Linking Research, Audit, Quality Improvement and Evidence-Based Medicine

1. Linking Research, Audit, Quality Improvement and Evidence-Based Medicine Dr Chris Cairns 2010

2. Overview Definitions Example Questions / debate��.

3. Research is�.. Clinical research determines the safety and effectiveness of�. Medications Devices Diagnostic products Treatment regimens Prevention, treatment, diagnosis, symptom relief.

4. EBM is�� Integration of�.. Best research evidence Bias Applicability Practicality Clinical skills and experience Patient values

6. Clinical Audit is�.. �a process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria� Research and EBM will give us these criteria�� Audit may tell us is research is relevant to our own practise�..

7. Clinical Audit��..!! �a quality improvement process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria and the implementation of change�

8. Quality improvement is� Not quite so simple��. Improving patient care�..but how�..in what way�.to what end�..??

9. Institute of medicineInstitute of medicine

10. Quality improvement is��..!! �a quality improvement process that seeks to improve patient care and outcomes through systemic review of care against explicit criteria and the implementation of change� Audit for quality improvement with implementation of change Quality improvement using audit and implementation of change

11. Implementing Change Writing the EBM based protocol is easy� Converting this to a change in clinical practise which results in better patient outcomes is more difficult���..

12. Example

13. VAP SHO project � high VAP rate �We need Surveillance / protocol / pathway / guide / bundle� Chris��..what�s the evidence for stuff?

14. Evidence �Lots� of evidence for individual components Little evidence for �bundle� impact but evolving

15. Evidence - SICSEBM Elevation of bed Daily sedation break Sub-glottic ETT Chlorhexidine oral care Weaning trial

16. Evidence Elevation of bed EBM site: One study (1+), 90 pts, 1999. NNT of 4-5 to prevent one VAP. Daily sedation break EBM site: One study (1+), 150 pts, 2000. 2.4 vent days, 3.5 ICU days saved More recently � sedation break + weaning assessment.

17. Evidence - SICS Sub-glottic ETT: EBM site: one review, 4 studies, Grade A recommendation, NNT 12 to prevent one VAP. Chlorhexidine oral care: EBM site: one meta- analysis. NNT 14 to prevent one VAP.

18. Evidence - SICS Weaning trial: In combination with sedation holiday (EBM site / JICS) One study (1+) 336 patients. Daily sedation holiday and weaning trial. NNT Death (1 yr) 7 Reduced ICU & hospital stay

19. Others � not in bundle NIV � avoiding intubation Kinetic beds � no evidence HME vs Heated Water Humidification � equally effective SDD????

20. Evidence for �Bundle� Sepsis experience VAP ? Evolving SRI experience

21. SRI Experience � Nov 2005 VAP Prevention Bundle 30 - 45o positioning daily sedation holiday daily weaning assessment chlorhexidine mouthwash subglottic aspiration tube tubing management appropriate humidification avoidance of contamination In Nov 2005 our unit passively introduced its own VAP prevention bundle incorporating 6 elements of care; the initial 3 will be familiar from IHI literature and the others based on recommendations by the Scottish and Canadian critical care evidence-based medicine groups. A laminated copy was attached to each bedside trolley accompanied by adhoc encouragement from the newly appointed surveillance nurse who concurrently began to collect VAP acquisition data using HELICS database and definitions. In Nov 2005 our unit passively introduced its own VAP prevention bundle incorporating 6 elements of care; the initial 3 will be familiar from IHI literature and the others based on recommendations by the Scottish and Canadian critical care evidence-based medicine groups. A laminated copy was attached to each bedside trolley accompanied by adhoc encouragement from the newly appointed surveillance nurse who concurrently began to collect VAP acquisition data using HELICS database and definitions.

22. Additionally S/C enoxaparin pre-printed Ranitidine pre-printed Enteral feeding encouraged � if tolerated ranitidine cessation considered.

23. SRI experience At launch Consultant buy in Laminated charts by every bed space Unit posters Surveillance programme (Helix) Ahead of the game nationally

24. Job done? What is the VAP rate? What is the bundle compliance? Hawe, Ellis, Cairns, Longmate ICM, 2009

25. Job done? What is the VAP rate? What is the bundle compliance? Hawe, Ellis, Cairns, Longmate ICM, 2009

27. Process

28. Problem? � Solution? Passive interventions don�t work Educational interventions to reduce VAP Structure, Process, Outcome

29. Active Implementation Education: workshops: definition, epidemiology, pathogenesis, risk factors, consequences of VAP, evidence-base for the bundle. Written material distributed. Over 90% of the unit�s medical and nursing staff had completed by April 2007. Repeat cycles of process and outcome measurement and feedback.

30. Sequential Process Measurements

31. Study Period

33. Lessons Passive implementation of the VAP prevention bundle failed. Compliance improved during an active multimodal implementation. This was associated with a significant reduction in the occurrence of VAP.

34. The Scottish Patient Safety Programme Title of the session & name of faculty

35. Post spsp improvements

38. VAP - Key Points Surveillance / constant feedback Education Process measurement / management Resources � without the above, bundles are �futile�

39. CVCrBSI Same principles SPSP target Lessons learnt in VAP applied to CVCrBSI

41. CVC

42. Summary Definitions Example Questions / debate��.

43. Debate How do we link these all together nationally? What should we me measuring? Is quality improvement part of the remit of SICSAG or��? Is quality improvement a sub-specialty?

44.