1. EVIDENCE-BASED CARE PROGRAM ©2004-2010 Grey Bruce Health Network www.gbhs.ca www.gbhs.ca

2. GBHN Program began in 2001 and now consists of 11 hospital sites, partnering 3 corporations in Grey and Bruce with Open Source Order Sets Program began in 2001 and now consists of 11 hospital sites, partnering 3 corporations in Grey and Bruce with Open Source Order Sets The corporations are unified in providing consistent care according to evidence based standards and expert practice recommendations The corporations are unified in providing consistent care according to evidence based standards and expert practice recommendations All clinical practices are evidence / expert based All clinical practices are evidence / expert based Together we form a collective mind in the pursuit of better patient outcomes Together we form a collective mind in the pursuit of better patient outcomes

3. Evidenced Based Care This program coordinates, educates and evaluates the development and implementation of clinical pathways, order sets and other evidence-based care tools. This program coordinates, educates and evaluates the development and implementation of clinical pathways, order sets and other evidence-based care tools. The program is based on current evidence and clinical practice guidelines, as well as addressing workflow issues and the needs of rural healthcare The program is based on current evidence and clinical practice guidelines, as well as addressing workflow issues and the needs of rural healthcare

4. What is a Clinical Pathway? A mapping of a patients condition that organizes, sequences and times the major interventions of nursing staff, physicians and other departments for a particular case type, subset or condition Research shows this mapping improves patient outcomes and reduces length of stay All pathways are generalized and must be critiqued to the individual Pathways are nursing tools, are initiated by nursing and DO NOT require a Physician order

5. What is an Order Set? Order sets replace Preprinted orders that were traditionally individual physician specific Order sets can be implemented ONLY by the physician when signed by them or delegate Order sets are diagnosis specific and based on published guidelines and research Order sets are initiated for MOST RESPONSIBLE diagnosis for admission Order sets are generalized in approach and critiqued to the individual and their comorbidities

6. Where does the evidence come from? The ideal evidence-based system would have automatic links summarizing all relevant and important research evidence about all clinical problems, and update you whenever a patients chart was accessed, based on their diagnosis and co-morbidities. The ideal evidence-based system would have automatic links summarizing all relevant and important research evidence about all clinical problems, and update you whenever a patients chart was accessed, based on their diagnosis and co-morbidities. Critical thinking of the practitioner is still the vital link to successful patient outcomes Critical thinking of the practitioner is still the vital link to successful patient outcomes Research data The Development Teams and Annual Review Teams review the Research Data found to create and update our Clinical Pathways

7. How do we find the evidence? Review published guidelines for various diagnosis and organizations Review published guidelines for various diagnosis and organizations The EBC Program chairs an expert based multidisciplinary team who is responsible for up to date practice guidelines The EBC Program chairs an expert based multidisciplinary team who is responsible for up to date practice guidelines Being a member of Open Source Order Sets grants access to expert advice and practices from across Canada Being a member of Open Source Order Sets grants access to expert advice and practices from across Canada Workflow and resource considerations from front line staff Workflow and resource considerations from front line staff

8. What if there is no evidence? Personal experience Personal experience Expert opinion Expert opinion

9. Comparison of Expert-Based Care and and Evidence-based Care

10. Expert-based Care Expert opinion Expert opinion Experts or publication by experts essential Experts or publication by experts essential Hierarchical approach Hierarchical approach Expert-to-pupil relationship Expert-to-pupil relationship High value of clinicians High value of clinicians

11. Evidence-based Care Critical analysis by interested reader Critical analysis by interested reader Electronic access essential Electronic access essential Democratic approach Democratic approach More egalitarian relationship More egalitarian relationship Increased scrutiny of technology for proven benefit before adoption Increased scrutiny of technology for proven benefit before adoption High value of statisticians as well as clinicians High value of statisticians as well as clinicians

12. Clinical Pathways aim to have… The right people The right people Doing the right things Doing the right things At the right time At the right time In the right place In the right place With the right outcome With the right outcome All with attention to the patient experience All with attention to the patient experience And to compare planned care with care actually given And to compare planned care with care actually given

13. Who is Impacted by Pathways and Order Sets?

14. Corporate Level Improved financial outcomes resulting in a snowball reaction across the network Improved financial outcomes resulting in a snowball reaction across the network Enables acute care institutions to serve mandated populations by decreasing ALC volumes Enables acute care institutions to serve mandated populations by decreasing ALC volumes

15. Caregiver and Client -Improved quality and coordination of care -Improved clinical outcomes -Reduced practice variations -Increased use of Best Practice -Improved communication and information transfer across multi-disciplinary teams and organizations -Provide consistent patient education across the network

16. Responsibilities of Allied Health Professionals Participate - at the corporate level Participate - at the corporate level Participate – at the caregiver level Participate – at the caregiver level Participate – at the patient level Participate – at the patient level

18. Clinical Pathway Packages Preprinted orders/order sets Preprinted orders/order sets Clinical pathway/expected outcomes Clinical pathway/expected outcomes Teaching checklist Teaching checklist Patient pathway Patient pathway Discharge checklist Discharge checklist Patient education materials Patient education materials Associated links (smoking cessation support; CHF/Stroke clinics Associated links (smoking cessation support; CHF/Stroke clinics

19. Available Pathways Include (but not limited to) General Medicine General Medicine –Eg. Community Acquired Pneumonia (CAP) Medical Oncology Medical Oncology –Eg. Febrile Neutropenia General Surgery General Surgery –Eg. Total Hip Replacement Labour and Delivery Labour and Delivery –Eg. Vaginal Birth

20. Available Order Sets Include (but not limited to) Adult Subcutaneous Insulin Order Set Adult Subcutaneous Insulin Order Set C-Diff Treatment Order Set C-Diff Treatment Order Set Newborn Circumcision Order Set Newborn Circumcision Order Set ACS Thrombolytic Therapy Order Set ACS Thrombolytic Therapy Order Set Cellulitis Admission Order Set Cellulitis Admission Order Set Many more developed and being developed Many more developed and being developed

21. Available Clinical Protocols Include (but not limited to) Bowel Care Clinical Protocol Bowel Care Clinical Protocol Hypoglycemic Clinical Protocol Hypoglycemic Clinical Protocol Hyperkalemia Clinical Protocol Hyperkalemia Clinical Protocol ALC Clinical Protocol ALC Clinical Protocol DVT Treatment Clinical Protocol DVT Treatment Clinical Protocol And many more developed and being developed And many more developed and being developed

22. Additional Linked Information Associated Documents are linked to the order set by clicking on the plus sign beside each order set Associated Documents are linked to the order set by clicking on the plus sign beside each order set These (AD) include referral forms, external associated educational workshops info These (AD) include referral forms, external associated educational workshops info Clinical Protocols (CP) that are listed within the associated order set also have an additional link here for viewing and printing Clinical Protocols (CP) that are listed within the associated order set also have an additional link here for viewing and printing

23. How to use order sets? Order sets are used in the same fashion as hand written Physician orders Order sets are used in the same fashion as hand written Physician orders Order sets are printed from source on demand – copies are NOT to be kept on hand unless otherwise specified by EBC program Order sets are printed from source on demand – copies are NOT to be kept on hand unless otherwise specified by EBC program indicates mandatory order unless crossed out by physician. indicates mandatory order unless crossed out by physician. Open Box indicates optional order, activated when checked. Open Box indicates optional order, activated when checked. (Note: pre checked medication routes DO NOT authorize the use of the drug unless drug itself selected) (Note: pre checked medication routes DO NOT authorize the use of the drug unless drug itself selected) Reference to additional information, policies, protocols are provided for guidelines and decision making support Reference to additional information, policies, protocols are provided for guidelines and decision making support

24. Next Steps Document in plan is an electronic version of the traditional paper pathway; 2 currently released are Acute Coronary Syndrome and Community Acquired Pneumonia Document in plan is an electronic version of the traditional paper pathway; 2 currently released are Acute Coronary Syndrome and Community Acquired Pneumonia Linkage of evidence electronically Linkage of evidence electronically CPOE (Computer Physician Order Entry) CPOE (Computer Physician Order Entry)

25. Data Nurses and Health Care Professionals are now being heard from the bedside Nurses and Health Care Professionals are now being heard from the bedside Data can be tracked requiring best practice standards shown to be met Data can be tracked requiring best practice standards shown to be met Careplans (document in plan) will be used more effectively and consistently Careplans (document in plan) will be used more effectively and consistently

26. Contact Information for Suggestions/Comments Open forum on order set repository links directly to the program Open forum on order set repository links directly to the program Contact information on web site Contact information on web site Andrea Rawn Andrea Rawn EBC Program Co Ordinator EBC Program Co Ordinator Education/Utilization Coordinator Education/Utilization Coordinator Evidence Based Care Program Evidence Based Care Program arawn@gbhs.on.ca arawn@gbhs.on.caarawn@gbhs.on.ca