challenges to the implementation of ebm · of ebm andre amaral, md assistant professor...
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Challenges to the implementation of EBM
Andre Amaral, MD
Assistant Professor
Interdepartmental Division of Critical Care Medicine
University of Toronto
Sunnybrook Health Sciences Centre
AGENDA
• To review the current state of implementation in CCM
• To understand challenges and opportunities using an implementation framework
• To analyze an example of implementation
DO WE DO WHAT WE SAY WE DO?
6%
12%
Vt (ml/Kg)
Lung Protective Ventilation
6 ml/Kg 12 ml/Kg
Treggiari M Am J Respir Crit Care Med 2007
ARDS
DO WE DO WHAT WE SAY WE DO?
Levy Crit Care Med 2010
20%
SEPSIS
Changing the way we work...
.....which, basically, is changing behaviour!
IMPLEMENTATION IS...
DO YOU ACTUALLY HAVE A PROBLEM?
HOW CAN YOU IMPROVE THIS?
OR THIS?
NOW, IF IT IS BROKEN...
FRAMEWORK FOR IMPLEMENTATION
Implementation
Intervention
• Simplicity
• Evidence
• Trialability
People
• Time
• Knowledge
• Memory
• Inertia
• Social Structure
Organization
• Resources
• Culture/Leadership
Amaral Year Book Int Care Med Emerg Med 2012
EDUCATION, FEEDBACK, REMINDERS...
Implementation
Intervention
• Simplicity
• Evidence
• Trialability
People
• Time
• Knowledge
• Memory • Inertia
• Social Structure
Organization
• Resources
• Culture/ Leadership
Amaral Year Book Int Care Med Emerg Med 2012
FRAMEWORK FOR IMPLEMENTATION
Implementation
Intervention
• Simplicity
• Evidence
• Trialability
People
• Time
• Knowledge
• Memory
• Inertia
• Social Structure
Organization
• Resources
• Culture/Leadership
Amaral Year Book Int Care Med Emerg Med 2012
CLINICAL INERTIA
“I’m catching up on my inertia”
CLINICAL INERTIA
Lazaro Rev Esp Cardiol 2010
Not Indicated
24%
Lipid Lowering Therapy
Indicated 76%
Inertia 42%
Treated58%
PEER PRESSURE...
...CAN BE GOOD!
TRYING TO IMPROVE LPV
6%
12%
Vt (ml/Kg)
Lung Protective Ventilation
6 ml/kg 12 ml/kg
Treggiari M Am J Respir Crit Care Med 2007
ARDS
TRYING TO IMPROVE LUNG PROTECTIVE VENTILATION
0%
5%
10%
15%
20%
25%
30%
Compliance with Lung Protective Ventilation
YOU HAVE TO ‘DIAGNOSE’ THE PROBLEM
Implementation
Intervention
• Simplicity
• Evidence
• Trialability
People
• Time
• Knowledge • Memory
• Inertia
• Social Structure
Organization
• Resources
• Culture/ Leadership
Amaral Year Book Int Care Med Emerg Med 2012
FRAMEWORK FOR IMPLEMENTATION
Implementation
Intervention
• Simplicity
• Evidence
• Trialability
People
• Time
• Knowledge
• Memory
• Inertia • Social Structure
Organization
• Resources
• Culture/Leadership
Amaral Year Book Int Care Med Emerg Med 2012
REMINDERS
WHAT HAPPENED?
Acidosis
Sedation issue
EOL
Not ARDS
TBI protocol
New MD order/discussionat rounds
Vent change made
No discussion/no changemade
Residual Inertia
AND WE MANAGED TO...
0%
5%
10%
15%
20%
25%
30%
Compliance with Lung Protective Ventilation
AND WE MANAGED TO...
0%
5%
10%
15%
20%
25%
30%
Compliance with Lung Protective Ventilation
PDSA
WE WERE WRONG IN THE DIAGNOSIS OF THE PROBLEM
Implementation
Intervention
• Simplicity • Evidence
• Trialability
People
• Time
• Knowledge
• Memory
• Inertia
• Social Structure
Organization
• Resources
• Culture/Leadership
Amaral Year Book Int Care Med Emerg Med 2012
• Implementation is still in it’s infancy in CCM
• Start with the identification of the problem
• ‘Diagnosis’ of the problem is fundamental before providing a ‘treatment’
SUMMARY
