Evidence-based Practice Change Research Articles

Perspectives on how evidence-based practice changes over time: A qualitative exploration of occupational therapy and physical therapy graduates.

The integration of evidence-based practice (EBP) into rehabilitation education programs has been widespread, but little is known about how graduates' EBP competencies evolve over time. To explore how and why the use of EBP by occupational therapists (OTs) and physical therapists (PTs) evolves during the first 3 years of clinical practice. We used an interpretive description methodology. We conducted semi-structured interviews with OTs and PTs who participated in a minimum of three out of four time points in a previous longitudinal pan-Canadian mixed methods study. Data analysis was guided by Braun and Clarke's approach to thematic analysis. Seventeen clinicians (13 OTs and 4 PTs) participated in the study. Our analysis identified six overarching themes: (1) evolution of "what EBP is and what it means"; (2) over time, evidence takes a back seat; (3) patients and colleagues have a vital and perennial role in clinical decision making; (4) continuing professional development plays a vital role in EBP; (5) personal attitudes and attributes influence EBP; and (6) organizational factors influence EBP. Our study highlights the dynamic nature of EBP use among OTs and PTs in the first 3 years of clinical practice, emphasizing the need for contextualized approaches and ongoing support to promote evidence-informed healthcare in rehabilitation.

Evaluating the Impact of Opioid-free Anesthesia Protocol on Provider Utilization: A Pilot Study at 2 Southeastern US Hospitals

Objective: Perioperative opioid medications are implicated as contributors to the opioid crisis and associated with significant negative side effects that complicate recovery, leading to increased hospitalization and healthcare costs. Implementation of opioid-free anesthesia (OFA) hospital protocols may be an effective strategy to familiarize healthcare providers with non-opioid strategies for treating perioperative pain. Methods: An exploratory, descriptive pilot study was conducted at 2 Southeastern US Hospitals with a preexisting OFA policy. An electronic survey was developed and distributed to the anesthesia departments with an OFA protocol for bariatric surgical procedures. The responses (n=14) were analyzed, and the qualitative data thematically categorized. Results: Two major and one minor theme emerged. Theme 1: utilizing an OFA protocol led to increased familiarity and a desire to utilize OFA in other surgical populations. Theme 2: implementation of regional anesthesia into a multimodal OFA plan improves pain management and perioperative team support. Minor Theme: opioid sparing may be preferable to OFA techniques among a minority of anesthesia providers. Conclusion: OFA protocol promoted familiarity and favorable attitude towards OFA techniques. Participants reported an increased willingness to utilize OFA beyond protocol requirements. Therefore, hospital protocol may be a useful tool to drive evidence-based anesthesia and pain management practice change.

A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice

BackgroundCurrent evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers. ObjectiveTo determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol (BOSS) compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload. Study DesignThe BOSS intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month post-intervention (BOSS) cohort to 6- month pre-intervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month wash out period was observed after BOSS initiation. We excluded patients <18 years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents (OME) prescribed. Pain control was measured by pain scores, post-discharge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and post-discharge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the BOSS protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables. Results416 patients were included in the primary analysis (207 BOSS, 209 Usual Care). Baseline demographics were similar between groups, except a lower proportion of IBS (13% vs 23%; p<0.01) and pelvic pain (15% vs 24.9%; p=0.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; p=0.02) in the BOSS cohort. The BOSS cohort was more likely to be discharged without opioids (68.1% vs 10.0%; p<.01). In those prescribed opioids, total OME on discharge was significantly lower in the BOSS cohort (48.1 vs 81.8; p<.01). The BOSS cohort had a 20.6 greater odds (CI 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to NSAIDs. The BOSS cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; p=0.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; p=0.77), emergency room visits for pain (3.4% vs 2.9%; p=0.76), postoperative pain scores (mean 4.7 vs 4.0; p=0.07), or patient satisfaction with pain control (81.5% vs 85.6%; p=0.21). After BOSS implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; p=0.02). Similar results were identified when non-adherent prescribing was included in the analysis. ConclusionsA bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.

Advancing Implementation Practice: Supplemental Tools to Aid in Selection of Implementation Strategies and Outcomes for Healthcare Practitioners

The field of implementation science has grown exponentially within healthcare and human service delivery settings. Scientists in the field have made tremendous strides in generating new knowledge aimed at increasing uptake of evidence into practice settings, including development of numerous theories, models, and frameworks to guide the process of implementation, strategies to operationalize optimal methods of implementing an evidence-based practice change, and designated outcomes to evaluate the progress of a change initiative. Despite these gains in scientific discovery surrounding implementation, routine use and application of this knowledge among healthcare practitioners seeking to implement a practice change in real world settings remains fragmented, risking development of a “secondary gap” between what we know from the science of implementation and what is actually done by frontline teams when implementing evidence-based practice changes. To address this gap, we developed two supplemental tools to bridge the language between implementation science and implementation practice: the Implementation Strategies Supplemental Tool (ISST), and the Implementation Outcomes Supplemental Tool (IOST). The purpose of this paper is to describe the development and intended use of these tools for healthcare practitioners seeking to use a science-informed approach when implementing an evidence-based practice change. We include a case example of how healthcare practitioners may apply these tools to improve implementation of evidence-based practices in real-world settings.

The Evidence-Based Practice Process Steps 4, 5, and 6: Integration, Evaluation, and Dissemination.

This is the final column in a series of columns that began with the January/February 2021 issue of Neonatal Network, describing the evidence-based practice (EBP) project. The series has taken the reader through sparking the spirit of inquiry, asking a compelling question, and searching and critically appraising the literature. This column will briefly describe the final three steps: step 4, the integration of evidence with clinical expertise and patient/family preferences; step 5, the evaluation of outcomes of practice changes based on evidence; and step 6, the dissemination of the outcomes of the EBP change.

The utility of PET imaging in depression.

This educational review article aims to discuss growing evidence from PET studies in the diagnosis and treatment of depression. PET has been used in depression to explore the neurotransmitters involved, the alterations in neuroreceptors, non-neuroreceptor targets (e.g., microglia and astrocytes), the severity and duration of the disease, the pharmacodynamics of various antidepressants, and neurobiological mechanisms of non-pharmacological therapies like psychotherapy, electroconvulsive therapy, and deep brain stimulation therapy, by showing changes in brain metabolism and receptor and non-receptor targets. Studies have revealed alterations in neurotransmitter systems such as serotonin, dopamine, GABA, and glutamate, which are linked to the pathophysiology of depression. Overall, PET imaging has furthered the neurobiological understanding of depression. Despite these advancements, PET findings have not yet led to significant changes in evidence-based practices. Addressing the reasons behind inconsistencies in PET imaging results, conducting large sample size studies with a more standardized methodological approach, and investigating further the genetic and neurobiological aspects of depression may better leverage PET imaging in future studies.

Describing nurses' communication about evidence-based practice change: A social network analysis of hospital nurses.

Nurses play a critical role in providing evidence-based, high-quality care to optimize patient outcomes. Models from implementation science suggest social networks may influence the adoption of evidence-based practices (EBPs). However, few studies have examined this relationship among hospital nurses. Social network analysis (SNA) mathematically evaluates patterns of communication, a critical step in implementation. Exploring hospital nurses' communication networks may provide insight into influences on the adoption of EBPs. This study aimed to describe complete communication networks of hospital nurses for practice changes on inpatient units, including upper level nursing administrators. This descriptive, exploratory, cross-sectional study used SNA on two inpatient units from one hospital. A sociometric survey was completed by nurses (unit to executive level) regarding communication frequency about practice changes. Network-level density, diameter, average path length, centralization, and arc reciprocity were measured. Attribute data were used to explore subnetworks. Surveys from 148 nurses on two inpatient adult intensive care units (response rates 90% and 98%) revealed high communication frequency. Network measures were similar across the two units and among subnetworks. Analysis identified central (charge nurses and nurse leaders) and peripheral members of the network (new-to-practice nurses). Subnetworks aligned with the weekend and shift worked. Established communication channels, including subnetworks and opinion leaders, should be used to maximize and optimize implementation strategies and facilitate the uptake of EBPs. Future work should employ SNA to measure the impact of communication networks on promoting the uptake of EBP and to improve patient outcomes.

Potential parental determinants of the pace of evidence-based practice change in children's mental health care.

Strength of evidence is key to advancing children's mental health care but may be inadequate for driving practice change. The Designing for Accelerated Translation (DART) framework proposes a multifaceted approach: pace of implementation as a function of evidence of effectiveness, demand for the intervention, sum of risks, and costs. To inform empirical applications of DART, we solicited caregiver preferences on key elements. In March-April 2022, we fielded a population-representative online survey in Illinois households (caregivers N = 1,326) with ≥1 child <8 years old. Six hypothetical scenarios based on the DART framework were used to elucidate caregivers' preferences on a 0-10 scale (0 = never; 10 = as soon as possible) for pace of implementation of a family-based program to address mental health concerns. Caregivers' pace preference scores varied significantly for each scenario. The highest mean score (7.28, 95% confidence interval [95% CI: 7.06, 7.50]) was for a scenario in which the child's provider thinks the program would be helpful (effectiveness) and the caregiver believes the program is needed (demand). In contrast, the lowest mean score (5.13, 95% CI [4.91, 5.36]) was for a scenario in which online information implies the program would be helpful (effectiveness) and the parent is concerned about the program's financial costs (cost). Caregivers' pace preference scores did not vary consistently by sociodemographic factors. In this empirical exploration of the DART framework, factors such as demand, cost, and risk, in combination with evidence of effectiveness, may influence caregivers' preferred pace of implementation for children's mental health interventions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Iterative Development: Going with the Flow to Improve Care.

Healthcare can benefit immensely from implementing an Agile mindset. Specifically, Agile principles of value-driven delivery, adaptive planning, and continuous improvement can exert a positive impact on projects-especially amid the constant changes in laws, evidence-based practices, and technology in healthcare. The best way to apply Agile is to combine the discipline and structure of a traditional linear model with the adaptability of iterative development. That mix allows for certain controls but with the flexibility for stakeholders to provide input and call for adjustments at different stages. To start, an organization must build teams of multidisciplinary personnel with diverse perspectives. Delivering value should be addressed as soon as possible by considering stakeholder priorities, using tools for continuous project planning, and employing retrospectives to provide feedback and identify root causes. When leaders embrace value-driven delivery, adaptive planning, and continuous improvement, healthcare projects can lead to positive results and ultimately improve patient care.

Cardiovascular Disease Risk Screening for Commercial Drivers Examined in Occupational Practice: Implementing Evidence-Based Practice to Champion the Health of Essential Workers.

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the United States, with 20% of deaths in adults under age 65. Commercial drivers have an increased CVD incidence rate of 50% compared to 30% for the general population, yet one third of drivers will not be screened for risk factors due to a lack of insurance or primary care. With approximately 3.5 million commercial drivers nationally and correlation of CVD to increased motor vehicle accidents, fatalities, and excessive healthcare costs, addressing the care gap for this high-risk population is imperative. An evidence-based practice (EBP) project synthesized the literature and implemented CVD risk screening for commercial drivers examined in an occupational practice setting. Using the non-laboratory Framingham CVD risk score calculator, over 90% of drivers were screened during mandated medical examinations and provided education regarding modifiable risk factors during a 2-month period. Over 40% of commercial drivers were at high risk for CVD with 25% uninsured and 32% without primary care. The average CVD risk score was twice the general population's risk score, with obesity, hypertension, and smoking being the most common risk factors discussed. Incorporating CVD risk screening and education during opportune encounters is logical, efficient, and financially prudent. The EBP change supports occupational professionals' standards, and ongoing review of CVD screening guidelines with integration into practice provides health promotion and promotes public safety for these essential workers.

Facilitating data-driven evidence-based practice change: the Best Practice Project

Facilitating data-driven evidence-based practice change: the Best Practice Project

Piloting the Clinically Aligned Pain Assessment Tool: An Evidence-Based Practice Change

Piloting the Clinically Aligned Pain Assessment Tool: An Evidence-Based Practice Change

A value-based approach to prostate cancer image-guidance in a regional radiation therapy centre: a cost-minimisation analysis.

Usual practice for the insertion of prostate fiducial markers involves at least one week delay between insertion and simulation. An evidence-based practice change was implemented whereby fiducial marker insertion occurred on the same day as radiotherapy simulation. The aim of this study was to quantify the health service costs and clinical outcomes associated with this practice change. A cost-minimisation analysis was undertaken from the perspective of the local health service. A retrospective chart audit was conducted to collect data on 149 patients in the pre-implementation cohort and 138 patients in the post-implementation cohort. Associated costs with insertion and simulation were calculated and compared across the two cohorts; this included subsided travel costs for rural and remote patients. Fiducial marker positions on planning CT and first treatment CBCT were measured for all patients as the surrogate clinical outcome measure for oedema. The health service saved an average of AU$ 361 (CI $311 - $412) per patient after the practice change. There was no significant difference in fiducial marker position pre- and post- implementation (p<0.05). The practice change to perform insertion and radiotherapy simulation on the same day resulted in substantial savings to the health system, without compromising clinical outcomes. The decrease in number of required patient attendances is of real consequence to rural and remote populations. The practice change increases both the value and accessibility of best-practice health care to those most at risk of missing out.

Diagnostic Stewardship: the Central Role of Clinical Microbiology Laboratories

Diagnostic stewardship aims to improve diagnostic test utilization through evidence-based practices to improve care, quality, safety, and costs. Diagnostic stewardship is a collaborative effort that brings together multidisciplinary groups that have a common interest in promoting and ensuring best testing practices. For infectious disease testing, clinical microbiology laboratories are perhaps best positioned within their health care systems to lead these efforts, as they are not only diagnostic experts, but also directly oversee many of the tools and choices available to improve test performance and utilization. While some interventions may not fall under the direct purview of clinical microbiology laboratories, their expertise is nevertheless essential to inform these efforts, as well. Multiple stewardship strategies have been evaluated, providing laboratories with several opportunities to implement evidence-based practice changes to improve quality and outcomes. Further research is needed to continue advancing practice for well-established and emerging tests alike.

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis

ObjectivesTo share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care. MethodsWe applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability. Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings. Titles, abstracts and full texts were reviewed independently and in duplicate, resulting in 38 included articles. ResultsSocial movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organizations that, as voluntary and intrinsically motivated change agents, mobilize around a common cause to improve outcomes through knowledge uptake and sustainability. The 10 defining attributes, three antecedents and three consequences that we identified are dynamic and interrelated, often mutually reinforcing each other to fortify various aspects of the social movement. Examples of defining attributes include an urgent need for action, collective action and collective identity. The concept analysis resulted in the development of the Social Movement Action Framework. ConclusionsSocial movement action can provide a lens through which we view implementation science. Collective action and collective identity – concepts less frequently canvassed in implementation science literature – can lend insight into grassroots approaches to uptake and sustainability. Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for real-world change initiatives. By mobilizing individuals, groups, or organizations through social movement approaches, they can engage as powered change agents and teams that impact the individual, organizational and health systems levels to facilitate knowledge uptake and sustainability.

Implementation of an Evidence-Based Practice Change Removing Heparin From Implanted Vascular Access Devices.

The objective of this article was to describe the implementation and outcomes of an evidence-based practice change to remove heparin from implanted vascular access device (IVAD) management. An extensive search of the literature was performed, and articles were appraised and synthesized to determine the best practice. A common theme emerged from the literature, showing that 0.9% sodium chloride alone can be as effective as heparin in preventing occlusion in IVADs. In this nurse-led initiative, heparin was successfully removed from the IVAD deaccess process and replaced with a 0.9% sodium chloride flush using a pulsatile flushing technique. Alteplase administration rates were used to measure success of the project, with no statistically significant change observed in alteplase rates 6 mo postimplementation. Successful implementation of this practice change demonstrates that 0.9% sodium chloride may be used for IVAD lock when deaccessing.

The effectiveness of ERAS guidelines in reducing postoperative pain

AbstractBackgroundPoorly controlled acute postsurgical pain can promote chronic opioid use and misuse long after the initial surgical procedure. Enhanced recovery after surgery (ERAS) guidelines have shown promise in reducing opioid exposure and minimizing opioid‐related side effects.AimsThe aims of this evidence‐based practice (EBP) project were to assess the ERAS literature to guide postoperative pain management practice change at an adult colorectal surgical unit, evaluate the practice change outcomes, and disseminate the findings.MethodsA Population, Intervention, Comparison, Outcome, and Time (PICOT) question was established to guide an ERAS literature search. Found articles were critically appraised using the FULD Critical Appraisal Tool. Following the critical appraisal, the steps of EBP were utilized to implement an ERAS guideline for adult colorectal surgical patients in a 281‐bed medical center. Outcomes of the practice change were evaluated by comparing multimodal analgesic, regional anesthesia, and opioid pain medication use before and after guideline implementation.ResultsFive articles were critically appraised for guideline development. After implementation, data demonstrated an increase in the use of multimodal analgesics and regional anesthesia and a decrease in the use of opioid pain medication. These findings were disseminated through multiple venues within the hospital, including a presentation to the stakeholders.Linking Evidence to ActionEvidence‐based strategies to reduce postoperative pain are achievable while reducing perioperative opioid consumption. Engagement of key stakeholders and timely rollout of EBP changes are important for successful implementation. ERAS guidelines with a multimodal analgesia pathway are an effective way to reduce postoperative pain and perioperative opioid consumption.

JBI series paper 3: The importance of people, process, evidence, and technology in pragmatic, healthcare provider-led evidence implementation

In this paper, we describe and discuss evidence implementation as a venture in global human collaboration within the framework of “people, process, evidence, and technology” as a roadmap for navigating implementation. At its core implementation is not a technological, or theoretical process, it is a human process. That health professionals central to implementation activities may not have had formal training in implementation, highlights the need for processes and programs that can be integrated within healthcare organization structures. Audit with feedback is an accessible implementation approach that includes the capacity to embed theory, frameworks, and bottom-up change processes to improve the quality of care. In this third paper in the JBI series, we discuss how four overarching principals necessary for sustainability (Culture, Capacity, Communication, and Collaboration) are combined with evidence, technology, and resources for evidence-based practice change. This approach has been successfully used across hundreds of evidence implementation projects around the globe for over 15 years. We present healthcare practitioner-led evidence-based practice improvement as sustainable and achievable in collaborative environments such as the global JBI network as a primary interest of the practicing professions and provide an overview of the JBI approach to evidence implementation.

Corneal Injury Risk Reduction During Sedation for Colonoscopy: An Evidence Based Practice Change

PurposeThis evidence-based practice change project examined the use of supine positioning as a substitute for lateral positioning after sedation for endoscopic procedures for the purpose of preventing corneal injuries in this patient population. DesignThis study used a pre and post implementation design. MethodsRetrospective data was collected over 12 months, including 4,422 endoscopic procedures for comparison to the prospective data collected after implementing the practice change, which totaled eight months and 3080 procedures. FindingsIncidence rates for corneal injury and eye irritation were 0.158% before the practice change, with a decrease in incidence to 0.097% after the change. Using a two-sided Fisher's exact test, the results were not statistically significant (P => .05). Additionally, linear regression showed a slight downward trend with implementation; however, these results were also not statistically significant. ConclusionsThe intervention did not have a statistically significant impact on the incidence of corneal injury. It is possible that more than one risk factor was contributing to corneal injury in this setting and the intervention only addressed one potential risk factor.