Closing the Gap Between Research and
Practice: A Multidisciplinary Approach
Marita G. Titler, PhD, RN, FAAN
Rhetaugh Dumas Endowed Chair
Associate Dean for Practice Development and Scholarship
Division Chair Health Systems and Effectiveness Science
University of Michigan School of Nursing
August 2014
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
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.
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)
Funded Projects Co-Investigator
• Dissemination of Tobacco Tactics versus 1-800QUIT-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.
Model to Guide Implementation
(Rogers, 1995, 2003; Titler and Everett, 2001; Titler, 2008)
Characteristics of
the EBP
Communication
Process
Communication
Social
System
Rate & Extent
of Adoption
Users of
Innovation
Multifaceted strategies are necessary to translate research into
Practice (Greenhalgh et al, 2005)
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
Xianjin Xie, MS
Specific Aims
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.
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
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)
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)
Cancer Pain in Elders: Promoting
EBPs in Home Hospice Settings
Funded 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
Moving Beyond Fall Risk Scores:
Implementing an Evidence-Based Targeted
Risk Factor Fall Prevention Bundle
Marita G. Titler, PhD, RN, FAAN
University of Michigan School of Nursing
Paul Conlon, PharmD, JD
Senior Vice-President for Clinical Quality and Patient Safety
Trinity 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
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”
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
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,
Implementation Model & Intervention
Social System
Hospital; Patient Care Unit
•
•
EBP Practices – Risk Specific
•
•
•
Intervention:
QRGs
Posters
Key messages
•
•
•
•
•
•
Communication
Communication Process
Characteristics of the Innovation
Intervention:
Senior administrator support
Education program for senior leaders
and nurse managers
Meetings with pharmacists
Intervention:
Opinion Leaders (OL)
Staff education
Change Champions (CC)
Outreach visits
Train-the-trainer program
Users
Nurses, Pharmacists
•
•
•
Intervention:
Performance gap assessment
Audit and feedback
Teleconferences
Adoption of EBPs
Outcomes & Processes
•
•
•
Measures:
Fall rates
Fall injuries
Use of risk
specific fall
prevention
interventions
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).
Results
Falls Injury Type
100
90
89%
80
Percentage
70
83%
74%
60
Minor Injury
50
Moderate Injury
40
Major Injury
30
20
15%
11%
10
11%
0
Before Intervention
6%
Midpoint
7%
4%
After Intervention
Fall Prevention Interventions
Risk specific interventions***
Mobility
Before Intervention
Patient
Rate per
Days*
100
patient
days**
1285
31
After Intervention
Patient
Rate per
Days
100 patient
days
pValue
1333
88
<.001
Toileting/Elimination
853.7
50
917.7
66
<.001
Medication
1525
0.11
1562
0.1
0.981
Mental/Cognitive Status
Risk for injury
769
2.3
531
77
<.001
1142
66
1285
88
<.001
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)
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.”
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.””
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.
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.
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
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
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
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.”
Medical Care Volume 51, Number 4 Suppl 2, April 2013
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
Current Studies
• U01AG048270 NIA/PCORI. Clinical Trial
of a Multifactorial Fall Injury Prevention
Strategy in Older Persons. 30 million. PI:
Shalender Bhasin; Joint PIs: Thomas Gill;
David Reuben. Titler: Co-I and Lead for
Patient Engagement. Other CO-Is –
physical therapy, informatics, statistics.
Structure
• National Patient and Stakeholder Council
• Local Patient and Stakeholder Council at
each of the 10 clinical trial sites
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
Critical Care Nursing Clinics of North America,
December 2001
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
Outcomes to Date
•
•
•
•
•
Increasing EBP capacity across the state
Trained 39 teams
8 Health care systems
Institutionalizing practice change
Papers and conference presentations
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
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
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
Evaluation
• No change in
blood stream
infection rates
before and after
the practice
change
Lessons Learned
• Partnerships
• Implementation strategies
– Complexity of the clinical topic
– Context
– Communication
– Key stakeholders
Implementation Science and
EBP Requires Partnerships
and Collaboration
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
Implementation Strategies
• Complexity of the clinical topic
– Quick reference guides and decision aides
– Length of time for implementation
– Key messages
• Communication
– Education – necessary but not sufficient to
change practice; interactive; ongoing; new staff
– Opinion leaders and change champions – specific
to discipline
– Outreach to clinical practice sites (conversations;
sense making; “site visits” )
Implementation Strategies
• Identify clinicians who will be using the EBPs
– Engagement early and often
– Performance gap assessment – beginning to
discuss current state
• Audit and feedback – actionable, discussion,
not passive dissemination of reports; Data
perceived by the clinician as important and
valid.; Timely, individualized, non-punitive
feedback
Reality
“Because implementation
of a new practice almost
invariably requires
changing how things are
done, it affects multiple
individuals from multiple
specialties and their
interrelationships”
(Lucian Leape, 2005)
Context
matters
Context factors that affect adoption
•
•
•
•
Learning culture
Leadership (involve them from the beginning)
Managers of clinical sites
Capacity to evaluate the impact of the EBP during
and following implementation
• Effective implementation needs both a receptive
climate and a good fit with intended users needs
and values
(IOM 2001, McGlynn et al 2003, Stetler 2003, Rogers 2003a, Bradley et al 2004a, Ciliska et al 1999, Morin et al 1999, Fraser 2004a, 2004b,
Vaughn et al 2002, Anderson et al 2003, Anderson et al 2004, Anderson et al 2005, Batalden et al 2003, Denis et al 2002, Fleuren et al 2004,
Kochevar & Yano 2006, Litaker et al 2006, Cullen et al 2005a Redman 2004, Scott-Findlay & Golden-Biddle 2005)
Views through various disciplinary
lenses
• Listen to various perspectives
• Value of unique disciplinary perspectives
• More horizontal integration across
disciplines
Reflections for the Future
• PhD education: course work balanced with
mentorship – how much course work is
enough
• Trans-disciplinary PhD education
• Hillman scholars program – BSN to PhD
Reflections for the Future
• Plan efficacy studies with the end in mind
– how will or can the findings from this
study be used in practice
• Partner with communities of practice and
the public early on in designing the study –
traditionally have examined the state of
the science from research – is this topic
important to people?
Resources
• Education
–
–
–
–
–
–
Newsletters
14 Podcasts
How to start a journal club
EBP references
Eye on Evidence
Webinars – lunch and
learn; journal clubs
• Research
– Network of sites for
research
– Process for investigators
to access NNPN
organizations for research
– Organization context
measurement instruments
• Culture
• Climate
• Interactive human
relationships
WE ALL Have
Contributions to make
WISHING YOU THE SPIRIT of
COLLABORATION IN YOUR
DISCOVERY AND APPLICATION OF
EVIDENCE IN PRACTICE
Questions/Discussion