Developing A Culture Of Evidence-Based Practice

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Implementing an Evidence-Based Practice Change Beginning the transformation from an idea to reality.

This is the ninth article in a series from the Arizona State University College of Nursing and Health Innovation’s Cen- ter for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every other month to allow you time to incorporate information as you work to – ward implementing EBP at your institution. Also, we’ve scheduled “Chat with the Authors” calls every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May’s Evidence-Based Practice, Step by Step.

I n January’s evidence-based prac tice (EBP) article, Rebe -cca R., our hypothetical staff nurse, Carlos A., her hospital’s ex pert EBP mentor, and Chen M., Rebecca’s nurse colleague, began to develop their plan for implementing a rapid response team (RRT) at their institution. They clearly identified the pur- pose of their RRT project, the key stakeholders, and the vari- ous outcomes to be measured, and they learned their internal re view board’s requirements for re viewing their pro posal. To de- termine their next steps, the team consults their EBP Implementa- tion Plan (see Figure 1 in “Fol- lowing the Evidence: Plan ning for Sustainable Change,” Jan – uary). They’ll be working on items in checkpoints six and

seven: specif ically, engaging the stakeholders, getting administra- tive support, and preparing for and conducting the stakeholder kick-off meeting.

ENGAGING THE STAKEHOLDERS Carlos, Rebecca, and Chen reach out to the key stakeholders to tell them about the RRT project by meeting with them in their offices or calling them on the phone. Car – los leads the team through a dis- cussion of strategies to promote success in this critical step in the implementation process (see Strat ­ egies to Engage Stakeholders). One of the strategies, connect in a col­ laborative way, seems espe cially applicable to this project. Each team member is able to meet with a stakeholder in person, fill them in on the RRT project, describe the purpose of an RRT, discuss their role in the project, and an – swer any questions. They also tell each stakeholder about the initial project meeting to be held in a few weeks.

In anticipation of the stake- holder kick-off meeting, Carlos and the team discuss the fun – damen tals of preparing for an

im portant meeting, such as how to set up an agenda, draft key doc- uments, and conduct the meet – ing. They begin to discuss a time and date for the meeting. Carlos suggests that Rebecca and Chen meet with their nurse manager to up date her on the project’s pro gress and request her help in sched uling the meeting.

SECURING ADMINISTRATIVE SUPPORT After Rebecca updates her man- ager, Pat M., on the RRT pro ject, Pat says she’s impressed by the team’s work to date and of fers to help them move the project forward. She suggests that, since they’ve already invited the stake- holders to the upcoming meet ing, they use e-mail to communicate the meeting’s time, date, and place. As they draft this e-mail together, Pat shares the follow – ing tips to im prove its effective- ness: • communicate the essence and

importance of the e-mail in the subject line

• write an e-mail that’s engaging, but brief and to the point

• introduce yourself • explain the project

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Strategies to Engage Stakeholders • Spend time and effort building trust. • Understand stakeholders’ interests. • Solicit input from stakeholders. • Connect in a collaborative way. • Promote active engagement in establishing

metrics and outcomes to be measured.

By Lynn Gallagher-Ford, MSN, RN, NE-BC, Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, Bernadette

Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, and Susan B. Stillwell, DNP, RN, CNE

• welcome the recipients to the project and/or team and invite them to the meeting

• explain why their attendance is critical

• request that they read certain materials prior to the meeting (and attach those documents to the e-mail)

• let them know whom to con- tact with questions

• request that they RSVP • thank them for their partici-

pation Before they send the e-mail (see Sample E­mail to RRT and Stake­ holders), the team wants to make sure they don’t miss anyone, so they review and include all of the RRT members and stake holders. They realize that it’s im portant to invite the manager of each of the stakeholders and disciplines rep- resented on the RRT and ask

them to also bring a staff represen- tative to the meeting. In addition, they copy the administrative di rec – tors of the stakeholder depart- ments on the e-mail to en sure that they’re fully aware of the project.

PREPARING FOR THE KICK-OFF MEETING The group determines that the draft documents they’ll need to prepare for the stakeholder kick- off meeting are: • an agenda for the meeting • the RRT protocol • an outcomes measurement plan • an education plan • an implementation timeline • a projected budget To expedite completion of the doc- uments, the team divides them up among themselves. Chen volun- teers to draft the RRT protocol and outcomes measurement plan.

Carlos assures her that he’ll guide her through each step. Rebecca decides to partner with her unit ed- ucator to draft the education plan. Carlos agrees to take the lead in drafting the meeting agenda, im – plementation timeline, and pro- jected budget, but says that since this is a great learning opportu- nity, he wants Rebecca and Chen to be part of the drafting process.

Drafting documents. Carlos tells the team that the purpose of a draft is to initiate discussion and give the stakeholders an oppor tu – nity to have input into the final prod uct. All feedback is a positive sign of the stakeholders’ involve- ment, he says, and shouldn’t be per ceived as criticism. Carlos also offers to look for any tem- plates from other EBP projects that may be helpful in drafting the documents. He tells Rebecca

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Sample E-mail to RRT and Stakeholders To: ICU Nurse Manager, 3 North Nurse Manager, Respiratory Therapy Director, Medical Director of ICU, Director of Acute Care NP Hospitalists, Director of Spirituality Department

cc: EBP Council Chair, VP Nursing, VP Medical Affairs, ICU Nursing Director, Medical–Surgical Nursing Director, Finance Department Director, Communications Department Director, Risk Management Director, Education Department Director, HIMS (Medical Records) Director, Quality/Performance Improvement Director, Clinical Informatics Director, Pharmacy Director

Subject: Invitation to the Rapid Response Project Stakeholder Kick-off Meeting

Good afternoon. I would like to introduce myself. My name is Rebecca R. I am a staff nurse III on the 3 North medical– surgical unit. You have either spoken with me or with one of my colleagues, Carlos A. or Chen M., about an important evidence-based initiative that will help improve the quality of care for our patients. The increasing patient acuity on our unit and throughout the hospital, and the frequent need for patients to be transferred to the ICU, prompted us to ask important questions about patient outcomes. For the past few months, Carlos, Chen, and I have been investigating how our hospital can reduce the number of codes, particularly outside the ICU. We have conducted a thorough search for and appraisal of current available evidence, which we would like to share with you.

Our team and our managers would like to invite you to participate in a kick-off meeting to discuss an exciting evidence-based initiative to improve the quality of patient care in our hospital. The meeting will be held on March 1, 2011, at 10 am in the Innovation Conference Room on the 2nd floor. It is very important that you attend this meeting as you have been identified as a critical participant in this project. We need your input and support as we move for- ward. So please plan to attend the meeting or send a representative. To ensure that we have sufficient materials for the meeting, please RSVP to Mary J., unit secretary on 3 North.

I want to thank you in advance for your help with and support of this project. I look forward to seeing you at the meeting. If you have any questions, please feel free to contact me or any of the RRT project team members.

Rebecca R. and the RRT Project Team

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RRT Protocol Draft for Review Current evidence supports the effectiveness of an RRT in decreasing adverse events in patients who exhibit specific clinical parameters. Evidence-based recommendations include that RRTs should be available on general units of hospitals, 24 hours a day and seven days a week, staffed by intensive care clinicians, and activated based on established clinical criteria. The RRT serves a dual purpose of pro- viding both early intervention care to at-risk patients and education in recognizing and managing these patients to clin ical staff.

The RRT is available to respond to and assist bedside staff in caring for patients who develop signs or symptoms of clinical deterio- ration.

RRT Members RRT members are all ACLS certified. They include: Team Leader: Acute Care NP Hospitalist (credentialed in advanced procedures) Team Members: ICU RN

Respiratory Therapist (trained in intubation) Physician Intensivist (ICU MD on call and available to the RRT) Hospital Chaplain

Initiation of RRT Consult An RRT consult can be initiated by any bedside clinician. Consults should be initiated based on the following patient status criteria.

RRT Consult Initiation Criteria

Pulmonary

Ventilation: Color change (pale, dusky, gray, or blue)

Respiratory distress: RR < 10 or > 30 breaths/min, or Unexplained dyspnea, or New-onset difficulty breathing, or Shortness of breath

Cardiovascular

Tachycardia: Unexplained > 130 beats/min for 15 mins

Bradycardia: Unexplained < 50 beats/min for 15 mins

Blood pressure: Unexplained SBP < 90 or > 200 mmHg

Chest pain: Complaint of nontraumatic chest pain

Pulse oximetry: < 92% SpO2 Perfusion: UOP < 50 cc/4 hr

Neurologic

Seizures: Initial, repeated, or prolonged

Change in mental status: Sudden decrease in LOC with normal blood sugar Unexplained agitation for > 10 min New-onset limb weakness or smile droop

Sepsis

Clinical indicators of sepsis: Temperature > 38ºC

HR > 90 beats/min

RR > 20 breaths/min

WBC > 12,000, < 4,000

Nurse’s concern about overall deterioration in patient’s condition without any of the above criteria.

Scope of the RRT The RRT can be expected to perform any/all of the following interventions: Nasopharyngeal/oropharyngeal suctioning Oxygen therapy

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Initiation of CPAP Initiation of nebulized medications Intravenous fluid bolus(es) Intravenous fluid bolus(es) with medication CPR

The RRT can be expected to perform any/all of the following invasive procedures: Endotracheal intubation Intravenous line insertion Intraosseous line insertion Arterial line insertion Central line insertion

RRT Consult Procedure 1. Assess patient relative to the above criteria. 2. If any of the above criteria are identified, initiate the RRT consult by calling 5-5555. The operator will request the caller’s location,

the patient’s name, the patient’s location, and the reason for RRT activation. This call will generate both pages to the RRT members and an overhead announcement.

3. The RRT will arrive within five minutes (or less) of the call. 4. Be prepared to provide the RRT with appropriate information about the patient using the SBAR communication method. (See stan-

dardized communication protocol no. 7.) 5. While awaiting the arrival of the RRT, consider initiating any/all of the following actions:

• Call for a colleague to help you • Set up oxygen apparatus • Set up suction apparatus • Call for the code cart to be brought to the area • Communicate with the patient’s family (if present); tell them what you’re doing and why and that someone will be here shortly

to help them • Obtain proper documentation tools to be used during the RRT consult

RRT Arrival When the RRT arrives: 1. Provide information as indicated above. 2. Participate in the care of your patient and remain with the patient and the RRT. 3. Assist the RRT as needed. 4. Document activities, interventions performed, and patient responses to interventions. 5. Work with the chaplain to ensure that the patient’s family is informed of the situation at intervals. 6. Assist in arranging for transfer of the patient to a higher level of care if indicated. 7. Provide a detailed report to the nurse accepting the patient on the receiving unit, utilizing the SBAR communication method.

ACLS = advanced cardiac life support; cc = cubic centimeters; CPAP = continuous positive airway pressure; CPR = cardiopulmonary resusci- tation; hr = hours; HR = heart rate; ICU = intensive care unit; LOC = level of consciousness; MD = medical doctor; min = minute; mmHg = millimeters of mercury; NP = nurse practitioner; RN = registered nurse; RR = respiratory rate; RRT = rapid response team; SBAR = situation- background-assessment-recommendation; SBP = systolic blood pressure; SpO2 = arterial oxygen saturation; UOP = urine output; WBC = white blood count.

REFERENCES 1. Choo CL, et al. Rapid response team: a proactive strategy in managing haemodynamically unstable adult patients in the acute care hospitals.

Singapore Nursing Journal 2009;36(4);17-22. 2. Winters BD, et al. Rapid response systems: a systematic review. Crit Care Med 2007;35(5):1238-43. 3. Hillman K, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365(9477):2091-7. 4. Sharek PJ, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA 2007;

298(19):2267-74. 5. Mailey J, et al. Reducing hospital standardized mortality rate with early interventions. J Trauma Nurs 2006;13(4):178-82. 6. Dacey MJ, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007;35(9):

2076-82. 7. Benson L, et al. Using an advanced practice nursing model for a rapid response team. Jt Comm J Qual Patient Saf 2008;34(12):743-7. 8. Hatler C, et al. Implementing a rapid response team to decrease emergencies. Medsurg Nurs 2009;18(2):84-90, 126. 9. Bader MK, et al. Rescue me: saving the vulnerable non-ICU patient population. Jt Comm J Qual Patient Saf 2009;35(4):199-205. 10. DeVita MA, et al. Use of medical emergency team responses to reduce cardiopulmonary arrests. Qual Saf Health Care 2004;13(4):251-4.

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and Chen that he’s confident they’ll do a great job and shares his ex – cite ment at how the team has pro- gressed in planning an EBP practice change.

RRT protocol. Chen starts to draft the RRT protocol using one of the hospital’s protocols as a tem plate for the format, as well as definitions and examples of protocols, policies, and proce- dures from other organizations and the literature. She returns to the articles from the team’s origi- nal literature search (see “Critical Appraisal of the Evidence: Part I,” July 2010) to see if there is infor- mation, previously appraised, that will be helpful in this current step in the process. She recalls that the team had set aside some articles be cause they didn’t directly an – swer the PICOT question about whether to implement an RRT, but they did have valuable infor- mation on how to implement an RRT. In reviewing these articles, Chen selects one that’s a review of the literature, though not a sys tematic review, that includes

many examples of RRT member- ship rosters and protocols used in other hospitals, and which will be help ful in drafting her RRT protocol document.1 Chen includes this ex pert opinion ar- ticle be cause the informa tion it contains is consistent with the higher-level evidence already being used in the project. Using both higher and lower levels of evidence, when appropriate, al – lows the team to use the best infor – mation available in formulating their RRT protocol.

As she writes, Chen discovers that their hospital’s protocols and other practice documents don’t in – clude a section on supporting evi- dence. Knowing that evidence is critically important to the RRT pro tocol, she discusses this with the clinical practice council represen- tative from her unit who advises her to add the section to her draft document. He promises to present this issue at the next coun cil meet – ing and obtain the council’s ap – proval to add an evidence section to all future practice documents.

Chen reviews the finished product before she submits it for the team’s review (see RRT Protocol Draft for Review1-10).

Outcomes measurement plan. Based on the appraised evidence and the many discussions Rebe – cca and Chen have had about it, Chen drafts a document that lists the outcomes the team will mea- sure to demonstrate the success of their project, where they’ll ob tain this information, and who will gather it (see Table 1). In draf ting this plan, Chen realizes that they don’t have all the information they need, and she’s concerned that they’re not ready to move for ward with the stakeholder kick- off meeting. But when Chen calls Carlos and shares her con- cern, Car los reminds her that the document is a draft and that the re quired information will be ad – dressed at the meeting.

Education plan. Rebecca reaches out to Susan B., the clin ical educator on her unit, and requests her help in drafting the education plan. Susan tells Rebe cca how much

Table 1. Plan for Measuring RRT Success (Draft for Discussion)

Outcome Measurement Source/Owner

CRO • Codes outside of the ICU • EMR

Mortality rates: HMR and NIM

• Hospital mortality rates by unit • Discuss at meeting

UICUA • ICU admissions  planned  unplanned

• EMR; ICU admissions database; check box needed to indicate planned and unplanned

Return on RRT investment (cost of RRT compared with savings due to RRT)

1. Cost of RRT • Personnel • Supplies

2. Savings due to RRT • Cost of UICUA • Number of UICUA prevented

• RRT personnel cost/hour

• UICUA cost/day • LOS for average UICUA • Number of UICUA prevented

• Billing data • RRT response time and end time as re­

corded on the RRT data documentation tool

• Billing data • Disposition of RRT call as recorded on the

RRT data documentation tool

CRO = code rates outside the ICU; EMR = electronic medical record; HMR = hospital-wide mortality rates; ICU = intensive care unit; LOS = length of stay; NIM = non-ICU mortality; RRT = rapid response team; UICUA = unplanned ICU admissions.

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she enjoys the op portunity to work collaboratively with staff nurses on education pro jects and how happy she is to see an EBP project being implemented. Rebecca shares her RRT project folder (containing all the informa tion relative to the pro- ject) with Susan, focusing on the education about the project she thinks the staff will need. Susan commends the team for its efforts, as a good deal of the necessary work is al ready done. She asks Rebecca to clarify both the ulti- mate goal of the project and what’s most im por tant to the team about its rollout on the unit. Rebecca thoughtfully responds that the ultimate goal is to ensure that patients re ceive the best care possi- ble. What’s most im portant about its rollout is that the staff sees the value of an RRT to the patients and its positive impact on their own workload. She adds that it’s

im portant to her that the project be conducted in a way that feels pos itive to the staff as they work to ward sustain able changes in their practices.

Susan and Rebecca discuss which clinicians will need edu – cation on the RRT. They plan to use a variety of mechanisms, in – clud ing in-services, e-mails, news- letters, and flyers. From their conversation, Susan agrees to draft an education plan using a template she developed for this purpose. The template prompts her to put in key elements for planning an education program: learner objectives, key content, methodology, faculty, materials, time frame, and room location. Susan fills the template with in- formation Rebecca has given her, adding information she knows already from her expe rience as an educator. When Rebecca and

Susan meet to re view the plan, Rebecca is amazed to see how their earlier conversation has been transformed into a com- prehensive document (see the Education Plan for RRT Imple­ mentation at http://links.lww. com/AJN/A19).

Agenda and timeline. The team meets to draft the meeting agenda, implementation timeline, and budget. Carlos explains the purposes of a meeting agenda: to serve as a guide for the participants and to promote productivity and efficiency. They draft an agenda that includes the key issues to be shared with the stakeholders as well as time for questions, feed- back, and discussion (see the Rapid Response Team Kick­off Meeting Agenda at http://links. lww.com/AJN/A20).

Carlos describes how the time- line creates a structure to guide

Table 3. RRT Project Budget Draft (Draft for Discussion)

Annual Costs

Item Projected Cost/Unit No. Units Needed

Cost/Year Cost Center Approval Needed

Notes:

RRT pagers $30/month 8/month $2,880 Administration VP Nursing

Data collection

RRT leader, $45/hour

1 hour/month $540 Hospitalist VP Medical Affairs

Data entry Administrative assistant, $15/hour

1 hour/month $180 Nursing administration

Medical– surgical director

Data analysis

Data manager, $21/hour

1 hour/month $252 Quality Quality manager

First Year Start-Up Costs

Education prep

Advanced practice nurse, $45/hour

2 Project leaders, $30/hour

Nurse manager, $40/hour

6 hours

6 hours each

2 hours

$270

$360

$80

Total = $710

3 North Nursing 3 North Nurse manager

Unit educators will schedule their time to provide the in-services. No additional cost.

Education delivery

80 Staff members, $30/hour (average rate)

1/2 hour each $1,200 Departmental education budgets

Department managers

This is the cost for the pilot unit only.

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the project (see Table 2 at http:// links.lww.com/AJN/A21). The team further discusses how it can maintain the project’s momen- tum by keeping it moving for- ward while at the same time accommodate unexpected delays or resistance. There are a few items on the timeline that Carlos thinks may be underestimated― for example, the team may need more than a month to meet with other departments because of al- ready heavily scheduled calendars―­ but he decides to let it stand as drafted, knowing that it’s a guide and can be adjusted as the need arises.

Budget. Carlos discusses the budget with the team. Rebecca shares a list of what she thinks they’ll need for the project and the team decides to put this informa- tion into a table format so they can more easily identify any missing information. Before they construct the table, they walk through an imaginary RRT call to be sure they’ve thought of all the budget implications of the project. They realize they didn’t include the cost of each employee attending an education session, so they add that figure to the budget. They also realize that they’re missing hourly pay rates for the different types of employees involved. Car- los tells Rebecca that he’ll work with the Human Resources De- partment to obtain this informa- tion before the meeting so they can complete the budget (see Table 3).

REVIEWING THEIR WORK The next time they meet, the EBP team reviews the agenda for the meeting and the documents they’ll

be presenting. The clerical person on Rebecca and Chen’s floor (some- times called the unit secretary) has kept a record of who’s attend- ing the meeting and the team is pleased that most of the stake- holders are coming. Carlos in- forms the team that he received notification that their internal re- view board submission has been approved. They’re excited to check that step off on their EBP Imple- mentation Plan.

Carlos suggests that they dis- cuss the kick-off meeting in detail and brainstorm how to prepare for any negative responses to their project that might occur. Rebecca

and Chen remark that they’ve never considered that someone might not like the idea of an RRT. Carlos says he’s not surprised; of- ten the passion that builds around an EBP project and the hard work put into it precludes taking time to think about “why not.” The team talks about the importance of stopping occasionally during any project to assess the environ- ment and par ticipants, recogniz- ing that people often have different perspectives and that everyone may not support a change. Carlos reminds the team that people may simply resist changing the routine, and that this can lead to the sabotage of a new idea. As they explore this possible resis- tance, Rebecca shares her concern that with everyone in the hospital so busy, adding something new may be too stressful for some peo- ple. Carlos tells Rebecca and Chen that helping project participants realize they’ll be doing the same thing they’ve been doing, just in a more efficient and effective way, is generally successful in helping them

accept a new process. He reminds them that many of the people on the RRT are the same people who currently take care of patients if they code or are admitted to the ICU; however, with the RRT pro- tocol, they’ll be intervening ear- lier to improve patients’ outcomes. The team feels confident that, if needed, they can use this approach at the kick-off meeting.

CONDUCTING THE KICK-OFF MEETING Rebecca and Chen are both ner- vous and excited about the meet- ing. Carlos has made sure they’re well prepared by helping them set up the meeting room, computer, PowerPoint presentation, and handout packets containing the agenda and draft documents. The team is ready, and they’ve placed themselves at the head of the ta – ble so they can be visible and ac- cessible. As the invitees arrive, they welcome each one individu- ally, thanking them for participat- ing in this important meeting. The team makes sure that the meeting is guided by the agenda and moves along through the presentation of information to thoughtful questions and a lively discussion.

Join the EBP team next time as they launch the RRT project and tackle the real-world issues of project implementation. ▼

Lynn Gallagher­Ford is assistant direc ­ tor of the Center for the Advancement of Evidence­Based Practice at Arizona State University in Phoenix, where Ellen Fineout­Overholt is clinical pro fessor and director, Susan B. Stillwell is associate di ­ rector, and Bernadette Mazurek Melnyk is dean and distinguished foundation pro ­ fessor of nursing at the College of Nursing and Health Innovation. Contact author: Lynn Gallagher­Ford, lynn.gallagher­ford@ asu.edu.

REFERENCE 1. Choo CL, et al. Rapid response team:

a proactive strategy in man aging haemodynamically unstable adult patients in the acute care hospitals. Singapore Nursing Journal 2009; 36(4);17-22.

With the RRT protocol, staff will be intervening earlier to improve

patients’ outcomes.