consistency, quality & quantity of findings

• Volume of studies with sample characteristics similar to patient population

• Consistency of the evidence across sources

• Feasibility for practice• The risk/benefit ratio

Writing an EBP standard/policy/procedure

• Incorporate essential elements from the evidence tables and evidence sources in the standards of practice.

• What do clinicians at the point of care need to know and need to document.

• Electronic health record


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Dietary Restrictions for NeutropenicOncology 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


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Synthesis of Evidence

• Myelosuppressive chemotherapy is the “gold standard” for treating oncology patients

• Neutropenia is an anticipated consequence of this treatment

• “Neutropenia precautions” are often implemented to protect patients

Synthesis of Evidence

• One component of neutropenic precautions has been restriction of patient’s intake of fresh fruits and vegetables.

• Diet not directly linked to blood stream infections.

• Safe food handling and preparation are more likely to reduce food-borne infection than restrictions of fresh fruits and vegetables.


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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


Base?



Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based

Practice Recommendations4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Recommendations


Conduct Research

Yes No

= a decision Point


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Purpose of Evaluation

• To collect and analyze data in the natural clinical setting related to both the PROCESS and the OUTCOMES

• To use data for decision making

Satisfaction with Adult Inpatient

Services

Basic Concepts for Evaluation

• Measure both the processes and outcomes– Align the metrics (i.e. process and outcome

measures) with the phenomenon of interest and the evidence.

– To make improvement in outcomes, focus on the processes!!!!

• Watch for trends and do not overreact to one or two data points.

• Integrate with QI Program• Data sources

• Pick the most reliable• Try and use what is already being collected


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Evaluation• No change in

blood stream infection rates before and after the practice change

Is ChangeAppropriate for

Adoption inPractice?

Continue to EvaluateQuality of Care and

New Knowledge

No YesInstitute the Change in Practice

Monitor and Analyze Structure,Process, and Outcome Data

- Environment- Staff- Cost- Patient and Family

Disseminate Results

= a decision Point


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Instituting the EBP More Widely

• Attention to implementation steps and strategies

• Education and competencies of staff

• Include key stakeholders

• Unit/clinic based change champions

• Ongoing evaluation as part of your QI program

Why Listen to Bowel Sounds?

(see December 2005 AJN)

Diane Madsen, RN


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Literature Summary• Auscultation of bowel sounds first proposed in

1905 (Cannon - reported in Nachlas, Younis, Roda, et al, 1972)

• Motility involves electrical activity coordinated with motor/muscle contraction leading to propulsion (Livingston & Passaro, 1990)

• Return of motility: small intestine, stomach, colon (Hotokezaka, et al, 1996; Livingston & Passaro, 1990; Schippers, et al, 1991)

Literature Summary• Return of bowel sounds likely represents early

uncoordinated motor activity in small intestine and not coordinated propulsion in colon (Boghaert, et al, 1987; Nachlas, et al 1972 ; Rothnie, et al, 1963; Benson, et al, 1994; Morris, et al, 1983)

• Ability to tolerate feeding is limited by stomach and colonic motility (Cali, et al, 2000; Hotokezaka, et al, 1996; Nachlas, et al, 1972)

• Monitoring bowel sounds does not serve to indicate recovery of motility s/p abdominal surgery patients (Huge, et al, 2000)


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Why Listen to Bowel Sounds?

TRADITION

EBP Standard

• Primary markers of return of GI motility (Bauer et al, 1985):

– First flatus– First BM

• Additional markers of return of GI motility:– Return of appetite– Benign abdomen or absence of other symptoms

• Monitoring for complications


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Excerpts from an Evidence-Based Practice Policy and Procedure

GI assessment after abdominal surgery in adults:

• Assess for:

– Flatus within the last 8 hours R1, R6, R12, L3

– Bowel movement, within last 12-24 hours R1, R6,

R12, L3

• Precautions, Observations, General Considerations:

– Auscultation does not serve to monitor recovery of post-op motility R7, R7, R9

Myths and Realities of Implementation

Implementation is a process


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Model to Guide Selection of Strategies for Implementation

(Rogers, 1995, 2003; Titler and Everett, 2001)

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)

Implementation Model



Characteristics of the EBP

SocialSystem

Users ofthe EBP

Com

mun

icat

ion

(Rogers, 2003; Titler and Everett, 2001)


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Myths• Dissemination of trustworthy practice

guidelines promotes use of EBPs.

• The evidence is strong, thus clinicians will change their practice – we just have to show them the evidence.

• An EBP standard will change practice

Characteristics of EBP that influence adoption

• Complexity of EBP (simple versus complex)• Relative advantage of EBP – effectiveness,

relevance to the task, social prestige • Compatibility with values, norms, work flow and

perceived needs of end-users: clinicians, patients and families

• Strength of the evidence – needs to have an evidence-base.

• Leader/facilitator as well as clinicians needs to have an understanding about the evidence-base


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Important Principle• Attributes of the EBP topic as perceived by

users and stakeholders (e.g. ease of use, valued part of practice) are neither stable features nor sure determinants of their use.

• Rather it is the interaction among the characteristics of the EBP topic, the intended users, and a particular context of practice that determines the rate and extent of adoption.

Strategies for adoption related to characteristics of the EBP topic

• Practitioner review and use of the EBPs to fit the local context - localization.

• Use of quick reference guides and decision aides

• Use of clinical reminders – CDS; electronic reminders.

(Balas et al, 2004; Berwick, 2003; Bradley et al, 2004; Fung et al, 2004; Grimshaw et al, 2006; Guihan et al, 2004;Wensing, et al, 2006)


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TRF- 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,

– use a fall as a learning opportunity to improve care,


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Characteristics of the Innovation

SocialSystem

Users ofInnovation

Com

mun

icat

ion


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Myths

• Clinicians stay abreast of the latest evidence in their specialty.

• Clinicians learn about new evidence from …

• We just need to educate them about the EBP – didactic presentation preferred.

Communication factors that influence adoption

• Interpersonal communication channels

• Methods of communication

• Social networks of users

• Interdisciplinary, trans-disciplinary perspective.

• Who will be influenced by the EBP? Who will be users of the EBPs? Stakeholders


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CommunicationThe Stickiness Factor:

There is a simple way to package information that, under the right circumstances, can be irresistible. Memorable ideas spur us to action. (Gladwell, 200)


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Strategies for adoption r/t communication

• Education is necessary but not sufficient to change practice.

• Interactive education is more effective than didactic education alone.

• Knowledge and skills to carry-out the EBPs.

• Key messages at the site of care


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Strategies for adoption r/t communication

• Opinion leaders

• Change champions

• Educational outreach/academic detailing


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Opinion Leader• Practitioner within a specific discipline

(nurse, physician, administrator)• Viewed as an important and respected

source of influence amongst peer group• Role expectations:

– Organizational leadership– Experts in practice– Promote needed changes in

organizational infrastructure (e.g., documentation systems) to support evidence-based practice

(Greenhalgh et al 2005, Irwin & Ozer 2004, Redfern & Christian 2003, O’Brien et al 1999, Berner et al 2001, Cullen 2005, Locock et al 2001)

Change Champions• Expert clinicians

• Informal leaders

• Positive working relationship

• Committed to providing quality care

(Rogers 2003a, Titler 2004a, Titler et al 2006b, Harvey et al 2002, Rogers 2003b, Shively et al 1997, Titler & Mentes, 1999b, Titler 1998a)


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Role of Change Champion• Imparts information about evidence-based practice to

peers • Encourages staff to align their practice with the best

evidence• Teaches and demonstrates skills necessary to carryout

evidence-based practice (1:1; small group)• Orientation of new personnel• Models practice• Recognizes/rewards staff

Educational Outreach

• Educated person who meets with practitioners in their setting to provide information about the EBPs, address questions, positive comments about aligning practice with the evidence .

• Feedback on provider performance

• Consultation on issues

• Who does this?

• Opinion leader

• Consistent person/consistent message

Greenhalgh et al 2005, Feldman et al 2005, Horbar et al 2004, Jones et al 2004, Loeb et al 2004, McDonald et al 2005, Murtaugh et al 2005, Titler et al 2006b, O’Brien et al 1997, Hendryx et al 1998


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Outreach visits

• What I was thinking is her site visits. … was very inspirational to the staff. … is very inspiriting and it really motivated people to think outside the box, or "How can we be better at this?"

• And after she rounded on the units, we would meet in a room and talk more about our audits that we would provide her and looking at our risk factors and our interventions and how we were doing with those. That was useful for the team.

Implementation




SocialSystem

Users ofInnovation

Com

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Who are/will be the Users of the Evidence-Based Practice

• Nurses• Physicians• Respiratory Therapists• Physical Therapists• Pharmacists• Others

“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)


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Myths

• Clinicians will adopt EBPs at about the same pace

• I just have to get those resistors on board.

• Focus on the resistors first and others will follow

• “If I build it, they will come” AKA: If I tell them, they will do it!

Diffusion• Diffusion is the process by which (1) an Innovation (2) is

communicated through certain channels (3) over time (4) among the members of a social system

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Per

cent

of A

dopt

ion

Innovation I

Later Adopters

ADOPTERsEarly

Take-Off

Innovation II Innovation III

Time

Rogers, E.M. (1995). Diffusion of Innovations (4th Ed.). New York, NY: The Free Press.


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Strategies r/t users of the EBP

• Identify users of the EBPs

• Performance gap assessment – beginning of the change; indicators related to EBP topic.

• Audit and feedback – during the practice change. Discussion forums rather than passive reports

• Trying the practice –plan as part of the implementation process.

Performance Gap Assessment

• Recommended practice compared to current practice

• Key indicators - do not try to assess all performance measures.

• Do early in process/beginning

• Get the data to those providing care/discussion

• Positive effect on changing practitioner behavior

(Baskerville et al, 2001; Davis et al 1995; Flore et al, 1996; Hobar et al, 2004; McCartney et al, 1997;Titler et al, in review)


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Performance Gap Assessment – Pain Management

0

10

20

30

40

50

60

70

80

90

ATCanalgesia

Painintensity <3

Demeraoluse

PCA

Benchmark

Hospital A

Hospital B

Audit and Feedback

• Effective Strategy; during implementation• Keep feedback actionable• Link with organizational quality improvement

structure and processes• Data perceived by the clinician as important and

valid.• Timely, individualized, non-punitive feedback

Bradly, et al, 2004; BootsMiller, et al., 2004; Dranitsaris, et al., 2001; Dulko, D. 2007; Hysong, et al., 2006; Morrison, et al., 2006; Pineros, et al., 2004; Won, et al., 2004; Wright, et al., 2007


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% of Patients with Every 4 Hour Pain Assessment

during first 48 hrs. – Postop surgery

***

***Change begun

Audit Feedback Example

Fictitious data

Fall Rate


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SocialSystem

Users ofInnovation

Com

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Titler & Everett, 2001


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Myths

• “One size fits all”

• Practice cultures are the same or similar in our organization.

• Changing practice is the NM’s responsibility

Context matters


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Organizational factors that affect adoption

• Learning culture

• Leadership

• 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)

Organizational Strategies to Promote Adoption of EBPs

• Professional roles – expect EBP in each role

• Performance criteria aligned with use of EBP; Career ladder programs

• Multidisciplinary teams • Policies/procedures/documentation • Technology for knowledge management

to support patient care


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“Institutionalize” EBP as a Normal Part of Work (Stetler et al, 2009)

• Role model site: Deliberately and strategically building the capacity to implement and institutionalize EBP over a period of 5 years. – Why/motivation for EBP clear– How or methods of strategic EBP change– What including infrastructures (governance) for EBP

• Beginner site: EBP rarely seen as an ongoing explicit priority or vision.

Role model site: Context to create and sustain EBP

• Creating and sustaining a clear vision

• Role modeling• Developing

supportive relationships

• Mentoring

• Beyond isolated projects

• Fabric of organization– Building structures– Provision of resources– Monitoring progress– Providing feedback– Changing formal

leaders who did not “fit” with the strategic vision.

LeadershipManagement


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Clinical Context for Evidence-Based PracticeBridie Kent and Brendan McCormick



Extentof Adoption


SocialSystem

Users ofInnovation

Com

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Myths

• Evaluation is not that important

• I can inform others verbally

• Stories tell the impact

Results

• A 22% reduction in fall rates (outcome)• 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). (process)


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Transformative – We've really transformed the culture …– I think as a system, we're so much better now– I think this has created a teamwork that I've

not seen before. – But I personally feel we've made a much safer

place for our patients, because we've made people aware for multiple different ... you know all of the different disciplines that work with the patient are now much more aware of the fall risk of the patient.

Hawaii State Center for Nursing• Hawaii Nurses Shaping Healthcare: A

State-Wide Evidence-Based Practice Initiative

• Legislative mandate to for EBP and quality outcomes

Debra D. Mark, RN, PhDNurse Researcher, Hawai’i State Center for [email protected]


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Outcomes to Date • Increasing EBP capacity across the state

• Trained 39 teams

• 8 Health care systems

• Institutionalizing EBP

• Papers and conference presentations


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Questions/Discussion

Documents

version twoA model for EBP and Translation Science · Models for EBP and Translation Science Marita G. Titler, PhD, RN, ... – EBCs – Technology ... 1995, 2003; Titler and Everett,