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Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
1
Evidence-Based PainManagement in the Ambulatory Setting
ASPMN® 25th National Conference
Michele Farrington, BSN, RN, CPHON
Trudy Laffoon, MA, RN-BC
Carmen Kealey, MA, RN
Cindy Dawson, MSN, RN, CORLN
Conflict of Interest Disclosure
The speakers do not have any conflicts of interestor disclosures to report.
Objectives
Outline steps in the evidence-based practiceprocess using the Iowa Model of Evidence-BasedPractice to Promote Quality Care andImplementation Guide.
Describe an EBP project regarding translation ofevidence-based interventions related toneedlestick pain into practice in ambulatorysettings.
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
2
Iowa Model of Evidence-Based Practice to Promote Quality Care
Iowa Model of
Evidence-Based
Practice to Promote
Quality CareTitler et al., 2001
Problem Focused Triggers1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking
Data4. Financial Data5. Identification of Clinical
Problem
Knowledge Focused Triggers1. New Research or Other
Literature2. National Agencies or
Organizational Standards & Guidelines
3. Philosophies of Care4. Questions from Institutional
Standards Committee
Triggers
Titler et al., 2001
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
3
Organizational Priority
Titler et al., 2001
Is this Topica PriorityFor the
Organization?
Team
Titler et al., 2001
Evidence
Titler et al., 2001
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
4
Sufficient Research Base
Is Therea SufficientResearch
Base?
Base Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory
No
Titler et al., 2001
Piloting
Is Therea SufficientResearch
Base?
Titler et al., 2001
Yes
Adopt Practice Change?
Is Change Appropriate for
Adoption in Practice?
No YesContinue to Evaluate Quality of Care and New Knowledge
Institute the Change in Practice
Monitor and Analyze Structure, Process, and Outcome Data Environment Staff Cost Patient and Family
Disseminate Results
Titler et al., 2001
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
5
Diffusion of Innovations
Illusions about Implementation
Implementation isn’t that difficult
They know what to do
We already provide the best care
They just need to know the evidence
If it works for them, it should work for us
We just need to tell them what to do
We just need to find the one right way toimplement a practice change
Nature of the Innovation –Resistance to Change
Nursing traditions – sacred cows
Lack of authority and support
Landmines
It takes time
Evidence can be overwhelming – access,amount, quality, ability (critique, synthesis,statistics, etc.)
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
6
Diffusion is theprocess by which aninnovation iscommunicatedthrough certainchannels over timeamong the membersof a social system
Diffusion Theory – Rogers
Rogers, 2003
Diffusion Rate100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Pe
rcen
t o
f A
do
pti
on
Innovation I
Later Adopters
Innovation II
Time
Adopters
Innovation III
Adopters
Earlier
Rogers, 2003
Diffusion Model –Innovation-Decision Process
I.Knowledge
II.Persuasion
III.Decision
IV.Implementation
V.Confirmation
AwarenessAwareness
& Attitude Change
Awareness, Attitude &
Behavior Change
Passive Active Interactive
Logan & Graham, 1998; Rogers, 2003; Veniegas et al., 2009
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
7
Implementation Strategies
EBP Implementation Model
Laura Cullen, DNP, RN, FAANSusan Adams, PhD, RN
Cullen, L., & Adams, S. (2012). Planning for implementation of evidence-based practice. Journal of Nursing Administration, 42(4), 222-230.
I.Create
Awareness & Interest
II.Build
Knowledge & Commitment
III.PromoteAction & Adoption
IV.Pursue
Integration & Sustained Use
Implementation Phases
Cullen & Adams, 2012
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
8
Clinicians
Organizational Leaders
Key Stakeholders
Social System
Organizational Context
Implementation Target Groups
Cullen & Adams, 2012
ImplementationStrategies for
Evidence-Based Practice
Cullen & Adams, 2012
Evidence-Based Strategies
Empirical Evidence in Healthcare* Audit and feedback
Little Evidence in Healthcare Unit posters E-mail broadcasts
Cullen & Adams, 2012
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
9
Phase I:
Goals What are the positives
about the EBP? Think of this as
marketing the EBP. Should be fun and eye
catching.
Strategies Highlight advantage
Highlight compatibility
Sound bites
Create Awareness & Interest
Cullen & Adams, 2012
Phase II:Build Knowledge &Commitment
Goals How do clinicians within
a discipline like tolearn?
Build upon the naturaltendency for cliniciansto learn from eachother.
Keep an eye towardbuilding the EBP intothe system to make iteasy to do it right.
Strategies Education Change agents Educational outreach or
academic detailing Gap assessment/gap
analysis Local adaptation and
simplify Action plan
Cullen & Adams, 2012
Phase III:Promote Action andAdoption
Goals Use highly interactive
and personalapproaches.
Demonstrate with returndemonstration andreinforcement.
Expand upon contextfocused strategies.
Strategies Educational
outreach/academicdetailing
Try the practice change Change agents Audit key indicators Actionable and timely
data feedback Report into quality
improvement program
Cullen & Adams, 2012
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
10
Phase IV:Pursue Integrationand Sustained Use
Goals Think about booster
shots or periodic reinforcement.
Build toward EBPbecoming the norm or standard way to practice.
Building EBP into thesystem is critical to help clinicians.
Strategies Peer influence Audit and feedback Report into quality
improvement program
Cullen & Adams, 2012
Implementation in Action…
http://www.crucialskills.com/2009/09/all-washed-up/
Ambulatory Evidence-Based
Pain Management
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
11
Problem Focused Triggers1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data5. Identification of Clinical Problem
Knowledge Focused Triggers1. New Research or Other Literature2. National Agencies or Organizational
Standards & Guidelines3. Philosophies of Care4. Questions from Institutional
Standards Committee
Is this Topica PriorityFor the
Organization?
Form a Team
Yes
= a decision point
Titler et al., 2001
Iowa Model
Purpose
■ The purpose of this evidence-based practiceproject was to ensure a consistent, standardizedapproach when offering interventions formanagement of needlestick pain across adult andpediatric ambulatory clinics at a large academicmedical center.
Critique & Synthesize Research for Use in Practice
Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based
Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline
Base Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory
Conduct Research
Titler et al., 2001
Iowa Model (cont.)
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
12
Synthesis of Evidence
■ Pain management recognized as right of allpatients since 2001 by The Joint Commission
■ Pain – prevalent global health concern; one ofmost common reasons people seek health care
■ Pain assessment and treatment – complex■ Multifactorial influences to assessment and
treatment provided by health care team■ Ineffectively treated pain negatively impacts
overall healthcare costs
Bernhofer, 2011; De Ruddere et al., 2011; Fishman et al., 2013; Gaskin & Richard, 2011; Hirsh et al., 2010; Layman Young et al., 2006; Schreiber et al., 2014; The Joint Commission, 2014
Immunization Experience…
http://tedmed.com/talks/show?id=299421
Synthesis of Evidence (cont.)
Evidence-based interventions available: Topical anesthetic creams Breastfeeding Distraction (child-, clinician-, or parent-led) Sucrose solution Patient positioning Tactile stimulation Breathing exercises Buzzy® device Bacteriostatic normal saline Vapocoolant spray
Abuelkheir et al., 2014; Baxter et al., 2009; Canbulat et al., 2015; Chambers et al., 2009; Hogan et al., 2014; Inal & Kelleci, 2012; Whelan et al., 2014; Windle et al., 2006
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
13
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based
Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline
Base Practice on OtherTypes of Evidence1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory
Conduct Research
Iowa Model (cont.)
Titler et al., 2001
Practice Change
Adult and pediatric patients in ambulatory clinics Injections/immunizations, blood draws, or IV starts
Evidence-based pharmacologic, physical, andpsychological interventions must be routinelyoffered to patients/caregivers
Focus: Topical anesthetic creams Buzzy® device Bacteriostatic normal saline Vapocoolant spray
Cullen & Adams, 2012
I.Create
Awareness & Interest
II.Build
Knowledge & Commitment
III.Promote Action & Adoption
IV.Pursue
Integration & Sustained Use
• Highlight advantages oranticipated impact
• Highlight compatibility• Slogans & logos• Divisional newsletter• Unit inservices• Distribute key evidence• Posters and postings/fliers• Publicize new equipment
• Ambulatory nursing pain committee formed
• Education• Pocket guides• Change agents• Clinician input• Local adaptation & simplify• Match practice change with
resources & equipment• Troubleshoot use/application• Inform organizational leaders• Action plan
• Reminders or practice prompts
• Skill competence• Give evaluation results to
colleagues• Try the practice change• Role model• Documentation• Patient decision aides• Report at shared governance
committees• Link to patient/family needs
& organizational priorities• Divisional orientation
• Peer influence• Revise policy, procedure or
protocol• Project responsibility in unit
or organizational committee• Present in educational
programs
Implementation Strategies
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
14
Specific Strategies
Web-based training (PPT) Staff Education Committee approval
Total # completed (n=1124)
Hands-on pain competency station Super-Users (n=22)
Regular attendees (n=502)
Pocket Card – Adults
Pocket Card – Pediatrics
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
15
Patient Education
Interventions Poster
Interventions TableInterventions for Needlestick Pain
Choose option/combination of options best meets patient need considering: Time, Age, Allergies, Contraindications, & Patient/Family Preference
Use if:
<30 minutes prior to
needlestick
Use if:
30-60 minutes prior to
needlestick
Use if:
>60 minutes prior to
needlestick
Order Per Protocol
(Yes/No/Not Applicable)
Policy Number/Title Additional Information
Sucrose > 32 weeks gestation (effectiveness 3 months – 1 year of age)
Not Applicable – Order Not Needed
N-CWS-PEDS-02.175 “24% Sucrose Solution, Use of”
Obtained from Stores(PS# 992213)
Breastfeeding Dependent on age/NPO status; ability of infant to coordinate suck/swallow
2-3 minutes prior toprocedure, during
procedure, and after procedure
Comfort Positioning, Distraction, or Mindfulness-Based Stress Reduction
Developmentally appropriate interventions Buzzy
Without cold wings: >46 weeks gestational age – 2 years of age and sickle cell disease With cold wings: >2 years of age and desired
Not Applicable –Order Not Needed
N-CWS-PEDS-02.013 “Buzzy® Usage”
Obtained from Stores (PS# 59950 – Buzzy;
PS# 59951 – Ice Pack Wings)
Bacteriostatic Normal Saline >30 days of age; able to tolerate 30 gauge needle; no allergy to benzyl alcohol
No No Yes N-08.092 “Protocol for the Use of Bacteriostatic 0.9% Sodium Chloride with
Benzyl Alcohol Prior to Venipuncture for IV Cannulation or Lab Draw”
RN OnlyObtained from Stores
(PS# 992171 – Bacteriostatic Normal Saline; PS# 038531 –
30 gauge needle)
Pain Ease >3 years of age; able to understand cold spray is used to help with pain versus induce pain; not for use with blood cultures
No No Yes N-08.094 “Protocol for the Use of a Topical Anesthetic Skin Refrigerant/Vapocoolant for
Needle Procedures”
Obtained from Stores (PS# 992130)
LMX4 >37 weeks gestational age; no allergy to lidocaine/amides; caution in liver failure
No Yes N-08.090 “Protocol for Topical Numbing Agents: EMLA, L.M.X.4™ Cream”
MA Competency Checklist before able
to administer; Obtained from
Pharmacy EMLA
>37 weeks gestational age; no allergy to lidocaine/prilocaine/ amides; methemoglobinemia concern for infants <12 months of age; some blanching/ vasoconstriction; caution in liver failure
No No Yes N-08.090 “Protocol for Topical Numbing Agents: EMLA, L.M.X.4™ Cream”
MA Competency Checklist before able
to administer; Obtained from
Pharmacy
Additional resources: Aircare – Adult Aircare – Pediatric & Neonatal Emergency Department Charge Nurse Pediatric Vascular Access Nurse Pagers 1131/1136 Pager 3210 Phone 3-6261 Pager 4213
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
16
Evaluation – Staff Questionnaire
Response Rate Pre-Implementation – 26.5% (n=195/735)
Post-Implementation – 29.2% (n=203/696)
Staff Knowledge 57.5% correct (pre) improved to 69.1% correct
(post)
Evaluation – Staff Questionnaire (cont.)
StronglyDisagree
StronglyAgree
Evaluation – Process
Customized question added to Ambulatory PressGaney® survey, starting March 2015
Patient feedback received from a staff member... “I used the Buzzy yesterday on a women in her late 60s … had
been stuck several times a couple of weeks ago, but was still a little bruised and tender … used continuous mode while drawing … blood and she loved it! She reported she did not feel a thingand thought it was the neatest thing ever!”
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
17
Conclusions
Staff knowledge improved & perceptions changed
Ongoing re-infusion will be needed forsustainability and integration
Positive outcome – materials revised ordeveloped being used by other areas within thehospital
Continue to EvaluateQuality of Care andNew Knowledge
Institute the Change in Practice
Monitor and Analyze Structure,Process, and Outcome Data
- Environment- Staff- Cost- Patient and Family
Disseminate Results
Iowa Model (cont.)
Titler et al., 2001
Next Steps
Incorporated content: Divisional orientation
Annual competencies
Purchased items and developed pain toolkits foreach clinic
Obtained funding for small freezers – Buzzy® gelwings
CE program and Grand Rounds – October 2015
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
18
A special thanks to the Super-Users who helped with the hands-on pain competency training: Sharon Baumler, Tracy Bloebaum,Carol Callaghan, Lieshia Davis, Marybeth Doerrfeld, Amy Ellsworth, Glenda Eubanks, Karlene Fuller, Marla Grosvenor, Jennifer Johnson, Nancy Mata, Sarah Smith, Deborah Steinbaker, Maggie Stoner, Jane Utech, Marie Voegele, and Marilyn Wurth!
Thank you to Kristin Eveland and Terri Werling for all of their assistance!
Acknowledgement
Questions/Comments
[email protected]@uiowa.edu
[email protected]@uiowa.edu
References
Abuelkheir, M., Alsourani, D., Al-Eyadhy, A., Temsah, M-H., Meo, S.A., & Alzamil, F. (2014). EMLA® cream: A pain-relieving strategy for childhood vaccination. Journal of International Medical Research, 42(2), 329-336.
Baxter, A.L., Leong, T., & Mathew, B. (2009). External thermomechanical stimulation versus vapocoolant for adult venipuncture pain: Pilot data on a novel device. Clinical Journal of Pain, 25(8), 705-710.
Bernhofer, E. (2011). Ethics and pain management in hospitalized patients. OJIN: The Online Journal of Issues in Nursing, 17(1),http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/ OJIN/Columns/Ethics/Ethics-and-Pain-Management-.html.
Bick, D., & Graham, I. (2010). Evaluating the impact of implementing evidence-based practice. United Kingdom: Wiley Blackwell Publishing and Sigma Theta Tau International.
Canbulat, N., Ayhan, F., & Inal, S. (2015). Effectiveness of external cold and vibration for procedural pain relief during peripheral intravenous cannulation in pediatric patients. PainManagement Nursing, 16(1), 33-39.
Chambers, C.T., Taddio, A., Uman, L.S., McMurtry, C.M., & HELPinKIDS Team. (2009). Psychological interventions for reducing pain and distress during routine childhood immunizations: A systematic review. Clinical Therapeutics, 31(Suppl 2), S77-S103.
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
19
References (cont.)
Crucial Skills. (2014). All washed up with Hyrum Grenny. Available at: http://www.crucialskills.com/2009/09/all-washed-up/.
Cullen, L., & Adams, S. (2012). Planning for implementation of evidence-based practice. Journal of Nursing Administration, 42(4), 222-230.
Cullen, L., Hanrahan, K., Tucker, S., Rempel, G., & Jordan, K. (2012). Evidence-based practice building blocks: Comprehensive strategies, tools and tips. Iowa City, IA: Nursing Research and Evidence-Based Practice, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics.
Czarnecki, M.L., Turner, H.N., Collins, P.M., Doellman, D., Wrona, S., & Reynolds, J. (2011). Procedural pain management: A position statement with clinical practice recommendations. Pain Management Nursing, 12(2), 95-111.
De Ruddere, L., Goubert, L., Prkachin, K.M., Louis Stevens, M.A., Van Ryckeghem, D.M.L., & Crombez, G. (2011). When you dislike patients, pain is taken less seriously. Pain, 152, 2342-2347.
Fishman, S.M., Young, H.M., Arwood, E.L., Chou, R., Herr, K., Murinson, B.B., … Strassels, S.A. (2013). Core competencies for pain management: Results of an interprofessional consensus summit. Pain Medicine, 14(7), 971-981.
References (cont.)
Gaskin, D.J., & Richard, P. (2011). The economic costs of pain in the United States. In: Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press.
Hirsh, A.T., Jensen, M.P., & Robinson, M.E. (2010). Evaluation of nurses’ self-insight intotheir pain assessment and treatment decisions. The Journal of Pain, 11(5), 454-461.
Hogan, M.E., Smart, S., Shah, V., & Taddio, A. (2014). A systematic review of vapocoolants for reducing pain from venipuncture and venous cannulation in children and adults. Journal of Emergency Medicine, 47(6), 736-749.
Inal, S., & Kelleci, M. (2012). Distracting children during blood draw: Looking through distraction cares is effective in pain relief of children during blood draw. International Journal of Nursing Practice, 18(2), 210-219.
Layman Young, J., Horton, F.M., & Davidhizar, R. (2006). Nursing attitudes and beliefs in pain assessment and management. Journal of Advanced Nursing, 53(4), 412-421.
Logan, J., & Graham, I.D. (1998). Toward a comprehensive interdisciplinary model of healthcare research use. Science Communication, 20(2), 227-246.
References (cont.)
McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students’ Store.
Parry, G. J., Carson-Stevens, A., Luff, D. F., McPherson, M. E., & Goldmann, D. A. (2013). Recommendations for evaluation of health care improvement initiatives. Academic Pediatrics, 13(Suppl 6), S23-S30.
Rogers, E. (2003). Diffusion of innovations (5th ed.). New York, NY: The Free Press.
Schreiber, J.A., Cantrell, D., Moe, K.A., Hench, J., McKinney, E., Preston Lewis, C., … Brockopp, D. (2014). Improving knowledge, assessment, and attitudes related to pain management: Evaluation of an intervention. Pain Management Nursing, 15(2), 474-481.
Shah, V., Taddio, A., Rieder, M.J., & HELPinKIDS Team. (2009). Effectiveness and tolerability of pharmacologic and combined interventions for reducing injection pain during routine childhood immunizations: Systematic review and meta-analyses. Clinical Therapeutics, 31(Suppl 2), S104-S151.
The Joint Commission. (2014). Facts about pain management. http://www.jointcommission.org/topics/ pain_management.aspx. Accessed February 3, 2014.
Evidence-Based Pain Management in the Ambulatory SettingMichele Farrington, BSN, RN, CPHONTrudy Laffoon, MA, RN-BCCarmen Kealey, MA, RNCindy Dawson, MSN, RN, CORLN
ASPMN® 25th National Conference September 18, 2015
0830 – 0930
20
References (cont.)
Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., … Goode, C.J. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.
Veniegas, R.C., Kao, U.H., Rosales, R., & Arellanes, M. (2009). HIV prevention technology transfer: Challenges and strategies in the real world. American Journal of Public Health,99(Suppl 1), S124-S130.
Whelan, H.M., Kunselman, A.R., Thomas, N.J., Moore, J., & Tamburro, R.F. (2014). The impact of a locally applied vibrating device on outpatient venipuncture in children. Clinical Pediatrics, 53(12), 1189-1195.
Windle, P.E., Kwan, M.L., Warwick, H., Sibayan, A., Espiritu, C., & Vergara, J. (2006). Comparison of bacteriostatic normal saline and lidocaine used as intradermal anesthesia for the placement of intravenous lines. Journal of PeriAnesthesia Nursing, 21(4), 251-258.
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
NoYes
Yes
Is ChangeAppropriate for
Adoption inPractice?
YesInstitute the Change in Practice
No
Continue to Evaluate Qualityof Care and New Knowledge
No
Disseminate Results
Problem Focused Triggers
1. Risk Management Data2. Process Improvement Data3. Internal/External Benchmarking Data4. Financial Data5. Identification of Clinical Problem
Knowledge Focused Triggers
2. National Agencies or OrganizationalStandards & Guidelines
3. Philosophies of Care4. Questions from Institutional Standards Committee
1. New Research or Other Literature
ConsiderOther
Triggers
Is this Topica Priority For the
Organization?
Form a Team
Is Therea SufficientResearch
Base?
Pilot the Change in Practice1. Select Outcomes to be Achieved2. Collect Baseline Data3. Design Evidence-Based
Practice (EBP) Guideline(s)4. Implement EBP on Pilot Units5. Evaluate Process & Outcomes6. Modify the Practice Guideline
Base Practice on Other Types of Evidence:1. Case Reports2. Expert Opinion3. Scientific Principles4. Theory
Conduct Research
Monitor and Analyze Structure, Process, and Outcome Data• Environment• Staff• Cost• Patient and Family
The Iowa Model of Evidence-Based Practice to Promote Quality Care
DO NOT REPRODUCE WITHOUT PERMISSION Revised April 1998 © UIHC
= a decision point Titler, M.G., C., Steelman, V.J., Rakel., B. A., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The Iowa Model Of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.
REQUESTS TO: Department of Nursing
University of Iowa Hospitals and Clinics Iowa City, IA 52242-1009
Implementation Strategies for Evidence-Based Practice Co
nnec
ting
with
Clin
ician
s, Or
gani
zatio
nal L
eade
rs
and
Key S
take
hold
ers
Highlight advantages* oranticipated impact*
Highlight compatibility* Continuing education
programs* Sound bites* Journal club* Slogans & logos Staff meetings Unit newsletter Unit inservices Distribute key evidence Posters and postings/fliers Mobile ‘show on the road’ Announcements & broadcasts
Education (e.g., live, virtual orcomputer-based)*
Pocket guides Link practice change & power
holder/stakeholder priorities* Change agents (e.g., change
champion*, core group*,opinion leader*, thoughtleader, etc.)
Educational outreach oracademic detailing*
Integrate practice change withother EBP protocols*
Disseminate credibleevidence with clearimplications for practice*
Make impact observable* Gap assessment/gap
analysis* Clinician input* Local adaptation* & simplify* Focus groups for planning
change* Match practice change with
resources & equipment Resource manual or materials
(i.e., electronic or hard copy) Case studies
Educationaloutreach/academic detailing*
Reminders or practiceprompts*
Demonstrate workflow ordecision algorithm
Resource materials and quickreference guides
Skill competence* Give evaluation results to
colleagues* Incentives* Try the practice change* Multidisciplinary discussion &
troubleshooting “Elevator speech” Data collection by clinicians Report progress & updates Change agents (e.g., change
champion*, core group*,opinion leader*, thoughtleader, etc.)
Role model* Troubleshooting at the point
of care/bedside Provide recognition at the
point of care *
Celebrate local unit progress* Individualize data feedback* Public recognition* Personalize the messages to
staff (e.g., reduces work,reduces infection exposure,etc.) based on actualimprovement data
Share protocol revisions withclinician that are based onfeedback from clinicians,patient or family
Peer influence Update practice reminders
Build
ing
Orga
niza
tiona
l Sys
tem
Sup
port
Knowledge broker(s) Senior executives
announcements Publicize new equipment
Teamwork* Troubleshoot use/application* Benchmark data* Inform organizational leaders* Report within organizational
infrastructure* Action plan* Report to senior leaders
Audit key indicators* Actionable and timely data
feedback* Non-punitive discussion of
results* Checklist* Documentation* Standing orders* Patient reminders* Patient decision aides* Rounding by unit &
organizational leadership* Report into quality
improvement program* Report to senior leaders Action plan* Link to patient/family needs &
organizational priorities Unit orientation Individual performance
evaluation
Audit and feedback* Report to senior leaders* Report into quality
improvement program* Revise policy, procedure or
protocol* Competency metric for
discontinuing training Project responsibility in unit or
organizational committee Strategic plan* Trend results* Present in educational
programs Annual report Financial incentives* Individual performance
evaluation
* = Implementation strategy is supported by at least some empirical evidence in healthcare
DO NOT REPRODUCE WITHOUT PERMISSION Requests to: Department of Nursing
[email protected] The University of Iowa Hospitals and Clinics
Iowa City, IA 52242-1009 ©University of Iowa Hospitals and Clinics / Laura Cullen, MA, RN, FAAN
Build Knowledge & Commitment
Promote Action & Adoption
Pursue Integration & Sustained Use
Create Awareness & Interest