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Making Changes To Practice
Principal investigator: Dr Malcolm Daniel Investigating the process of integrating new evidence into our practice - i.e. making changes to clinical practice Current State: Complete. Published December 2004.
Making Changes To Practice
Dr Malcolm Daniel on behalf of the SICS EBM Group.
Consultant in Anaesthesia and Intensive Care, Department of Anaesthesia, Walton Building, Glasgow Royal Infirmary, 84 Castle Street, G4 0SF Correspondence to: md23s@udcf.gla.ac.uk
SICS EBM web site December 2004
Citation: EBM Reviews. Scottish Intensive Care Society EBM Group. Daniel M. Making Changes To Practice. 2004.Background: The gap between what we know and what we do is considerable. One of the biggest challenges we face is integrating new evidence into our practice - i.e. making changes to clinical practice. Although we are just recognising this issue now, as the knowledge base expands this problem will continue. Critical care areas are complex - multiple staff members from a variety of backgrounds. We make multiple diagnostic, therapeutic and prognostic decisions every day, but making changes and sustaining changes in our practice is difficult. Other sections of this website show evidence of interventions that make a difference. But how are you going to make those changes to integrate the evidence into the practice of the area you work in? This section gives you some suggestions to think about. It relies predominantly on some systematic reviews carried out by the Cochrane Effective Practice and Organisation of Care group (EPOC); there are also some individual examples from critical care practice. Note that although many of the articles in the systematic reviews are based outwith the critical care setting, the end point that they focus on - changing practice - is what we are interested in here. It does introduce us to a whole new lexicon of terms to describe the techniques required to translate knowledge into practice. We recognise the quality of the evidence does not tell us how effective an intervention is likely to be in our own practice (there are no NNTs here). This section does give you strategies and techniques to think about. We hope this helps make the changes you plan more likely to succeed. Each critically appraised topic (CAT) contains a brief (1 page) summary of the article reviewed. This includes 3 useful features: • The level of evidence using the current Scottish Intercollegiate Guidelines Network (SIGN) method of grading healthcare recommendations. This grading reflects only the weight of the evidence, not the clinical importance of the recommendation. • A web link to the full-text article or abstract is provided, depending on the journal the article was published in. This allows you to check the article too! • The search strategy used to find the article reviewed. This will allow repetition of the same search in the future to check if new evidence has accumulated. A combination of “explode” commands (exp), standard medical subject headings (MeSH), and textword (tw) terms were used to make the searches broad, in the hope of avoiding failing to find any articles. The truncation symbol $ finds all the words from a single stem. Evidence based quality filters were also used. Evidence based quality filters select out articles of a certain publication type such as randomised controlled trials or systematic reviews or cohort studies. This helps set your search towards therapeutic interventions, diagnostic procedures or prognostic factors depending on the quality filter used. Trish Greenhalgh’s BMJ article “How to read a paper: The Medline database” gives further useful details on how do this, together with details of search strategies that can be used. This collection does not tell you how to change practice: you can draw some conclusions about what strategies are more likely to be effective in promoting change. We hope this gives you some thoughts as how to deal with the change in your own practice environment. But gentle reader I know you are thinking about all those studies that you seem to remember reading about making changes to critical care practice. Why have they not been included? The reason is simple: these are usually before and after studies looking at practice in the same group of individuals. Attribution of causation of the change in practice is not possible in these before and after studies. This is why we require further high quality RCTs of each of the intervention listed below to clearly define the benefits associated with each intervention and the cost-effectiveness of each approach. Main Results: 1. Audit and feedback: (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Audit and feedback can lead to changes in practice but the effects vary. When it is effective the effects are small to moderate. The effects are more likely to be larger when baseline compliance is low. Grade B recommendation 2. Lectures: either Didactic: lectures or presentations that may or may not have question and answer session; or Interactive: some type of interaction in small (<20 participant) groups. Didactic teaching sessions did not lead to changes in practice, in contrast interactive teaching sessions, in small groups, more likely to change practice but the magnitude of the effect varies. Grade B recommendation 3. Printed education materials: produce small effects of uncertain clinical importance. Limited conclusions given small volume of available evidence. Grade B recommendation 4. Local opinion leaders: defined as "healthcare providers nominated by their colleagues as being educationally influential" In each study reviewed the investigators must have explicitly stated the opinion leaders were identified by their colleagues. Local opinion leaders in comparison to no intervention: consistently had an effect, but the magnitude varies. Local opinion leaders in comparison to no audit and feedback: local opinion leaders were more effective of the 2 primary studies reviewed. Grade B recommendation Think about the definition. Opinion leaders in one practice environment may not necessarily be leaders in another. For example a clinical director may be an "administrative leader" but may not necessarily also be an "opinion leader". 5. Educational outreach: defined as use of a trained person who meets with providers in their practice settings to provide information with the intention of changing practice. Educational outreach visits, especially when combined with another intervention, appear to be a promising approach to modifying health professional behaviour, there is good evidence for this in the field of prescribing. The effects were consistent, although small to moderate in size, but are likely to be clinically important. We don’t know the duration of effect (weeks, months, years) of such an intervention. Grade A recommendation References (with links to each CAT):
Reviewed for the SICS EBMG by BC & GRN © SICS EGMG, 2004
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