Evidence Based Practice: Benefits and Pitfalls

1. Evidence Based Practice: Benefits and Pitfalls Nina Shik, MSN, RN, ARNP-CNS, CIC Director of Nursing Practice and Clinical Excellence

2. Objectives • Describe the trend for standardized medical and nursing practices • Discuss challenges, benefits and pitfalls • Identify strategies for a balanced approach

3. Evidence Based Practice • Definition: the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences. (APA, 2006). American Psychological Association.  (2006).  APA presidential task force on evidence based practice.  Washington, DC: Author

4. EBP: Not a New Concept Used statistics to describe medical outcomes.

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6. Florence Nightingale • Reformed healthcare in Crimean War, 1854 by collecting and acting on evidence for: • Cleanliness • Fresh air • Pure water • Hygiene • Nutrition • Reduced mortality rate from 42.7% to 2.2% in Military Hospital in Turkey Nightingale, F. (1860). Notes on nursing: What it is, and what it is not. Appleton and Co.: NY.

7. Goal of EBP • Ensure a culture of safety in an increasingly complex environment • Busy hospitals • High patient acuities • Increasing expectations and transparency • EBP has led to “Standardized Practice” initiatives • Standardized Care decreases variance • If standards are based on valid scientific principles, patients should have the best possible outcomes.

8. National Expectations • Core Measures • Care Bundles • Patient Care Protocols • It still can take from 10-17 years for research to be put into practice. Bundles, Core Measures and Protocols speed this up. • Are being used in a variety of ways • Published as benchmarks • Allow prospective patients to make decisions about where to seek care • Affect payment (CMS and others)

9. Hand Hygiene Heart Failure Pneumonia VAP AMI Restraints Too much of a good thing? CLABSI VTE SCIP Falls Prevention Rapid Response CAUTI HAPU Stroke BRT

10. IHI VAP Bundle • Elevation of the Head of the Bed >30º • Daily "Sedation Vacations" • Daily Assessment of Readiness to Extubate • Peptic Ulcer Disease Prophylaxis • Deep Venous Thrombosis Prophylaxis  • Daily Oral Care with Chlorhexidine Each component must be followed

11. Effectiveness of VAP Bundle Bundle hardwired with: Standard order set, daily rounds with checklist to make sure all measures are addressed, early weaning protocols for independent RT care

12. Objections • Valid concerns • Following this recommendation is wrong for this specific patient because… • New evidence is published that provides a compelling reason to change practice • Document the specific reason why recommendation was not followed • Will prevent it from being counted as noncompliance with core measure

13. Resistance • Invalid concerns • Resistance to being told how to practice • Complaints of “cookbook medicine • My patients are sicker or different • I learned it this way in school • Reluctance to accept evidence • Generational differences may affect response • Executive support may be needed to promote compliance

14. Ignaz Semmelweis

15. Maternal Mortality Rate due to “Childbed Fever”

16. Intervention

17. Impact of Hand Hygiene

18. Adoption into Practice • Hand hygiene was not widely adopted by physicians in Europe until 40 years later. • “Semmelweis Reflex” • Automatic rejection of new knowledge because it contradicts entrenched norms, beliefs or paradigms. • Named after Semmelweis, whose evidence based, simple hand-washing suggestions were ridiculed and rejected by his contemporaries.

19. To Promote Standardized Care • Prioritize for your patient populations • Track outcomes closely, collect data • Make the data easy to understand and share it widely • Review adverse outcomes quickly and thoroughly • If recommended measures are not being followed, look at systems before you look at individuals, but address individual behavior if needed

20. Pitfalls • Reliance on standards alone is not enough. • Ordering evidenced based care is the first step. • Consistently providing the best care is the biggest challenge. • Critical thinking and accountability must also occur.

21. Bridge the Gap

22. Is Technology the Answer? • Electronic medical records, safety monitors, infusion pumps and bar codes are examples of technology that have been introduced to help us meet guidelines and standardize practice.

23. Reliance on Technology • In 2006, the British village of Luckington reported drivers heading straight into the Avon River. In each case, the driver was following a GPS-recommended route, despite signs on both sides of the road informing them that the bridge was out. • The village of Crackpot had to deal with drivers whose navigation systems directed them to the edge of a cliff with a hundred-foot drop. http://www.engadget.com, “UK drivers trust GPS more than own eyes”

24. Crackpot Village Sign

25. Effectiveness • Technology can be helpful. • Computers, cell phones… • Visensia™ is a system that continuously monitors heart rate, resp. rate, skin temp, O2 Sat, BP and aggregates data into a single number, 1 through 5 • Central monitoring techs track index levels • High numbers trigger action: call nurse, doctor, rapid response

26. Visensia™ • Saint Mary’s Health Care in Grand Rapids,MI decreased their patient mortality by 50% using this system. • It doesn’t provide a new level of care, but it makes it easier to translate data into action.

27. Effective Technology • Effective technology makes it easier to provide the best care. Should be intuitive and support efficiency. Solicit staff input when purchasing. • Potential pitfalls to consider: • Too many alarms may lead to alert fatigue • Reliance on technology may: • Diminish staff ability to recognize and respond to problems • Reduce staff ability to perform technical skills • Take the place of critical thinking

28. Technology can help, but… Actual occurrence at hospital in Kansas City area: • Post-op patient complained of pain despite PCA pump and increasing doses of IV pain medication. • This continued all night, after the patient was transferred from PACU to floor. • The morning nurse consulted the Pain Management team. They came, assessed the patient. • PCA pump tubing was disconnected and the medication was infusing to the floor.

29. Hardwiring Best Practice • Strategies: • Medication reconciliation • Unapproved abbreviations • Bedside safety checks and hand offs • Pre-procedure Time Outs, site marking • Rapid Response Teams • High risk medication double checks • Line insertion checklist • Only work if done consistently

30. Hardwiring Best Practice • Patient Handoffs • Formal process any time a patient’s care is transferred from one caregiver to another • Done at the patient’s bedside • Infusion check, line check • Essential information communicated • Questions answered • Every patient, every handoff, every time. • Easier said than done!

31. Challenges • Critical thinking and accountability • Healthcare systems are complex. • The healthcare environment is always changing. • Patients are people. Each has unique expectations and needs. • Communication is harder than we think. • Consequences of shortcuts not always apparent. • Distractions abound and are difficult to control. • Staff generational differences are real. • A true culture of safety is difficult to achieve.

32. Striking the Right Balance

33. U.S. Airways Flight 1549

34. Miracle on the Hudson • Jan 15, 2009 U.S. Airways Airbus jet struck flock of geese, knocking out both engines. • Pilots C. Sullenberger and J. Skiles: • Right skill set and training • Ability to assess situation • Consider options and select the best one • Implement the right protocol in the right way • Successful balance between thinking critically and implementing best practice.

35. To Promote Balance • Focus on doing the right thing for each patient. • Promote the use of care bundles, core measures, protocols and technology. • Communicate the intent behind them • Staff who understand the evidence and reasons for a recommendation will be best able to determine when it may not apply to a patient or situation. • Encourage people to think critically, ask questions and keep up with current literature. • Recognize and reward successes.

36. Optimize Outcomes • Make it possible for your staff to: • Have the right skills and training • Understand the evidence and the basis for national standards and protocols • Be able to quickly assess each situation • Select the best course of action • Implement the right measures in the right way

37. To Hardwire Compliance • Consider EBP a cornerstone of your organization’s culture of safety • EBP goes hand-in-hand with measures to assure employee buy-in, compliance and accountability. • Evidence and standards tell you what you should do to ensure best care and outcomes • A culture of safety is needed for it to consistently be carried out.

38. Thanks for your attention! Are there any questions?