Moving Evidence into Practice Dawn Stacey RN, PhD, CON(C), - PowerPoint PPT Presentation

CANO 2010 - Research Workshop: Moving Evidence into Practice Dawn Stacey RN, PhD, CON(C), University of Ottawa Denise Bryant-Lukosius, RN, PhD,CON(C), McMaster University, Hamilton Andrea Maria Laizner, RN, PhD, McGill University Health Centre, Montreal On behalf of Cancer Care Ontario’s Community of Practice Nursing Research Group and CANO Research Committee

Workshop Outline 1. Welcome & introductions (~30 min) 2. Clinical Practice Guidelines – what, how to find them, appraising their quality (~30 min) 3. Strategies for implementing guidelines in clinical practice (~20 min) 4. Case study: implementation of guidelines in oncology nursing practice (~30 min) 5. Wrap-up and workshop evaluation (~10 min)

Best Practices Guidelines • Improve patient care • Standardize care • Integrate research into practice • Develop knowledge base • Assist with clinical decision-making • Recognize deviations • Stop ineffective interventions • Decrease costs 3

Goals of MUHC Best Practice Guideline Program • Improve performance – Patient Outcomes (PU, Pain, falls with injury) – Nurse Outcomes (practice, documentation) – System Outcomes (costs, efficiency, collaboration) • Harmonization (decrease variation) • Increase knowledge transfer capacity • Leadership development (Ritchie, O’Connor, Rose, Sourdif, Jan 29, 2009)

PARIHS Framework Guided MUHC Implementation • Evidence – Research, clinical and patient experiences, as well as local data • Context or environment (HCS, research to be implemented, where change to occur) – Culture, leadership, evaluation – Complexity, readiness, feedback mechanisms • Facilitation or process of enabling (help, support, strategies that enable reflection) (Roycroft-Malone, 2004)

Workshop Outline 1. Welcome & introductions (~30 min) 2. Clinical Practice Guidelines – what, how to find them, appraising their quality (~30 min) 3. Strategies for implementing guidelines in clinical practice (~20 min) 4. Case study: implementation of guidelines in oncology nursing practice (~30 min) 5. Wrap-up and workshop evaluation (~10 min)

Case study: Implementation of guidelines in oncology nursing practice Andrea Maria Laizner, R.N., Ph.D. Nursing Practice Consultant-Research, MUHC Assistant Professor, School of Nursing, McGill University CANO 2010

McGill University Health Centre • Academic health center • Patient-family centered care – clinical practice, education, research • Specialized care across the life span • Over 3,000 nurses across 6 sites • 7 Clinical missions, includes Oncology & Palliative Care • Professional Practice and Research – Emphasis on patient safety, research & quality care – 65 Clinical Nurse Specialists – 30 Nurse Educators 8

McGill University Health Centre 9

MUHC BPG Steering Committee 10

Evaluation • Prevalence Survey  Annually with each admitted patient (1 hospital site per day) • Study 1(31 units) and Study 2 (17 units)  30 patients per unit  Categorized units:  Level of improvement: Low, Medium, High Based on number of criteria met a change of > 10% from baseline 11

Strategies: Task Force • Responsible for determining priorities and rollout plan for indicator for which they are responsible • Review and select RNAO BPG recommendations • Co-chairs clinicians, educators or administrators • Interdisciplinary: RN, physio, MD, quality & risk management, patient representative, researcher, and others • Select indicators, including criteria and benchmark • Develop implementation plan, time-line, documentation, other tools and manual • Provide support and coaching 12

Support from Task Forces • Content ‘Experts’ • Design & give learning activities • Resource packages • Pocket guides for assessment • Resource binders, BPG bulletin boards, Posters • Hold focus groups/celebrations with frontline staff • Provide coaching & problem solving especially to unit-based champions re content of change • $ 5,000 to each Task Force

Strategies: Unit • 8-12 weeks implementation • Stakeholder assessment • Facilitation – External: TF Co-chairs, Advocate support (CNS, Educator, Other) – Internal: Unit Champions (RN, ANM, PABs) • Workshops on Change management and implementation for champions and leadership team • Train the Trainer sessions for the champions • Regular audit with feedback to staff • Pocket tools and posters 14

Strategies: Organisation • Workshops and Information sessions • Regular reporting to Council of Nurses and Leadership groups • Advocates facilitate practice change • Communication – Needs to be frequent and at multiple levels • Practice guidelines linked to patient safety agenda and planning for equipment (business case). 15

Support from Advocates • BPG Implementation ‘Experts ‘; General content • Provide external implementation guidance – Participate in unit group or focus group meetings – Review with unit re EBP and BPG implementation – Coach unit-based champions on change model; help develop unit plan and strategies – Suggest evidence-based strategies; plan sustainability • Leading change workshops • General leadership advice!

Coordinator Role • Coordinates and facilitates: – implementation and work reorganization activities associated with implementation – Research activities associated with evaluation of implementation • Provides support to Task Forces • Reports to BPG Project Leaders

RNAO Toolkit : 6 Steps to Guide Implementation 1. Stakeholder Analysis 2. Preparation of Workplace 3. Potential Barriers 4. Implementation Plan 5. Evaluation 6. Required Resources 18

RNAO Toolkit : Stakeholder Assessment Worksheet for Planning Implementation 1. Key stakeholder 2. Nature of vested interest 3. Stakeholder • influence (high versus low) • Support (high versus low) 1. Management strategies 2. Revisions 19

Environmental Readiness 20

Clinical Practice Guidelines RNAO Pain Toolkit 21

RNAO Nursing Best Practice Guidelines for the Assessment and Management of Pain 78 recommendations for clinical practice, education and organization of care with goal: • To provide direction in the assessment and management of pain in both institutional and community settings • To prevent pain wherever possible 22

BPG: Based on following Principles • Pain is an individual experience and unique to each person • Pain has important physiological and psychological effects on the person • Pain influences recovery from illness, alters physical and emotional functioning and decreases quality of life • Nurses need to learn to assess and manage pain • There are a variety of methods to manage pain, pharmacological and non-pharmacological 23

Assessment and Management of Pain • Best Practice recommendations • Implementation strategies • Evaluation • Facilitating factors • Results, including Unit example • Lessons learned 24

Tools Developed • Patient Information Sheet developed to encourage patients to talk about their pain • Revised protocols for PCA, epidural analgesia, and surveillance of opioids • Guide for prescription of opioids and other analgesics for physicians • Algorithm for the assessment and management of pain (poster) • Revision and implementation of documentation tools (paper, electronic, etc) 25

Numeric Scale Numeric Scale 0 1 2 3 4 5 6 7 8 9 10 no pain Pain as bad as you can imagine 0 1 2 3 4 5 6 7 8 9 10 Pas de La pire douleur que douleur vous pouvez imaginer

FACES (Revised Revised Bieri) Bieri) FACES (

MUHC Infothèque • MUHC Health Education Collection • Includes pamphlets meeting specific health literacy standards • http://infotheque.muhc.ca/Results.aspx?QY=find%28FileNumber=612%29

Starting dose Starting dose in in opioid- opioid-naïve* Equianalgesic Onset of Duration Peak of action naïve* patients with dose action of action patients WITH NO risk factor risk factor(s) (Adults) (Adults) DRUG IV SC/IV SC SC/IV SC/IV PO (PO) PO (PO) 2-5 min IV: 15 min 4 hrs 2.5 mg SC/IV 5 mg SC/IV Morphine 5 mg 10 mg (15 min) SC: 30 min (4-6 hrs) 5 mg PO 10 mg PO PO: 30-60 min 6 min IV: 15 min 4 hrs 0.5 mg SC/IV 1 mg SC/IV 1 mg 2 mg Hydromorphone (15 min) SC: 15 min (4-6 hrs) 1 mg PO 2 mg PO PO: 30-60 min 30-60 1-2 min Fentanyl 50 mcg N/A IV: 5-15 min min 25 mcg SC/IV 50 mcg SC/IV (N/A) SC: 5-15 min (N/A) PO: N/A 60 mg 100 mg Codeine (IV not 4-6 hrs 30 mg PO 60 mg PO recommended) 30-60 min (4-6 hrs) PO: 2-4 hrs IV/SC: N/A I/VSC: N/A N/A Oxycodone N/A 7.5 mg 5mg PO 7.5 mg PO (15 min) PO: 30-60 min (3-6 hrs)