Closing the Gap Between Research and Practice: A Multidisciplinary Approach

1. 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 ScienceUniversity of Michigan School of NursingAugust 2014

2. 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

3. 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.

4. 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)

5. 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.

6. Model to Guide Implementation(Rogers, 1995, 2003; Titler and Everett, 2001; Titler, 2008) Social System Rate & Extent of Adoption Characteristics of the EBP Communication Process Communication Users of Innovation Multifaceted strategies are necessary to translate research into Practice (Greenhalgh et al, 2005)

7. TRIP Intervention Saves Healthcare Dollars and Improves Quality of Care Funded by AHRQ RO1 HS10482 Investigators PI: Marita G. Titler, PhD, RN, FAAN John Brooks, PhD Kathleen C. Buckwalter, PhD, RN, FAAN William Clarke, PhD Linda Everett, PhD, RN Keela Herr, PhD, RN, FAAN J. Lawrence Marsh, MD Margo Schilling, MD Bernard Sorofman, PhD Toni Tripp-Reimer, PhD, RN, FAAN XianjinXie, MS

8. 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

9. 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

10. 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)

11. 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)

13. Cancer Pain in Elders: Promoting EBPs in Home Hospice SettingsFunded by NCI R01 CA115363 Investigators PI: K. Herr, PhD, RN Co-PI: M. Titler, PhD, RN P.G. Fine, MD S. Sanders, PhD, MSW J. Cavanaugh, PhD

15. Moving Beyond Fall Risk Scores: Implementing an Evidence-Based Targeted Risk Factor Fall Prevention Bundle Marita G. Titler, PhD, RN, FAANUniversity of Michigan School of Nursing Paul Conlon, PharmD, JDSenior Vice-President for Clinical Quality and Patient SafetyTrinity 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

16. 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”

17. 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

18. 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,

19. Intervention: • Senior administrator support • Education program for senior leaders • and nurse managers • Meetings with pharmacists Communication • Intervention: • Opinion Leaders (OL) • Staff education • Change Champions (CC) • Outreach visits • Train-the-trainer program EBP Practices – Risk Specific Adoption of EBPs • Intervention: • QRGs • Posters • Key messages Users • Intervention: • Performance gap assessment • Audit and feedback • Teleconferences Implementation Model & Intervention Social System Hospital; Patient Care Unit Communication Process Characteristics of the Innovation Outcomes & Processes • Measures: • Fall rates • Fall injuries • Use of risk specific fall • prevention • interventions Nurses, Pharmacists

20. 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).

21. Results

22. 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)

23. 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.”

24. 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.””

25. 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.

26. 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.

27. 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

28. 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

29. 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

30. 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.”

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

32. 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

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

36. Structure • National Patient and Stakeholder Council • Local Patient and Stakeholder Council at each of the 10 clinical trial sites

38. 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

39. Critical Care Nursing Clinics of North America, December 2001

41. Hawaii State Center for Nursing • Hawaii Nurses Shaping Healthcare: A State-Wide Evidence-Based Practice Initiative Debra D. Mark, RN, PhD Nurse Researcher, Hawai’i State Center for Nursing debramar@hawaii.edu

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

44. Dietary Restrictions for Neutropenic Oncology Patients Project Director Linda Moeller, RN, BSN Team Deb Bohlken, RN, BSN, OCN Laura Suchanek, RN, MA, AOCN Linda Abbott, RN, MSN, AOCN

45. 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

46. 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

47. Evaluation • No change in blood stream infection rates before and after the practice change

48. Lessons Learned • Partnerships • Implementation strategies • Complexity of the clinical topic • Context • Communication • Key stakeholders

49. Implementation Science and EBP Requires Partnerships and Collaboration

50. 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