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TRANSCRIPT
Evidence-Based Practice: From Concept to Implementation through Team Engagement
Linda Miller, BSN, RN Rachel Smigelski-Theiss, MSN, RN, ACCNS-AG
Background
Unit 28 Twig, Inova Alexandria Hospital • 20 Bed Telemetry Unit • 25 RNs • 7 Clinical Technicians • Nurse Manager • CNS
Patient Profile • Congestive Heart Failure • Cardiac History/Diagnosis • Respiratory Failure, Pneumonia • Acute Kidney Injury
HCAHP Scores Prior to EBP Implementation
• Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?
• Top Box Score 50.0 • Rank 1
• Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?
• Top Box Score 28.6 • Rank 1
• Composite Score: Medication Communication • Top Box Score 39.3 • Rank 1
Problem
• Needed to improve patient engagement and knowledge regarding medication side effects
• Action: • Collaborated with Nursing Research & Evidence Based
Practice Council
• EBP team developed • Nurse Manager • Clinical Nurse Specialist • Clinical Practice Council representative
Mentorship
• “Application of the Johns Hopkins Nursing Evidence-Based Practice Model”
• PET Model
Practice Question
Evidence Translation
Development of PICO Question
• Population/Problem-Intervention-Comparison-Outcome Question
• P: In adult medical/surgical patients in a hospital care setting
• I: will an interactive patient education strategy related to medications
• C: (no comparison)
• O: result in improved patient perceptions/outcomes as measured by HCAHPS medications questions?
Review of Evidence
• Literature obtained by librarian and EBP mentors
• Subjects: patient education, teaching, medication adherence, implementation
• Keywords: teach-back, show me, return demonstration, repeat back, tell back, care transitions, treatment adherence, evidence-based practice
• 8 articles selected for review
• Reviewed articles discussed in daily huddles and monthly CPC meetings
The Literature Ranked
• Evidence Type: • Case Studies • Quality Improvement • Non Experimental • Literature Summary • Randomized Control Trial • Systematic Review
• Evidence Level & Quality: • One Level I Article (strongest) • One IIA Articles • Two II B Articles • One III A Articles • Three VB Articles (weakest)
Literature Findings
• “Teach-Back” was associated with increased knowledge retention
• Use of Ask 3/Teach 3 increased HCAHPS
• Teach-Back helped establish patient understanding
• Patients with low health literacy are more likely to report poor communication
• Teach-Back confirms comprehension & reveals misunderstanding
• Documentation of understanding was correlated with a 30% lower readmission rate
Project Implementation
• Kickoff
• Standard Workflow
• Formal Education on Ask 3/Teach 3
Project Implementation
• Focus on the congestive heart failure (CHF) patient population • Improve awareness of CHF patients • Focus on cardiac medications
• Ace Inhibitors/ Angiotensin Receptor Antagonists • Alpha Adrenergic Agonist • Anti-arrhythmic • Anti-coagulant • Anti-platelets • Beta Blockers • Calcium Channel Blockers • Diuretics • Lipid-Lowering Agents • Potassium
Standard Workflow Operating Unit Process Name Process
Location Target Time Created Reviewed/ Revised Author
IAH Ask 3 Teach 3 U28 12 minutes 5/22/2014 5/22/2014 U28 EBP Team
Step Process Step Responsible Time Goal Critical Notes on Step
1 RN receives order for CHF patient to receive cardiac medication. RN
2 When nurse pulls medication from med room, RN also pulls appropriate Ask 3 Medication card and takes to patient's room. RN <1 minute
3 In patient's room, prior to medication administration, RN completes Ask 3 Card (fills in name of medication). RN <1 minute
4 RN shows patient Ask 3 card and educates patient on medication name, purpose, and side effects. RN 5 minutes Use key words, such as "side effects"
5 Patient teaches back to the nurse the medication name, purpose, and side effects. RN 5 minutes
Ask the patient, "What is the name of your medication? Why do you need to take it? What are common side effects?"
6 If information is not clearly understand, RN should retry education. RN 5 minutes
7 The RN clips the medication card to the white board. RN <1 minute
8 Medication name, purpose, and side effects reviewed with each medication administration. RN 2 minutes
9 Education of medication is included in iShaped reporting RN <1 minute
10 Following shift, RN verifies patient can teach back information on medication card. RN <2 minutes
Standard Workflow
Building Team Engagement
Anticipation
Selection Excitement
Motivation
Follow-Through
• True North Wall
• Identification of CHF patients
• Data Collection
• Coaching
HCAHPS Scores Post EBP Implementation: What the medication was used for
HCAHPS Scores Post EBP Implementation: Side Effects
HCAHPS Scores Post EBP Implementation: Composite Score Medication Communication
Barriers to Implementation & Sustainability
• Language Barriers
• Cognitive Function
• Accurate Identification of CHF Patients
• Relocation
Conclusion
• Formal EBP Education
• Real Time Implementation
• Mentorship • Staff involvement
was instrumental in the successful implementation of an EBP project.
Acknowledgements
• Joni Brady, MSN, RN, CAPA • Suzy Fehr, PhD, RN-BC, NE-BC • Mary Ann Friesen, PhD, RN, CPHQ • Larisa Golding, MSN, RN-BC • Inova Alexandria Leadership Team • Nursing Research & Evidence-Based
Practice Council • Unit 28 Twig Staff Members
References
1. Ahrens, S. L., & Wirges, A. M. (2013). Using evidence to improve satisfaction with medication side-effects education on a neuro-medical surgical unit. American Association of Neuroscience Nurses, 45(5), 281-287.
2. Bowskil, D., & Garner, L. (2012). Medicines non-adherence: adult literacy and implications for practice. British Journal of Nursing, 21(19), 1156-1159.
3. Cloon, P., Wood, J., & Riley, J.B. (2013). Reducing 30-day readmission. The Journal of Nursing Administration, 43(7/8), 382-387.
References
4. Jager, A. J., & Wynia, M.K. (2012). Who gets a teach-back? Patient reported incidence of experiencing a teach-back. Journal of Health Communication: International Perspectives, 17, 294-302.
5. Kandula, N.R., Malli, T., Zei, C.P., Larsen, E., & Baker, D.W. (2011). Literacy and retention of information after a multimedia diabetes education program and teach-back. Journal of Health Communication: International Perspectives, 16, 89-102.
6. Kimbal, S., Buck, G., Goldstein, D., Largaespada, E., Logan, L., Stebbins, D.,…Kalman-Yearout, K. (2010). Testing a teaching appointment and geragogy-based approach to medication knowledge at discharge. Rehabilitation Nursing, 35(1), 31-40.
References
7. Poe, S. S. & White, K. M. (2010). Johns hopkins nursing evidence-based practice: Implementation and translation. Indianapolis, IN: Sigma Theta Tau International.
8. Van Scoyoc, E.E., & DeWalt, D.A. (2010). Interventions to improve diabetes outcomes for people with low literacy and numeracy: A systematic literature review. Diabetes Sepectrum 23(4), 228-237.
9. White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel J. (2013). Is “teach back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? Journal of Cardiovascular Nursing 28(2), 137-146.