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
Overview History of knowledge translation Change is difficult Change is needed Effects of our attempts …
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
So how do we effect change in our department! Busy ED ~ 40 000pa Many challenges / barriers.
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
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.
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.
Does “ the evidence ” help? Grimshaw et al Systematic review of 235 evaluations of guideline dissemination 86% showed improvement with compliance Overall improvement was 10%
Attempted change Most effective strategies Reminders How do you implement a reminder What form? Education Audit and feedback. By who and how often
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
Guideline characteristics Good evidence Simple, decreases workload Common, important or acute disease Accessible, usable Local champion Available in the front of the medical record
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.
EBM Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ”
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.
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)