Making Sense of Evidence-Based Practices

If ever there was a buzzword in healthcare currently, it might just be “evidence-based practices.” But does the average healthcare worker understand the term’s purpose and significance?

Ward (2000) notes, “Evidence-based practice is seen as a way of providing more effective healthcare and is considered to be vital in the current healthcare climate. However, in many areas of practice, and specifically in infection control, there is often little or no evidence to back or refute certain practices.”

Ward says that healthcare professionals daily are faced with ritualistic practices, interventions with indirect evidence to support them, and practices with overwhelming evidence in their favor that are not always followed. She adds that nurses need to integrate the best available evidence with clinical judgment and ensure that available evidence is disseminated appropriately. “Although the term ‘evidence-based practices’ is pretty intuitive and most healthcare practitioners have a good sense of what this means, it can, at times, be a bit confusing,” says Mark E. Rupp, MD, professor in the Department of Internal Medicine, Section of Infectious Diseases at the University of Nebraska Medical Center, and president of the Society for Healthcare Epidemiology of America (SHEA). “First of all, I think all of us in infection control are dedicated to the scientific theory and providing patients with the best care possible. We’ve accepted the premise that the scientific method is the best way to establish what is the truth and what is best practice. However, what is ‘best’ continues to evolve as additional data is accrued and sometimes folks have trouble changing their viewpoints when contrary evidence accumulates. Also, what is proven effective in a study setting may not be generalizable or applicable to other patient-care settings or other patient populations. Sometimes this is difficult for practitioners to understand.”

Rupp continues, “Clearly, this is a place where guidelines are helpful. Content experts with good common sense need to interpret the available data and craft guidelines that are helpful to practitioners. Guideline authors need to acknowledge where limitations exist but still offer helpful suggestions on how to deal with the here and now. Lastly, this is why it is so important that continued investigation and study proceeds — we won’t push back the barriers of our knowledge base without continued investigation. There are many very important questions in infection control that we need to address — the infection control field needs additional funding and resources to effectively answer the vital questions that remain. SHEA is working hard identify the vital questions of the day, to help set the research agenda, and advocate for adequate resources.”

Last October, SHEA, along with the Infectious Diseases Society of America (IDSA), the Association of Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and the Joint Commission, released the SHEA/IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute-Care Hospitals.

“As was noted this year in a report by the Government Accountability Office (GAO), the numerous recommendations in infection prevention and control present real challenges to those seeking concise advice on how to best combat healthcare-associated infections (HAIs),” Rupp says. “This document, supported by 29 organizations in the field, synthesizes the many existing guidelines to provide a practical tool for hospitals to use to prevent six common HAIs.”

The six HAIs covered in the Compendium are surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA). The Compendium outlines minimum basic practices that should be adopted by all acute-care hospitals, and special approaches for use in locations or populations within hospitals when infections are not controlled using these basic practices.

“The joint SHEA/IDSA Compendium is a helpful resource in converting evidence into practice,” Rupp says. “Really, this is a whole separate issue — how to change healthcare workers’ thinking and behavior in order to improve patient care. The Compendium does a great job in distilling a huge body of evidence into key recommendations.”

Rupp says that while given the need for behavioral changes among healthcare workers, a paradigm shift approach to care is not required.

“Oftentimes, relatively small and fairly simple changes can make a big impact; however, we do need to do a better job in telling folks how to make the changes, how to make them stick, and what they should measure in order to know if the changes are making a difference,” Rupp adds. “Again, the SHEA/IDSA Compendium is a great place to start when trying to make these changes happen in an institutional setting. In addition, SHEA recently published metrics that can be used to measure progress.”

Bundling evidence-based practice theory with products and implementation guidance has become an increasingly popular and effective way to ensure interventions are implemented in a comprehensive way. The concept of care bundles was created during the VHA-sponsored Idealized Design at Intensive Care Unit (IDICU) innovation project, which identified the need to improve care for ventilated patients as a priority in the ICU. (Joint Commission, 2006)

Fulbrook and Mooney (2003) note that the theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcomes. They add that care bundles are relatively easy to develop, implement and audit, and provide practitioners with a practical method for implementing evidence-based practices.

“I think bundles are a terrific means to take the most important recommendations, put them together, and combine them with practical and effective means to ensure compliance and sustainability — like the checklist,” says Rupp.

Carol Haraden, PhD, vice president and patient safety expert at the Institute for Healthcare Improvement (IHI), a strong proponent of bundling, notes, “IHI developed the concept of ‘bundles’ to help healthcare providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks. A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.”

Haraden adds, “The power of a bundle comes from the body of science behind it and the method of execution: with complete consistency. It’s not that the changes in a bundle are new; they’re well established best practices, but they’re often not performed uniformly, making treatment unreliable, at times idiosyncratic. A bundle ties the changes together into a package of interventions that people know must be followed for every patient, every single time.”

Robyn Whalen, marketing director for North America Medical Devices at Kimberly-Clark Health Care, confirms that there are clinical advantages to bundling evidence-based practice theory with products and implementation guidance. “Over the years, we’ve seen facilities lower infection rates by combining their use of product bundles with other best practices outlined by professional organizations such as the Centers for Disease Control and Prevention (CDC), the American Association of Critical Care Nurses (AACN), SHEA and others,” she says. “For example, the ICU facility at Memorial Hermann Texas Medical Center modified its VAP bundle program to be more proactive by treating all patients as if they were going to develop VAP. The respiratory team started treating all vented patients with increased sigh breathing and vibratory therapy. They also incorporated products from Kimberly-Clark’s VAP portfolio, which complemented their efforts and in the end helped reduce their VAP rates by 48 percent.”

Whalen says that based on best practices, the company has organized its products and services by platform to complement the efforts of its customers. “For example, our VAP portfolio includes diagnostics solutions that help the healthcare worker collect samples from the patient’s lung,” Whalen says. “The CDC’s guidelines for VAP prevention encourage this practice to help prevent microaspiration of secretions into the lungs. The portfolio also includes endotracheal tubes, closed suctioning systems and oral care solutions that are designed to help healthcare workers meet their facility’s best guidelines more easily and with consistency. Kimberly-Clark products, sales process and educational programs are designed to support the implementation of clinical best practices, whether they are dealing with surgical site infection or VAP.”

Whalen continues, “Product selection is not only important for positive patient outcomes but also critical to a facility’s bottom line. However, it’s important for healthcare workers to think beyond the cost of the product(s) and understand its role within the various patient care practice bundles. Certainly there is concern about the additional cost some tools and devices may add to the facility’s bottom line, but when compared to the cost of VAP, for example, the difference in both dollars and lives puts prevention costs in perspective.

References:

Ward D. Implementing evidence-based practice in infection control. British J Nurs. Vol. 9, No. 5. Pages 267-271. March 9, 2000.

Fulbrook P and Mooney S. Care bundles in critical care: a practical approach to evidence-based practice. Nursing in Critical Care. Vol. 8, No. 6. Pages 249-255. December 2003.

Raising the Bar with Bundles. Joint Commission Perspectives on Patient Safety. Vol. 6, No. 4. April 2006. Accessed at: http://www.ihi.org/NR/rdonlyres/B1B01671-B6EE-4C14-B0C93047D450FCFB/0/RaisingtheBarwithBundlesJtCommPerspectivesApr06.pdf

Institute for Healthcare Improvement (IHI). What is a Bundle? Accessed at: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/WhatIsaBundle.htm

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