Evidence-Based Practice: From Concept to Implementation through Team Engagement

Linda Miller, BSN, RN Rachel Smigelski-Theiss, MSN, RN, ACCNS-AG

Background

Unit 28 Twig, Inova Alexandria Hospital • 20 Bed Telemetry Unit • 25 RNs • 7 Clinical Technicians • Nurse Manager • CNS

Patient Profile • Congestive Heart Failure • Cardiac History/Diagnosis • Respiratory Failure, Pneumonia • Acute Kidney Injury

HCAHP Scores Prior to EBP Implementation

• Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?

• Top Box Score 50.0 • Rank 1

• Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?

• Top Box Score 28.6 • Rank 1

• Composite Score: Medication Communication • Top Box Score 39.3 • Rank 1

Problem

• Needed to improve patient engagement and knowledge regarding medication side effects

• Action: • Collaborated with Nursing Research & Evidence Based

Practice Council

• EBP team developed • Nurse Manager • Clinical Nurse Specialist • Clinical Practice Council representative

Mentorship

• “Application of the Johns Hopkins Nursing Evidence-Based Practice Model”

• PET Model

Practice Question

Evidence Translation

Development of PICO Question

• Population/Problem-Intervention-Comparison-Outcome Question

• P: In adult medical/surgical patients in a hospital care setting

• I: will an interactive patient education strategy related to medications

• C: (no comparison)

• O: result in improved patient perceptions/outcomes as measured by HCAHPS medications questions?

Review of Evidence

• Literature obtained by librarian and EBP mentors

• Subjects: patient education, teaching, medication adherence, implementation

• Keywords: teach-back, show me, return demonstration, repeat back, tell back, care transitions, treatment adherence, evidence-based practice

• 8 articles selected for review

• Reviewed articles discussed in daily huddles and monthly CPC meetings

The Literature Ranked

• Evidence Type: • Case Studies • Quality Improvement • Non Experimental • Literature Summary • Randomized Control Trial • Systematic Review

• Evidence Level & Quality: • One Level I Article (strongest) • One IIA Articles • Two II B Articles • One III A Articles • Three VB Articles (weakest)

Literature Findings

• “Teach-Back” was associated with increased knowledge retention

• Use of Ask 3/Teach 3 increased HCAHPS

• Teach-Back helped establish patient understanding

• Patients with low health literacy are more likely to report poor communication

• Teach-Back confirms comprehension & reveals misunderstanding

• Documentation of understanding was correlated with a 30% lower readmission rate

Project Implementation

• Kickoff

• Standard Workflow

• Formal Education on Ask 3/Teach 3

Project Implementation

• Focus on the congestive heart failure (CHF) patient population • Improve awareness of CHF patients • Focus on cardiac medications

• Ace Inhibitors/ Angiotensin Receptor Antagonists • Alpha Adrenergic Agonist • Anti-arrhythmic • Anti-coagulant • Anti-platelets • Beta Blockers • Calcium Channel Blockers • Diuretics • Lipid-Lowering Agents • Potassium

Standard Workflow Operating Unit Process Name Process

Location Target Time Created Reviewed/ Revised Author

IAH Ask 3 Teach 3 U28 12 minutes 5/22/2014 5/22/2014 U28 EBP Team

Step Process Step Responsible Time Goal Critical Notes on Step

1 RN receives order for CHF patient to receive cardiac medication. RN

2 When nurse pulls medication from med room, RN also pulls appropriate Ask 3 Medication card and takes to patient's room. RN <1 minute

3 In patient's room, prior to medication administration, RN completes Ask 3 Card (fills in name of medication). RN <1 minute

4 RN shows patient Ask 3 card and educates patient on medication name, purpose, and side effects. RN 5 minutes Use key words, such as "side effects"

5 Patient teaches back to the nurse the medication name, purpose, and side effects. RN 5 minutes

Ask the patient, "What is the name of your medication? Why do you need to take it? What are common side effects?"

6 If information is not clearly understand, RN should retry education. RN 5 minutes

7 The RN clips the medication card to the white board. RN <1 minute

8 Medication name, purpose, and side effects reviewed with each medication administration. RN 2 minutes

9 Education of medication is included in iShaped reporting RN <1 minute

10 Following shift, RN verifies patient can teach back information on medication card. RN <2 minutes

Standard Workflow

Building Team Engagement

Anticipation

Selection Excitement

Motivation

Follow-Through

• True North Wall

• Identification of CHF patients

• Data Collection

• Coaching

HCAHPS Scores Post EBP Implementation: What the medication was used for

HCAHPS Scores Post EBP Implementation: Side Effects

HCAHPS Scores Post EBP Implementation: Composite Score Medication Communication

Barriers to Implementation & Sustainability

• Language Barriers

• Cognitive Function

• Accurate Identification of CHF Patients

• Relocation

Conclusion

• Formal EBP Education

• Real Time Implementation

• Mentorship • Staff involvement

was instrumental in the successful implementation of an EBP project.

Acknowledgements

• Joni Brady, MSN, RN, CAPA • Suzy Fehr, PhD, RN-BC, NE-BC • Mary Ann Friesen, PhD, RN, CPHQ • Larisa Golding, MSN, RN-BC • Inova Alexandria Leadership Team • Nursing Research & Evidence-Based

Practice Council • Unit 28 Twig Staff Members

References

1. Ahrens, S. L., & Wirges, A. M. (2013). Using evidence to improve satisfaction with medication side-effects education on a neuro-medical surgical unit. American Association of Neuroscience Nurses, 45(5), 281-287.

2. Bowskil, D., & Garner, L. (2012). Medicines non-adherence: adult literacy and implications for practice. British Journal of Nursing, 21(19), 1156-1159.

3. Cloon, P., Wood, J., & Riley, J.B. (2013). Reducing 30-day readmission. The Journal of Nursing Administration, 43(7/8), 382-387.

References

4. Jager, A. J., & Wynia, M.K. (2012). Who gets a teach-back? Patient reported incidence of experiencing a teach-back. Journal of Health Communication: International Perspectives, 17, 294-302.

5. Kandula, N.R., Malli, T., Zei, C.P., Larsen, E., & Baker, D.W. (2011). Literacy and retention of information after a multimedia diabetes education program and teach-back. Journal of Health Communication: International Perspectives, 16, 89-102.

6. Kimbal, S., Buck, G., Goldstein, D., Largaespada, E., Logan, L., Stebbins, D.,…Kalman-Yearout, K. (2010). Testing a teaching appointment and geragogy-based approach to medication knowledge at discharge. Rehabilitation Nursing, 35(1), 31-40.

References

7. Poe, S. S. & White, K. M. (2010). Johns hopkins nursing evidence-based practice: Implementation and translation. Indianapolis, IN: Sigma Theta Tau International.

8. Van Scoyoc, E.E., & DeWalt, D.A. (2010). Interventions to improve diabetes outcomes for people with low literacy and numeracy: A systematic literature review. Diabetes Sepectrum 23(4), 228-237.

9. White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel J. (2013). Is “teach back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? Journal of Cardiovascular Nursing 28(2), 137-146.