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Without current best evidence, practice risks becoming rapidly out of date…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