How to Translate Science into Better Patient Care

Canadian Critical Care Forum – November 9, 2018

No Disclosures Many Acknowledgements

Objective – Tell You an Implementation

Science Story

Illustrate the limitations of passive diffusion

Brief introduction to implementation science

Highlight some considerations for practice

Research Should Inform Clinical

Practice

Clinical

Practice

New Practicee.g., Lytics for STEMI

Practice Updatee.g., new lytics

De-adopt

Existing Practice

e.g., Flecainide MI

Discover

Replace

Reverse

Research

Evidence-Based Medicine

Conscientious, explicit, and

judicious use of current best evidence in

making decisions

David Sackett 1934-2015

Evidence-Based Medicine

Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough...

Without clinical expertise, practice risks becoming tyrannised by evidence…

Without current best evidence, practice risks becoming rapidly out of date…

Translating Science into Better Care

Patient Care

Discovery

Clinical

Implementation

Sustainability

Potential

JAMA Intern Med 2015; 175: 801-09

The Tale of Tight Glycemic Control

Leuven I (2001)

NICE-SUGAR (2009)

Single center RCT

N = 1,548

NNT = 29 (survival)

Multi-center RCT

N = 6,104

NNH = 38 (death)

Tight Glycemic Control

Predictors of Adoption

Predictors of De-Adoption

Implementation Science Facilitates Research Use

Graham J Con Ed Health Prof 2006

Most Common Interventions

0

10

20

30

40

50

60

70

80

90

No

. S

tud

ies

Sinuff Crit Care Med 2013

Most Effective Interventions

0

10

20

30

40

50

60

70

80

90

No

. S

tud

ies

Sinuff Crit Care Med 2013

Observations of Interventions from Other Areas

Passive education – limited impact

Professional interventions (e.g., reminders) ~10% ∆ Closer to point of care larger impact

Financial interventions - volume of care

Patient or family directed – ?quality of care?

Multifaceted not better than single component

Tailored not better than non-tailored

Impact modest & variable

Which Practices to Focus on?

Inconsistent Scientific Findings

Ioannidis JAMA 2005, Prasad et al. Arch Int Med 2011, Prasad et al. Mayo Clinic Proc. 2013

44%

46%

38%

Time to Reproduction of Research

Niven et al. BMC Med 2018

0 1 2 3 4 5 6 7 8 9 10

Tight glycemic control in sepsis

Hydroxyethyl starch in sepsis

Erythropoeitin in traumatic brain injury

Trophic enteral nutrition

Anti-TNF-alpha antibodies in sepsis

N-acetylcysteine to prevent AKI

rhIL1-RA in sepsis

Pulmonary artery catheter

Statins in ARDS

H2-receptor antagonists to prevent pneumonia

CRRT compared to IRRT

Chlorhexidine skin preparation for CVC insertion

NIV for hypoxemia after major abdominal surgery

Daily interruption of sedation

NIV for acute hypoxemic respiratory failure

Mechanical ventilation weaning protocol

Lung protective ventilation in ARDS

Selective decontamination digestive tract

Number of consistent studies

Lack of Efficacy

RCTs SR/SR-MAs

Efficacy

Harm

Optimizing VTE Prophylaxis

Calgary

Edmonton

• Controlled before-after

• 1 year & 1 year

• All patients admitted to

ICUs in 2 cities

• Calgary – intervention

• Edmonton – control

Intervention

Clinical decision support Guideline

Computerized order set

Education

Point-of-care reminders

Audit & feedback

Primary Outcome - Prophylaxis

Manuscript under peer review

Secondary Outcomes

Hospital

Measures

Ratio of Odds/Mean Ratios (95%

CI)

DVT or PE 1.13 (0.51-2.46)

Bleeding 1.22 (0.97-1.54)

HIT ***

Death 1.02 (0.77-1.34)

Costs 1.09 (1.00-1.20)

Lessons Learned

Research impacts practice through discovery, replacement and reversal

Passive diffusion of research is slow & ineffective

Active implementation & evaluation of research findings is essential to see how they function in real world conditions

Persistent Questions

When should we adopt or de-adopt a

patient care practice?

Magnitude of benefit/harm?

Nature of the science?

Cost?

Acknowledgements

Mentors

Sharon Straus

Collaborators

Sean Bagshaw

Deborah Cook

Chip Doig

Kirsten Fiest

Barry Kushner

Dan Niven

Jeanna Parsons Leigh Dan Zuege

Dave Zygun

Trainees

Kea Archibold

Kyla Brown

Chloe de Grood

Hasham Kamran

Research Team

Jamie Boyd

Rebecca Brundin-Mather

Andrea Soo

Funding Agencies

Alberta Innovates

CIHR

NCE

Thank You