How many doctors does it take to change a light bulb?

1. How many doctors does it take to change a light bulb? Steve Doherty October 2006

2. A History of change • James Lancaster • East India company 1591 and 1601

3. An orange a day keeps the doctor away • James Lind • Experiments on scurvy in 1747

4. Well maybe not… • Results published in 1754 • Not used by Royal nave for over 40 years

5. Louis and Leeches

6. But that’s all ancient history… • “Failure to translate research evidence into clinical practice is one of the two major barriers preventing benefit from the biomedical sciences.” • Sung et al. Central challenges facing the national clinical research enterprise. JAMA 2003;289:1278-87

7. Overview • History of knowledge translation • Change is difficult • Change is needed • Effects of our attempts…

8. The History of Knowledge Translation

9. Guidelines • An important component in summarising evidence from research. • Developed by many different organisations. • Many different formats.

10. Guideline Implementation • Time and money spent on developing guidelines • Guidelines don’t implement themselves

11. Guideline Implementation • Guideline dissemination strategies generally involve little money, little time, little effort and little expertise.

12. Guideline Implementation • CEC pilot study.

13. The challenge of change • > 10 000 new trials on medline each year • Traditional approaches – mail outs, conferences, review articles will only produce limited change. • Grol,and Grimshaw Lancet 2003;362:1225-1230

14. So how do we effect change in our department! • Busy ED ~ 40 000pa • Many challenges / barriers.

15. Challenges • Department with relatively few senior medical staff • Rotating junior staff • High numbers of short term locums • Night locums • Inability to allocate nursing staff for all beds

16. Challenges • No formal orientation for locum staff hence guideline awareness “hit and miss” • Increasingly high nursing staff turn over and hence loss of continuity. • No formal nursing education program / meetings.

17. Challenges • No dedicated (to the ED) quality improvement or data collection staff. • EDIS, via keywords, unable to generate guidelines or remind staff to use them • The likelihood, that these changes will not be sustained.

18. Does “the evidence” help? • Grimshaw et al • Systematic review of 235 evaluations of guideline dissemination • 86% showed improvement with compliance • Overall improvement was 10%

19. Attempted change • Most effective strategies • Reminders • How do you implement a reminder • What form? • Education • Audit and feedback. • By who and how often

20. Evidence also exists for… • Focusing on the organization and processes rather than just the individual clinician • Opinion leaders • Characteristics of the guideline • Clear planning • Identification of evidence-practice gaps • Identification of barriers • Involvement of targeted group • Clear expression of desired behaviour

21. Guideline characteristics • Good evidence • Simple, decreases workload • Common, important or acute disease • Accessible, usable • Local champion • Available in the front of the medical record

25. Evidence-based Implementation • There is sufficient “evidence” to guide attempts at changing clinical practice. • Our strategy was to appraise this evidence and to apply it to our department.

26. EBM • Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”

27. Evidence-based Implementation • An analagous triad • Best available evidence (on implementing change in practice) • Judiciously used (by the implementation team) • Applied to an individual department, service etc.

28. Change Is Needed

29. Sore Throat • Rate of bacterial infection causing sore throat varies with age • 3-13 years 30-40% • Other age groups 5-15% • BEACH study • 4% of all GP presentations (sore throat) • prescribing rates of 88% • (Australian GP 2001)

30. Sore Throat Clinical Indicators

31. Otitis Media • Australia has one of the highest rates of antibiotic prescribing in the world (>90%) • The Netherlands the lowest (< 5%) • For the same outcomes

32. Asthma • 7 clinical indicators across area • Assessment of severity • Spirometry • Spacer use • Steroid use • STAMPs • Ipratropium overuse • Antibiotic overuse

33. Assessment of Severity

34. Spirometry

35. Spacer use

36. Steroid use

37. STAMP use

38. Atrovent - Mild

39. Antibiotics

40. 7 Clinical Indicators combined

41. Other projects • Same strategy has been used for gastro, bronchiolitis, croup, head injury. • Some adult equivalents • Ottawa rules • Applied in small rural district hospitals • Future plans • Mental health

42. Summary • Changing behaviour in a complex organisation is difficult. • Evidence exists for some strategies. • Addressing “individuals” is not the answer – whole systems need to be addressed.

43. The End!