Learning Evidence-Based Practice and Quality ... - chw.org/media/Files/For Patients And...

10/8/2014

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Learning Evidence-Based Practice and

Quality Improvement

Following a Team of Child Life Specialists in

their Journey to Create a More Comfortable

Injection Experience

Evidence-Based Practice

Learning Objectives

• Gain experience with the Evidence-Based Practice

(EBP) process

• Recognize how recommendations, when

implemented systematically, can change hospital

practice

• Feel empowered to begin EBP by developing a

clinical question and search terms

• Develop an enhanced understanding on best

practices surrounding injections by following a child

life EBP project


History of Evidence-Based Practice

• Dr. Archie Cochrane, a British epidemiologist challenged the

public to pay only for care that had be empirically supported with

evidence. In 1972 he published a foundational book that

criticized the medical profession for not providing rigorous

reviews of evidence.

• Founded the Cochrane Collaboration to assist individuals in

making well-informed decisions about healthcare by developing

a public systematic reviews of healthcare interventions.

• This work began in medicine, but spread to all areas of

healthcare including: Occupational and Physical Therapy,

Nursing Care, Respiratory Therapy, and Speech Therapy.

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What is Evidence-Based Practice? • Also known as: Evidence-Based Decision Making

and Evidence-Based Medicine

• Evaluates and considers gathered empirical evidence

• Incorporates family and patient preferences as well

as professional expertise

• Guides clinical decision making and treatment

planning

• Interdisciplinary

• Unites the child life profession as a whole

• Provides high quality care

• Validates: Why we do. What we do.


Differences

© CCHMC EBP Mentors, 2013



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1. Assess Practice Need

• Identify need for change or clarification of

best clinical practice

• Consider the priority level of addressing this

need

Resource: Cochrane Handbook

Child Life Council


Develop Clinical Question

Use PICOT format

• Population of interest

• Intervention or issue of interest

• Comparison intervention or issue of interest

• Outcome of interest

• Time involved to demonstrate outcome

Resource: Evidence‐Based Practice in Nursing and Healthcare: A Guide to Best

Practice by Bernadette Mazurek Melnyk and Ellen Fineout‐Oveholt, Chapter 2.

Child Life Council


Questions in Practice


Should I provide

medical play for

medical procedure

preparation in a

child with an abuse

history?

Does teaching a child

coping skills help

them with general

anesthesia?

Is using praise

more effective

than using a

reward

system?

Do numbing

agents help

with

injections?

Does offering support during

procedures decrease a child’s

anxiety?

In what ways

should I process

grief with

siblings?

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Your Turn: What clinical questions are

you wondering about?

• What is a problem that you consistently

encounter?

• What is an area of interest?

• A clinical problem that you encounter in your

practice could be related to patients,

therapeutic approaches or interventions,

personnel, collaboration, technology, physical

materials, etc.?

Define a Clinical Question

P

I

C

O

T


What clinical issue are

you passionate about?

What questions do you

have?

Search for Evidence

• Use PICO question to determine search

criteria or search terms

• Include all appropriate databases

• Cochrane Database of Systematic

Reviews, CINAHL, MEDLINE,

PsychINFO, National Guideline

Clearinghouse, Children’s Hospital

Association

• Eliminate articles that do not address the

clinical question

Resource: Cochrane Handbook

Child Life Council


Search Terms:

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Critically Appraise the Evidence

• Determine whether each study

is valid and reliable

• Use the LEGEND (Let

Evidence Guide Every New

Decision) system to evaluate

the quality level for each article

Resource: LEGEND (Let Evidence Guide Every New

Decision): Tools for Evaluating the Evidence, available

at:

http://www.cincinnatichildrens.org/research/project/cpe‐rebp/resources.htm

Child Life Council


Valid: Were the results of the study

obtained using sound scientific

methods? Does the test measure

what the test says it is really

measuring?

Reliable: Can you reproduce it?

Does the test consistently produce

the same results when administered

to the same individuals under the

same conditions?

Cookie Analogy

Warm chocolate chip cookies

from the oven

Oreos

Cookies from your favorite

bakery

Systematic Reviews, Meta-

analysis

Randomized Control Trials

Chips Ahoy chocolate chip

cookies

Frosted animal cookies

Qualitative, Case Control, Longitudinal,

Cross Sectional, Descriptive Studies,

Case Series

Published expert opinion,

Guidelines, General

consensus

Controlled Clinical Trials,

Cohort- Prospective


Levels of Evidence Evidence-Based Practice

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Incorporate Clinical Expertise and

Experience

• Use clinical expertise to make

recommendations when

evidence is inconclusive

• An interdisciplinary group of

experts may be formed to help

evaluate and make

recommendations

• Resource: Child Life Council


Incorporate Patient and Family Values

and Preferences • Are my patient’s and family’s values and preferences

satisfied by the treatment and its consequences?

• Is the treatment feasible in my care setting?

• Do the patient outcomes apply to my population or

question of interest?

• Are the likely benefits worth the potential harm and

costs?

• Were the patients in this study similar to my

population of interest?

Develop EBP Statement

• Summarize the evidence

incorporating clinical expertise

and patient/family values and

preferences

• Include possible implications

for practice and future

research needs

Resource: Child Life Council


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EBP Journey for Injections

• Request for “helping your child with injections”

came from the hospital wide pain team task

force and child life staff in July 2011.

• Completed the evidence-based decision

making process and created a PICO question:

– In pediatric patients receiving injections, do

pharmacological interventions (including topical

anesthetic agents), psychological, and physical

interventions versus no intervention reduce pain

during injections?

BESt: “Reducing Pain for Children and

Adolescents Receiving Injections”

• Completed in January 2013

• Recommendations:

1. It is strongly recommended that age-appropriate interventions

with strong evidence, be used to reduce pain during

injections* See cells marked “Strongly” in following table.

2. It is recommended that, when strongly recommended

interventions are not sufficient or feasible to reduce pain

during injections, additional age-appropriate consensus-based

interventions are used. See cells marked “Local Consensus”

in the following table.

Note: Combining an intervention with distraction is more effective

than a single intervention.

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Successes

• Strong support from EBP mentor program within the hospital

• Literature produced evidence which answered our PICO question

and strongly supports our practice as CCLSs

• Positive feedback from hospital BESt review committee

• “This statement has the potential to impact patients and

families at all points of care within the institution”

• Core group of CCLSs committed to completing EBP statement

• Team with mixed levels of experience in EBP

• Less experienced staff received support and guidance

from those more experienced

• BEST of the BESt award 2013

Challenges

• Lack of resources, time, and staffing

– Completing article appraisals

– Developing recommendation

– Disseminating recommendation

– Implementing practice change while maintaining

one’s patient-care load

• Limited number of child life staff

– Staff interested in learning more about EBP

– Staff with a passion for completing EBP work

• Scheduling conflicts with EBP team

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Following up with a Quality

Improvement (QI) Project

Implement EBP into Practice

• When there is little

evidence

• Research project

• Where there is

evidence to make a

practice change

• Quality improvement

project

• Education plan



Disseminate Recommendation

March 2013: Educational Materials

• Helping you Child Cope with Getting an Injection (Tips for Newborns and Children up to 5 years)

• Helping your Child Cope with an Injection

(Tips for School-age Children)

• Coping with an Injection

(Tips for Teens)

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October 2013: Educational slides for

Televisions in waiting area

• Created three slides based on developmental

level

• Currently being shown in cafeteria and 3rd floor

waiting areas within the 3430 building

What is Quality Improvement (QI)?

With the customer* as top priority:

• Improving what we’re already doing, by altering

how we do it

• Producing a measurable & positive difference by

changing outcomes

• That has a lasting impact

Why do QI or make changes?

• To meet or exceed customer expectations.

*Customer: staff, patients, families, those impacted by practice change

© CCHMC EBP Mentors, 2014


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Steps of Quality Improvement

Identify Problem

Document Current Process

Develop SMART AIM & Measures

Identify Key Drivers

Identify Potential Interventions

Identify & Analyze Process Failures

Design & Execute PDSAs

Run Charts

Scale-up Successful Interventions

Plan for Sustainability & Spread

Identify Root Causes

Develop SMART Aim

• An Aim statement describes what a team’s

focus is for their improvement work

• It indicates their goal as well as the baseline

to clearly define what the team is trying to

achieve

• Lastly, it gives a time frame for the work

• S - Specific

• M - Measurable

• A – Actionable

• R – Relevant

• T – Time bound

Develop SMART AIM & Measures

Key Driver Diagram

• Connects the aim/outcomes, key drivers, and

interventions

• Provides a roadmap for project

• Helps to focus the interventions accurately,

aligning the interventions to address root

causes and failures ultimately helping you

to achieve your SMART aim

Identify Key Drivers

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KEY DRIVER DIAGRAM

Project Name: Project Leader:

SMART AIM

KEY DRIVERS INTERVENTIONS (LOR)

Key

Dotted box = Placeholder for future additions

Green shaded = what we’re working on right now

Revision Date: __-__-__

GLOBAL AIM

2003 - 2009 © Cincinnati Children's Hospital MedicalCenter. All rights reserved.


• HOW to address the failures

• HOW to accomplish the Key Drivers, which

ultimately help you achieve your goal

• Example:

– Failure identified = staff lack of knowledge with

positioning

– Potential Interventions:

• Provide education for staff on positioning

• Visual resources and signage re: positioning

– Staff resources and visual reminders in procedure rooms

– Materials for parents/caregivers in exam rooms, waiting rooms


Design and Execute PDSAs

Plan

• What is the objective of the

test?

• What is needed to complete

test?

• How will you measure

outcome?

• Make a plan of action

Do

• Carry out your plan

• What were the results?

Design & Execute PDSAs

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PDSAs Study

• Was your prediction correct?

• What should be done for the next

test?

• What did you learn from the first

test?

ACT

• Adapt – make revisions to the

change

• Adopt – keep the change and try

on a larger scale

• Abandon

PDSA #1 • Global Aim: Reduce pain, distress, anxiety in infants, children,

and adolescents receiving injections.

• Smart Aim: Increase percentage of infants, children, and adolescents who receive the flu vaccine by December 31, 2014.

• Clear plastic brochure containers with educational materials were placed in all check-in areas and registration waiting areas.

• Created data collection form which prompted registration personnel to ask families, “Have you received the coping with injections brochure today?”

• Results: Families were more educated about strategies to help their child with vaccinations. 88% of high risk patients who came to Cardiac Clinic received a flu vaccine.

• Conclusions: Incorporate staff earlier in the quality improvement process. Identify key stakeholders from each discipline to provide knowledge and functioning of their area.

Oct. 2013: Cardiac Clinic

PDSA #1 Reflection

• Adapt, Adopt, or Abandon?

• Adapt what we learned from #1

– Involve staff as early as possible in the QI process

– Identify and team with key stakeholders as early

as possible

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April 2014: PPC proposal

• Partnering with the staff in PPC to reduce pain

during injections.

• Held an open forum

• Presentation to “Research Group”

• Areas of focus

– Patient and Family Education

– Staff Education

– Pain Relief Methods

• Standard Order Set

• Sucrose Solution for Infants

Implementation: SMART Aim 1

SMART Aim 2

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Patient and Family Education

• Use previously created educational pamphlets

for families.

• Provide educational slides on TVs in waiting

area.

• Child Life Specialist will provide informal

education to families and role model

approaches.

Staff Education

• Cross train with MAs from DDBP clinic.

• Provide hands on education and modeling by CLS one nurse, medical assistant/ one pod at a time.

• Provide an on-line education session

– Education focused on developmental appropriate strategies to decrease distress associated with injections

– This will include videos with these techniques being used with patients.

– Interacting with patients who have anxiety, anger, or are in acute distress related to injections. This will emphasize “safety.”

Pain Relief Methods

• Educate staff on use of EMLA & Elamax

– Appropriate ages

– Ways to administer

– Guidelines regarding which procedures and situations it is appropriate for use in

• Standard Order Set

– Create a standard order set for pain medications to be available when injections, blood draws, or IV’s are ordered.

– Need the ability to un-select this option when not appropriate.

– Need a physician to help champion this.

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Sucrose Solution for Infants

• Evidence-based intervention

• Used before injections to

change the perception of

pain for the infant

• Age range: up to 4-6 months

• Concern voiced that

potentially using sucrose in

clinic is modeling

inappropriate behavior for

parents with dental

implications

Scale-Up Successful Interventions

• Start in one small area

• After first round was

successful, scale up in 2

areas

• Then 4 areas

• Continue to scale up until

you’ve reached all areas

Scale-up Successful Interventions

Evaluate EBP

• Obtain outcome measures and concurrent

feedback on implementation of EBP

• Continually re-evaluate



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Plan for Sustainability and Spread

• Sustain - Make improvements “stick”

• Spread - Improvements from one practice

team or site are adopted by another team

• Both endeavors require change processes

but strategies are fundamentally different

from QI rapid change process

Objective:

• To successfully spread the improvement

beyond the original target patient population

or department if appropriate.

Plan for Sustainability & Spread

QI Journey: Implementation Challenges

• Difficulty finding/ keeping stakeholders

• Resistance from staff to change one’s practice

• Absence of standard order sets in the electronic

medical record

• Impact on patient and clinic flow

• Lack of resources, time, and staffing to

implement practice change while maintaining

one’s patient-care load

• Scheduling conflicts with QI team

• Prioritizing commitments with QI team

Implementation Successes

• Potential to help children and families who

are vulnerable

• Potential to affect the practice of many

nurses, medical assistants, and physicians

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What Can You Do to Help?

• Follow the BESt guidelines when helping patients

receive injections

• Encourage/ refer others to the guidelines and

information too

• Pass out educational brochures to families and role

model appropriate interventions

• Promote the use of non-pharmacological

interventions proven through research

• Help us with creating standard order sets

• Can we show our educational slides in your area?

• Be a part of an EBP project!

EBP Modules: http://childlife.org/Resource%20Library/EBPModules.cfm


References • Cincinnati Children’s Hospital Medical Center (2014). BESt Template.

http://centerlink.cchmc.org/content2/67597/

• Cincinnati Children’s Hospital Medical Center (2014). Quality Improvement

Education. Retrieved from http://centerlink.cchmc.org/content1/11151/

• Cincinnati Children’s Hospital Medical Center (2014). Strength of Evidence

Pyramid. Retrieved from http://centerlink.cchmc.org/content2/67597/

• Higgins, J.P.T., & Green, S. (Eds). Cochrane Handbook for Systematic Reviews of

Interventions Version 5.0.2 [updated September 2009]. The Cochrane

Collaboration, 2009. Retrieved from www.cochrane‐handbook.org.

• Lohr, K.N., Eleazer, K., & Mauskopf, J. (1998). Health policy issues and

applications for evidence‐based medicine and clinical practice guidelines. Health

Policy, 461‐19.

• Melnyk, B. M. and E. Fineout-Overholt (2005). Evidence-based practice in nursing

& healthcare : a guide to best practice. Philadelphia, Lippincott Williams & Wilkins.

• Morris, J. (2012). Child Life Council Evidence-Based Practice Position Statement.

Retrieved from http://childlife.org/files/CLCPositionStatementEBP.pdf

• Shamszad, K. (2014). Introduction to Quality Improvement Lecture Series.

Personal collection of K. Shamszad, Cincinnati Children’s Hospital Medical Center,

Cincinnati, OH.


http://childlife.org/Resource Library/EBPModules.cfm

http://childlife.org/files/CLCPositionStatementEBP.pdf

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Questions?

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