“AC3KTION NET” KNOWLEDGE TRANSLATION NETWORK

TRANSMISSION DES CONNAISSANCES « AC3KTION NET »

Tuesday, February 12, 2013 Mardi 12 février 2013

Your Hosts & Presenters Vos hôtes et présentateurs

Bruce Harries, Moderator Ardis Eliason, Technical Host John Muscedere, MD, FRCPC Paule Bernier, DtP., M.Sc.

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Interacting in WebEx: Today’s Tools Interagir dans Webex : outils à utiliser

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Be prepared to use: - Pointer - Raise hand - CHAT - Text Tool “writing on the slide” - Shape Tools

Have you used WebEx before? Avez-vous déjà utilisé WebEx? YES / OUI NO / NON

Soyez prêts à utiliser les outils : - le pointeur - lever la main - clavardage - Outil textuel pour « écrire sur la diapo » - Outils de forme

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Type your message & click ‘send’

Select ‘send to’

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Who’s Online? Qui est en ligne?

POINTER

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What professions are represented? Quelles professions sont représentées?

Nurse MD

Educator / Quality Improvement Professional

Infection Control

Administrator / Senior Leader

Other

POINTER

Respiratory Therapist

Nutritionist

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Objectives But de l’appel

1. To review the need for increased efforts to implement research evidence into bedside practice.

2. To review the need for measurement to identify gaps between best practice and actual practice.

3. To demonstrate why there is a need for increased knowledge translation efforts in critical care and how aCKTION Net proposes to fill this need.

1. Revoir la nécessité d’accroître les efforts pour intégrer les données probantes émanant de la recherche dans la pratique au chevet des patients.

2. Revoir la nécessité d’instaurer des mesures pour identifier les lacunes entre les pratiques exemplaires et les pratiques réelles.

3. Démontrer le besoin d’accroître les efforts en matière d’application des connaissances dans le domaine des soins critiques et la façon dont aCKTION Net propose de combler ce besoin.

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Dr. John Muscedere

“aC3KTion Net”

a Canadian Critical Care Knowledge Translation Network

“aC3KTion Net”

Learning Objectives

• To understand the need for knowledge translation (KT) in Critical Care

• To review the need for measurement as a means to improve practice

• To demonstrate how the Canadian Critical Care Knowledge Translation Network (aC3KTion Net) can address the KT needs identified for critical care.

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Need for Knowledge Translation in Critical Care

• Lag between generation of research evidence and its implementation into best practice

• Unknown penetration of new evidence into practice • Few large scale KT initiatives thus far

– Patient safety

• Minimal resources to conduct KS activities • Increasing focus on Quality

– Deriving best outcomes and best value from resources expended.

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What is Knowledge Translation?

CIHR defines knowledge translation (KT) as: “a dynamic and iterative process that includes

the synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the healthcare system”

Canadian Institutes of Health Research. www.cihr-irsc.gc.ca/e/39033.html.

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Why is there a need for KT efforts?

• Average of 17 years for new knowledge to have impact on bedside standards of practice

• Reasons include: – Slow diffusion of research evidence into practice – Limited comparative effectiveness research to guide

implementation, investments and use of technologies – Lack of health system policies across jurisdictions – Research groups and clinical communities working in isolation – Literature base is rapidly expanding such that it is difficult for

individual practitioners to remain current, assimilate and then apply evidence into practice.

IOM. Crossing the quality chasm: A new health system for the 21st century. 2001.

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Why is there a need for KT efforts?

• A large gulf remains between what we know and what we practice.

• Variation in implementation is common internationally, within countries, between regions and even between hospitals.

• Even where guidelines exist, large gaps continue to exist between best evidence and practice.

• Example- CV Medicine: – 30% to 40% of patients fail to receive treatments of proven

effectiveness – 20% to 25% of patients may receive care that is not needed or is

potentially harmful

Davis et al. BMJ 2003; 327: 33-35. Tremblay et al, Can J Cardiol 2004; 20:1195-98.

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Variation in Quality Scores for Pneumonia at Academic Medical

Centers (2004)

John Wennberg, The Eisenberg Legacy Lecture Stanford, California. Nov. 2, 2005.

45.0

55.0

65.0

75.0

85.0

95.0

Per

cent

age

(%)

Percentage of 3 care measures received: 1. Timely administration of antibiotics 2. Measurement of SaO2 3. Immunization

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Why Focus KT efforts on Critical Care?

• Patient Vulnerability: – ICU patients experience high morbidity and mortality – Ontario

• Level 3 pts- 20% mortality • Level 2 pts- 10% mortality

• Patient Volume:

– ICU patients per year: - Canada- 360,000 pts.

Globe and Mail, Nov. 24, 2011

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Why Focus KT efforts on Critical Care?

• Access:

– 80% to 100% increase in the number of critically ill patients over the next 20 years

– Demand will overwhelm capacity in the next 10 years

• Health Care Costs: – In Canada (2004): ICU costs were estimated

to account for 15.9% of the $39 billion spent on hospital services

– 0.5 – 1.0 % of GDP

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Best practices not uniformly applied in critical care

• Wide variations documented in application of commonly applied therapies for critically ill patients

• Sepsis • ARDS • Sedation practices • Transfusion practices • Non-invasive ventilation • Renal replacement therapy • End of Life Care • Etc.

Hirshberg et al, Chest 2008; 133: 1335. 17 02/12/2013

Uneven adoption of best practices- VAP prevention

Recent Survey (518 U.S. Hospitals) 21% used ETTs with SSD 40% use antimicrobial mouth rinses 82% utilized semi-recumbent positioning

Krein. Infect Control Hosp Epi. 2008 18 02/12/2013

Variance in the Application of Best Practices

• Reasons include: 1. Lack of research evidence

• Can inform future research directions

2. Lack of awareness or lack of dispersion of best practices • Can be improved by knowledge synthesis or knowledge

translation activities

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Expanding Critical Care Literature Base: Number of critical care RCTs published per year

500

550

600

2010

560

Modified from Kahn, CCM 2009; 37: S147

Challenge in delivery of Critical Care from a KT perspective

• Team based care – Need to reach RNs, RTs, Pharmacists, Dieticians, PTs etc.

• Physician challenges: – Large amounts of critical care delivered by non-intensivists – Critical care may only be a small proportion of their practice – Differing backgrounds for MD entry into critical care – Episodic care by physicians

• Institutional challenges – Variability in available resources.

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Bridging the Gap

Evidence-Based Best Practices

Clinical Practice

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Two phases: 1. knowledge creation; 2. action cycle

HOW? KNOWLEDGE-TO-ACTION CYCLE

Graham et al. 2006 02/12/2013 Graham et al. 2006

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aC3KTion Net • Network of ICUs (Networks) from across

Canada • Academic • Community

• Primary activity will be Knowledge Translation and development of Critical Care Knowledge Synthesis products

• Not KT Research

• Measurement of uptake/outcomes

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a Canadian Critical Care Knowledge Translation Network

aC3KTion Net

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aC3KTion Net Vision

To improve the care of critically ill through the application of best practices as defined by research evidence in a timely manner thereby reducing the morbidity, mortality and impact of critically patients on the health care system.

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aC3KTion Net Scope

• All critical care units in Canada will be eligible and encouraged to participate.

• Best practices that will be included in network activities will be those pertaining to: – clinical practice – ICU organization – administration and organization of critical care resources.

• We will include multi-professional representation to encompass the multi-disciplinary nature of ICU teams.

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aC3KTion Net Objectives 1. To bring together critical care researchers and

knowledge users (health care professionals, national professional associations, and health care system decision makers) to optimize resources and support collaborative knowledge translation activities.

2. To survey practice at baseline and after implementation efforts to guide knowledge translation activities and measure the results of our efforts.

3. To conduct knowledge synthesis activities and develop knowledge products to inform critical care best practices.

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aC3KTion Net Objectives Cont’d

4. To improve the care of critically ill patients through the dissemination of best practices, as defined by research evidence, into ICUs across Canada.

5. To improve critical care outcomes including morbidity, mortality and the health care system impact of critically ill patients.

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aC3KTion Net Partners/Decision Makers

BC • Ministry of Health CC Working Group

• Fraser Health CC

Alberta • Noel Gibney, Alberta CC clinical Network

Sask. • Susan Shaw, Chair, Sask. quality Council

Manitoba • B. Paunovic, Winnipeg Head CC U of Manitoba

Ontario • B. Lawless, CC Secretariat

Quebec • M. Légaré, SIQ

Maritimes • W. Patrick, CC Dalhousie U.

1. Canadian Critical Care Society 2. Canadian Association of Critical Care Nurses 3. Canadian Society of Respiratory Therapists 4. Canadian Patient Safety Institute 5. Canadian ICU Collaborative

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Network Activities • Knowledge Sources: Canadian Critical Care Trials

Group (CCCTG), Literature, Other • Knowledge Synthesis: Development of clinical

practice guidelines, evidence syntheses and scoping reviews.

• Testing of Knowledge Products: Reviewed and tested before implementation, to ensure acceptability, ability to achieve intended purpose and ascertain possible barriers

• Knowledge Implementation: Local teams will use strategies/tools tailored to knowledge product. – Education, protocols, checklists, order sets,

organizational changes and reminder systems – PDSA cycles to track implementation activities

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Incubator Units • Testing and modification of knowledge

products in a real world environment – Involvement of all members of health care

team – Knowledge products reviewed for:

• Acceptability • Possible barriers to implementation • Possible tools for implementation • Implementation tools designed

– Academic hospitals, Community hospitals

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Even when motivated to change our behavior, we cannot manage what we do not measure.

Measurement can identify gaps in best practice.

Measurement can illuminate the results of our efforts at implementing best practice.

Measurement can inform future research direction.

Measurement- Why?

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Data Collection

• Modified point prevalence surveys – Periodic data collection on cohorts of ICU patients

• 30 pts for large ICUs (> 15 beds) • 20 pts for small ICUs (< 15 beds)

• eCRF with MDS that is scalable and modular for new network initiatives as they are developed

• Reports of performance for each ICU from data collected

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KS/ KT Activity Core Data Set

Specific Initiatives

Core Data Set

Specific Initiatives

KS/ KT Activity

Core Data Set

Core Data Set

Core Data Set

Specific Initiatives

Core Data Set

Specific Initiatives

Core Data Set

Specific Initiatives

KS/ KT Activity KS/ KT Activity KS/ KT Activity KS/ KT Activity

CCCKTN Activity

Data Elements

1. Core Data Set

2. Practice Data – specific practices

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KT Initiatives- how to choose?

• Short term: Knowledge Products Ready for Implementation after first data collection period

• E.g. guidelines • VAP CPGs, Hypothermia Guidelines, Sepsis guidelines etc.

• Longer term: Initiatives based on demonstration of practice variation

• To be based on data collected during baseline data collection

• Will inform future KT activities/future Research activities • What data to collect?

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Selection process for initiatives

• Delphi technique – Input from Steering/Scientific Committee – Researchers, clinicians, knowledge users, decision

makers Composition of Steering/Committee

Scientific Committee

31 Members Total (Overlap) •21 MDs •4 RNs •1 Pharmacist •1 RT •9 Knowledge Users •5 National organization members (CCCS, CACCN, CSRT, CPSI, CICU)

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Top 5 CURRENT KT Initiatives

1. Pain/Analgesia/Delirium Guidelines 2. Sepsis guidelines: new surviving sepsis

guidelines 3. Canadian Nutrition Guidelines in the

Critically Ill 4. Implementation of revised Ventilator

Associated Pneumonia Guidelines 5. Non-Invasive Ventilation Guidelines

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Top 10 Future KT Initiatives

1. End of Life 2. Sedation/Analgesia 3. Sepsis (diagnosis/management) 4. Early Mobilization 5. Delirium (screening/treatment) 6. Communication in the ICU 7. Anti-Microbial Stewardship 8. Quality Improvement Initiatives 9. Fluid Therapy (resuscitation, maintenance) 10. Utilization of non-invasive mechanical

ventilation 39

Recruitment of ICUs • Main benefits of participation

– Access to KT activities – Access to KS products – Access to educational events/webinars – Opportunity to participate in incubator units – Ability to influence network activities – Benchmarked reports of performance with national peers – A vehicle to drive critical care quality improvement

• ICUs provide periodic data in return

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Recruitment of ICUs

• ICUs to be recruited through: • Provincial networks, provincial registries of ICUs • Advertisement through professional societies:

CCCS, CSRT, CACCN

• Partnerships with existing networks

• Any other recruitment strategies? • Any other ways to incentivize ICUs to

participate in the network?

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Timelines/Future Activities

• aC3TION Net website – Go Live, Feb 12, 2013

• Recruitment of participating ICUs – Feb 12, 2013 on ward

• Outreach to provincial partners, stakeholders – Spring, Summer 2013

• Café Scientifique (Town Hall meeting) – Pilot in Kingston, ??? Other cities

• Projected start of first data collection period – September 3, 2013

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Questions/Comments?

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QUESTIONS?

RAISE YOUR HAND / LEVEZ LA MAIN

OR/OU

CHAT TO “ALL PARTICIPANTS”

Canadian ICU Collaborative Faculty

Chaim Bell; MD, PhD, Associate Professor of Medicine and Health Policy, Management, & Evaluation CIHR/CPSI Chair in Patient Safety & Continuity of Care; University of Toronto; St. Michael's Hospital

Paule Bernier, P.Dt., Msc, Sir MB David Jewish General Hospital (McGill University), Montreal Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre Leanne Couves, Improvement Advisor, Improvement Associates Ltd. Vanda DesRoches; RN BN, Prince County Hospital, PEI Greg Duchscherer, RRT, FCSRT, Quality Improvement & Patient Safety Leader, Department of Critical Care Medicine, AHS (Calgary Zone) Bruce Harries, Collaborative Director, Improvement Associates Ltd. Gordon Krahn, BSc, RRT, Quality and Research Coordinator, BC Children’s Hospital Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology, University of Western

Ontario; Chair/Chief of Critical Care Western Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist – Critical Care, London Health Sciences Centre; Sherissa Microys MD, Assistant Professor, University of Ottawa; Intensivist, Ottawa Hospital; Major, Canadian Forces John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium Guidelines, Society of

Critical Care Medline (SCCM)

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Reminders Rappels

Call is recorded Slides and links to

recordings will be available on Safer Healthcare Now! Communities of Practice

Additional resources are available on the SHN Website and Communities of Practice

L'appel est enregistré Les diapositives et liens

vers les enregistrements seront disponibles sur Des soins de santé plus sécuritaires maintenant! Communautés de pratique

Des ressources supplémentaires sont disponibles sur le site Web SSPSM et Communautés de Pratique

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National Call Appel national

"Learnings from the Delirium Collaborative"

Monday, February 25, 2013

Guest Speaker: Yoanna Skrobik, MD, FRCPC, Intensivist, Hôpital Maisonneuve-Rosemont, Montréal

« Apprendre de la Collaboration sur le delirium »

Lundi Février 25 2013 Conférencier invité:

Yoanna Skrobik, MD, FRCPC, Intensiviste, Hôpital Maisonneuve-Rosemont, Montréal

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THANK YOU MERCI

This National Call is hosted by:

Supported by:

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