Closing the Gap Between Research and Practice: A Multidisciplinary Approach

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

Associate Dean for Practice Development and ScholarshipDivision Chair Health Systems and Effectiveness Science

University of Michigan School of Nursing

August 2014

Overview

• Describe interdisciplinary research in implementation science with examples (science of translation)

• Identify examples of application of evidence in practice with clinicians (doing of EBP in healthcare)

• Lessons Learned • Reflections on the future

Implementation Science

• Testing implementation interventions to improve uptake and use of evidence to improve patient outcomes and population health.

• Explicating what implementation strategies work for whom, in what settings, and why.

Program of Research: Implementation Science

• Evidence-Based Practice: From Book to Bedside (PI: Titler, R01 HS10482; AHRQ, 1.5 million)

• Book to Bedside: Sustaining Evidence-Based Practices in Elders (PI: Titler, R02 HS10482; 0.5 million)

• Cancer Pain In Elders: Promoting EBPS in Hospices (PI: Herr; Co-PI Titler; R01CA115363; 2.8 million; )

• Advancing Quality Care Through Translation Research (PI: Titler R13 HS014141; $50,000).

• Moving Beyond Fall Risk Scores: Implementing fall prevention interventions that target patient specific fall risk factors (Titler and Conlon RWJ INQRI 68266; $300,000)

Funded Projects Co-Investigator• Dissemination of Tobacco Tactics versus 1-800-

QUIT-NOW for Hospitalized Smokers. 1U01HL105218-01.PI: S. Duffy. 2010-2014.

• Effectiveness of Smoking Cessation Guidelines in the ED. 1R21 DA021607 PI: D. Katz, 2008 - 2011.

• Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans. VA IIR, D. Katz. 2008 – 2011.

• Statewide Implementation of Guidelines to Control MRSA. CDC. PI: L. Herwaldt, 2007-2010.

Model to Guide Implementation(Rogers, 1995, 2003; Titler and Everett, 2001; Titler, 2008)

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)

InvestigatorsPI: Marita G. Titler, PhD, RN, FAAN

John Brooks, PhDKathleen C. Buckwalter, PhD, RN, FAAN

William Clarke, PhDLinda Everett, PhD, RN

Keela Herr, PhD, RN, FAAN J. Lawrence Marsh, MD

Margo Schilling, MDBernard Sorofman, PhD

Toni Tripp-Reimer, PhD, RN, FAANXianjin Xie, MS

Funded by AHRQ RO1 HS10482

TRIP Intervention Saves Healthcare Dollars and Improves Quality of Care

Aim 1: To test the effect of the TRIP intervention on nurse and physician adoption of evidence-based acute pain management practices in elders.

Aim 2: To test the effect of the TRIP intervention on decreasing barriers to use of evidence-based acute pain management practices.

Aim 3: To determine the cost effectiveness of the TRIP intervention.

Specific Aims

Design • Cluster randomized trial

• Implementation model to guide the multifaceted implementation intervention.

• Implementation intervention had components aimed at organizational and individual level

• 12 hospitals (randomized 6 to experimental; 6 to comparison arm) in the Midwest United States

Findings: Improved Acute Pain Management

• Improved pain assessment (OR=7.5)• More around-the-clock opioid administration

(OR=6.6)• Less administration of Demerol (OR=.35)• Higher summative index of quality care for acute

pain management (overall adoption score. 0-18) (p<.0001).

• Less pain intensity (1.5 on a 0-10 scale)

(Titler et al, 2008 HSR)

Findings on Cost

• Total costs per patient were $1,495.89 less in the E group than the C group (p <0.0001)

• For each one-unit increase in the Summative Index, total costs decreased by $1,598.75 (p = 0.002)

• A net savings to the hospital of more than $131,000 per 100 patients, even after implementation costs are taken into account.

(Brooks et al, 2008 HSR)

Cancer Pain in Elders: Promoting EBPs in Home Hospice Settings

Funded by NCI R01 CA115363

Investigators

PI: K. Herr, PhD, RNCo-PI: M. Titler, PhD, RN

P.G. Fine, MDS. Sanders, PhD, MSW

J. Cavanaugh, PhD

Moving Beyond Fall Risk Scores: Implementing an Evidence-Based Targeted

Risk Factor Fall Prevention Bundle Marita G. Titler, PhD, RN, FAAN

University of Michigan School of Nursing

Paul Conlon, PharmD, JDSenior Vice-President for Clinical Quality and Patient Safety

Trinity Health System, Novi, Michigan

Alex Tsodikov, PhD

Biostats, SPH, University of Michigan

Margaret Reynolds, PhD, RN

Trinity Health System, Novi, Michigan

Funded by RWJ foundation INQRI program

Study Aims

Aim 1: Compare fall rates, fall injury rates, and types of injuries from falls prior to, during and following implementation of the

“targeted risk factor fall prevention bundle”

Aim 2: Evaluate level of adoption of the evidence-based “targeted risk factor fall prevention bundle” at baseline and following

implementation

Aim 3: Explore, using qualitative methods, components of the implementation intervention and the “targeted risk factor fall prevention bundle”

Design • Prospective pre post implementation

design 3 community hospitals (13 adult noncritical care units) in the THS

• Funded for 18 months• Sites

– Hospital A = 471 bed teaching hospital– Hospital B = 243 bed community hospital – Hospital C = 90 bed rural community hospital

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,

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

Implementation Model & Intervention

EBP Practices – Risk Specific

Intervention: • QRGs • Posters• Key messages

Intervention: • Opinion Leaders (OL)• Staff education• Change Champions (CC)• Outreach visits• Train-the-trainer program

Intervention:• Senior administrator support• Education program for senior leaders and nurse managers• Meetings with pharmacists

Intervention:• Performance gap assessment • Audit and feedback• Teleconferences

Users

Adoption of EBPs

Co

mm

un

icat

ion

Social System

Characteristics of the Innovation Communication Process

Hospital; Patient Care Unit

Nurses, Pharmacists

Outcomes & Processes

Measures:• Fall rates• Fall injuries• Use of risk

specific fall prevention interventions

Results

• A 22% reduction in fall rates• 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).

Results

Before Intervention Midpoint After Intervention0

10

20

30

40

50

60

70

80

90

100

74%83%

89%

15%11%

7%

11% 6% 4%

Falls Injury Type

Minor InjuryModerate InjuryMajor Injury

Perc

enta

ge

Fall Prevention Interventions

N=1638 total patient days before intervention; N=1606 total patient days after intervention

* Patient days are the number of days of labeled risk (denominator)

** Number of times intervention(s) was received per 100 patient days (example: Received mobility intervention 88 times per 100 patient days)

*** Sum of correct decisions based on risk profile; got one of the interventions that correspond to the risk profile (removes overlaps)

Before Intervention After InterventionRisk specific interventions*** Patient

Days*Rate per

100 patient days**

Patient Days

Rate per 100 patient

days

pValue

Mobility 1285 31 1333 88 <.001

Toileting/Elimination 853.7 50 917.7 66 <.001

Medication 1525 0.11 1562 0.1 0.981

Mental/Cognitive Status 769 2.3 531 77 <.001

Risk for injury 1142 66 1285 88 <.001

Focus Group Findings: Prior to Implementation

“It’s like we had a blanket fall prevention program and it excludes very few people … and so the nurses are more worried about the tasks of the flag and arm band and not honing in why this patient is a fall risk.”

Focus Group Findings: After

• “It is promoting more awareness … ‘what should we be doing for this patient?’”

• “You know all of the different disciplines that work with the patient are now much more aware of the fall risk for the patient.”

• “We take each patient and we look at specific fall risk. We are much more in depth into looking at the patient themselves compared to what we were before the falls study. It really did allow us to concentrate on “ok what are his needs.””

Collaboration

• That's one thing that I've noticed is that it's more of a team effort, between not just among staff but families and the patients are definitely more aware.

• I think this has created a teamwork that I've not seen before.

• the fact that physical therapy and occupational therapy were aboard. And working with our patients twice a day instead of once a day -- educating our CNA's on walking patients that prevent falls was very large.

QRGs and Posters

– I think the standardized interventions [QRGs] on specific interventions. That was nice to have that in a document that we can hand out in the units.

– we've had posters. And our fall champion's really good with putting out a lot of information on the falls.

– [QRGs] useful for a quick reference. You know, easy to read and bullets, and quick.

Challenges & Opportunities of INQRI PIs – Implementation Studies

• Telephone interviews – taped and transcribed

• Interview guide– Types and perceptions about implementation

strategies used– Successes, challenges and lessons

learned– Steps taken for sustainability

Titler et al, Medical Care 2013

Implementation Topics and Design

• Four Clinical Topics– Pain– Delirium – Fall prevention– Substance abuse- screening, brief intervention and

referral

• One professional development of nurse managers • Four were multi-site studies• Prospective pre post design

Challenges• IRB Approval

– Multi-site studies– IRBs not set-up for reviewing these types of studies

• Time frame for actual implementation (18 months of funding) – Most 4 to 6 months– “I am very worried we did not give units enough time to

make changes”

• Study specific challenges– Implementation tools/strategies not being used– Key stakeholders not being engaged early enough

Lessons Learned• Context

– “So in implementation science, it seems that context is so important. You know…Obviously this is a big lesson”

• Complexity of implementation– “Implementation is a complex process that takes time.

… Changing practitioner behavior is hard.”

• Communication– “One of the lessons learned is to use multiple

communication strategies with the sites to keep them engaged.”

Medical Care Volume 51, Number 4 Suppl 2, April 2013

Current Studies

• FOCUS: An Innovation in Care for Cancer Patients and Family Caregivers in the Cancer Support Community Network. PI: Titler. Co-I Dockham, MSW, Northouse, PhD, Ronis, PhD

Current Studies

• U01AG048270 NIA/PCORI. Clinical Trial of a Multifactorial Fall Injury Prevention Strategy in Older Persons. 30 million. PI: Shalender Bhasin; Joint PIs: Thomas Gill; David Reuben. Titler: Co-I and Lead for Patient Engagement. Other CO-Is – physical therapy, informatics, statistics.

Structure • National Patient and Stakeholder Council • Local Patient and Stakeholder Council at

each of the 10 clinical trial sites

Evidence-Based Practice• Integration of best research evidence with

clinical expertise and patient values (Sackett et al, 2000)

• Synthesis and use of evidence from scientific investigations (e.g. observational studies) and other types of knowledge (e.g. case reports; expert opinion) (Cook, 1998)

• Process not an event

Critical Care Nursing Clinics of North America, December 2001

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

State-Wide Evidence-Based Practice Initiative

Debra D. Mark, RN, PhDNurse Researcher, Hawai’i State Center for Nursingdebramar@hawaii.edu

Outcomes to Date • Increasing EBP capacity across the state• Trained 39 teams• 8 Health care systems• Institutionalizing practice change• Papers and conference presentations

Dietary Restrictions for Neutropenic Oncology 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

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

Evaluation• No change in

blood stream infection rates before and after the practice change

Lessons Learned

• Partnerships• Implementation strategies

– Complexity of the clinical topic– Context – Communication – Key stakeholders

Implementation Science and EBP Requires Partnerships

and Collaboration

Principles of Partnerships: Research and EBP

• Nurturing of relationships over time• Inclusion in all phases of research• Sustaining partnerships

– Identifying assets and strengths– Develop capacity for research – Develop capacity for EBP

Implementation Strategies• Complexity of the clinical topic

– Quick reference guides and decision aides– Length of time for implementation– Key messages

• Communication– Education – necessary but not sufficient to change

practice; interactive; ongoing; new staff– Opinion leaders and change champions – specific to

discipline – Outreach to clinical practice sites (conversations; sense

making; “site visits” )

Implementation Strategies

• Identify clinicians who will be using the EBPs– Engagement early and often– Performance gap assessment – beginning to

discuss current state• Audit and feedback – actionable, discussion,

not passive dissemination of reports; Data perceived by the clinician as important and valid.; Timely, individualized, non-punitive feedback

“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)

Reality

Context matters

Context factors that affect adoption• Learning culture• Leadership (involve them from the beginning)• Managers of clinical sites• 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)

Views through various disciplinary lenses

• Listen to various perspectives• Value of unique disciplinary perspectives• More horizontal integration across

disciplines

Reflections for the Future • PhD education: course work balanced with

mentorship – how much course work is enough

• Trans-disciplinary PhD education • Hillman scholars program – BSN to PhD

Reflections for the Future

• Plan efficacy studies with the end in mind – how will or can the findings from this study be used in practice

• Partner with communities of practice and the public early on in designing the study – traditionally have examined the state of the science from research – is this topic important to people?

Resources• Education

– Newsletters– 14 Podcasts– How to start a journal club– EBP references– Eye on Evidence– Webinars – lunch and

learn; journal clubs

• Research– Network of sites for

research– Process for investigators

to access NNPN organizations for research

– Organization context measurement instruments

• Culture• Climate• Interactive human

relationships

WE ALL HaveContributions to make

WISHING YOU THE SPIRIT of COLLABORATION IN YOUR DISCOVERY AND APPLICATION OF EVIDENCE IN PRACTICE

Questions/Discussion