Bridging the gap to move research evidence into practice to benefit patients across the health care system in Ontario is an ongoing challenge. It requires leadership to spread research evidence and implement it across the system, rather than just create islands of excellence and innovation, said Karen Michell, Executive Director of the Council of Academic Hospitals of Ontario (CAHO). In 2010, CAHO took on this leadership role through the creation of the Adopting Research to Improve Care (ARTIC) Program. “There is a need to drive quality improvement across the system. Whether we’re talking about curing disease, finding more efficient ways to take care of the elderly or reducing the spread of infection, we want to get better results,” Michell said. “You start with the evidence from research, but implementing the evidence into practice requires a concerted effort.”
CAHO took on the challenge to move research evidence to the bedside by harnessing the collective capabilities of its 24-member academic hospitals. “From there, ultimately the goal is to implement evidence into practice across the entire health system,” Michell said.
The ARTIC program has funded four projects, which are currently in various stages – from implementation through to completion. The projects include:
CAHO is also set to announce two new projects this fall, but Michell noted that lessons learned over the past two years have led to a different approach in choosing new initiatives for the ARTIC Program. “Hospitals are very busy places with dedicated professionals focused on constantly working to ensure they are doing the best for their patients. There are time and resource constraints,” Michell explained. “We have found that one of the key factors for success in moving evidence into practice is to focus on projects that align with broader system priorities.”
“There is more likelihood of getting people to buy into a project that relates to a broader priority of the institution and of the system.” So, the next phase of ARTIC projects will be aligned to the challenge of improving transitions in care to support patients in moving seamlessly from different health care settings and providers throughout the course of their treatment and care, Michell said. Improving transitions in care is one of the priorities within Ontario’s Action Plan for Health Care.
Much has already been learned from the existing ARTIC projects and results have been achieved that are improving patient care and driving quality across the system, Michell said.
Improving patient care and outcomes, while reducing cost
CAHO ASP in ICUs Project is translating into real change in how antimicrobial medication is being prescribed in intensive care units in hospitals. The sickest patients are in ICU and about 70 percent of them are on antimicrobials. Dr. Andrew Morris, Director of the ASP at Mount Sinai Hospital and the University Health Network led a pilot that was adopted as an ARTIC project after its initial success in significantly reducing the use of antibiotics. “We had great success in our initial sites. There was a reduction in antibiotic use, antibiotic cost and antibiotic resistance. We were making patients better, saving money and improving care and safety. Few interventions cut across all these areas,” Dr. Morris said. “In the pilot phase we reduced on average antimicrobial use by 30 per cent over the greater part of two years.”
The CAHO ASP in ICUs Project began rolling out at other CAHO hospitals last July and over a 12-month period is being phased into 14 sites including, the Hospital for Sick Children, St. Joseph’s Health Care Hamilton and The Ottawa Hospital. The program works by supporting a multidisciplinary ICU team to more carefully assess on a daily basis whether there are patients receiving antibiotics unnecessarily. “The ASP physician and the pharmacist meets with the ICU team and discusses each patient to see if a broad spectrum antibiotic can be changed to a more narrow spectrum medication or if an antibiotic can be stopped altogether,” Dr. Morris said. “This kind of engagement with the team at the bedside is important because physician anxiety about infection is understandably high in the ICU. The ASP team supports the ICU in ensuring that patients are on the right antibiotics and only on antibiotics if they really need them.” The CAHO ASP in ICUs Project is evolving into the largest coordinated antimicrobial stewardship effort of its kind in North America, Dr. Morris added.
The CAHO ASP in ICUs Project is looking at tracking not only the reduction in antibiotic use, but also how this correlates with the incidence of drug-resistant infections including C. difficile, Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococci (VRE) and invasive fungal infections at the participating hospital sites. It is anticipated that the establishment and expansion of the ASP will help to reduce the incidence of drug-resistant and invasive fungal infections in hospitals. “During the pilot, three intensive care units saw a reduction in invasive fungal infections,” Dr. Morris noted. A report on the overall outcomes of the CAHO ASP Project will be completed by January 2014.
Evolving a tool to enhance hospital efficiency and marketing it to the world.
“Anything we can do to try and prevent accidents and prevent infections, we see as part of our mandate,” said Dr. Geoff Fernie, Institute Director of the Toronto Rehabilitation Institute, where HandyAudit which measures hand hygiene compliance was developed. HandyAudit is a tool that uses a tablet or other handle-held device to provide a more consistent and standardized way to monitor hand hygiene being carried out by providers in health care settings. This is key because since 2008, all hospitals in Ontario must publicly report on hand hygiene compliance as a patient safety indicator. Proper hand hygiene is the first line of defence in curbing the spread of infection.
The CAHO ARTIC Program led to the innovative HandyAudit tool being adopted by 16 academic hospitals in Ontario and subsequently generating interest from the health care field on a much broader scale, including internationally. “HandyAudit introduced a new level of objectivity into the system. This improved upon the system of recording observations on a paper form,” Dr. Fernie said. “It frees a person who is auditing hand hygiene from the job of interpreting whether what is being observed is correct or not,” he noted. The HandyAudit tool allows the observer to simply note what is happening – when a health care provider starts rubbing their hands with an alcohol gel, when the person stops.” HandyAudit’s computer program calculates compliance based on an established set of rules. “The program applies exactly the same rules to every single case, ensuring consistency. It also factors in missed opportunities and can be used as a teaching tool,” Dr. Fernie explained. “It provides a better base for institutions to use to see if they are improving with hand hygiene.”
HandyMetrics was set up as a newly incorporated Ontario-based company – that now employs seven people – to market and distribute HandyAudit. “The initial 16 academic hospitals that placed orders gave us the critical mass to get going. But now we have over 100 significant customer sites.” The CAHO HandyAudit ARTIC Project has wrapped up, but the ARTIC Program provided the leverage to implement and commercialize the HandyAudit technology that has spread well beyond Ontario hospitals.
The other important legacy of the HandyAudit project is that it created a community of health care professionals – who through teleconferencing – regularly connected to share their success and challenges around hand hygiene compliance. “It created a community of people working together to develop best practices,” Dr. Fernie said.
The HandyAudit project provided a template for the ARTIC Program on how to accelerate the transition of evidence into practice on a significant scale. The lessons learned from this initial project are being replicated in other ARTIC projects, Michell noted. For example, The CAHO MOVE ON ARTIC Project – which focuses on keeping older patients consistently mobile during their hospital stay – holds a monthly teleconference of participants currently implementing the project. MOVE ON was jointly developed by Sunnybrook Health Sciences Centre and St. Michael’s Hospital, in response to research findings in 2010-2011 that in Toronto academic hospitals less than 30 per cent of elderly patients were regularly kept mobile. Elderly patients quickly lose muscle strength each day in hospital if they are not kept sufficiently mobile. Fourteen CAHO hospitals are participating in the CAHO MOVE ON ARTIC Project “Inter-professional teams are sharing with each other what is working well for them, what doesn’t work, how to overcome barriers and challenges. This sharing with colleagues is important to the spread and implementation of evidence into practice,” Michell said.
Similarly, nurses participating in the CAHO Canadian C-Spine Rule (CCR) ARTIC Project to Improve ER Wait Times and increase efficiencies by maximizing the use of inter-professional resources – have been part of a knowledge and collaboration event held in Toronto to share their experiences and encourage the spread of expertise across the system. The Canadian C-Spine Rule is a clinical decision-making tool that was developed by Dr. Ian Stiell at The Ottawa Hospital to rule out a cervical spine injury without the need for an x-ray. This decreases the amount of time many trauma patients need to be kept immobilized upon arrival at an emergency room. The CCR has been rigorously tested and widely adopted for use by ER physicians. The ARTIC project has supported the application of the rule reliably and safely among ER triage nurses. This has the potential to decrease ER wait times and increase patient satisfaction by quickly and effectively identifying patients who not need to be immobilized. “The project is creating nurse champions who can help spread effective use of the C-spine rule,” Michell said. Both the MOVE ON and the CCR ARTIC projects are ongoing and are anticipated to continue to produce results that will improve patient care.
The CAHO ARTIC projects have gone a long way in translating research evidence into practice that improves patient care, across research hospitals in Ontario and beyond. “The goal is to spread these evidence-based changes outside the walls of CAHO institutions to the overall system.” This spread being leveraged by ARTIC will help enhance both the quality of care and contribute to the sustainability of the health system.
Learn more about CAHO ARTIC projects.
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