UTA NURS 4325 - Deimplementation in Clinical Practice

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Clinical InquiryMary Beth F. Makic is Professor and Clinical Nurse Specialist Program Director, College of Nursing, University of Colorado Anschutz Medical Campus, 13120 East 19th Ave, ED 2 North, Room 4213, C288-19, Aurora, CO 80045 ([email protected]). Bradi B. Granger is Professor, Duke University School of Nursing, and Director, Duke Heart Center Nursing Research Program, Durham, North Carolina. The authors declare no conflicts of interest.DOI: https://doi.org/10.4037/aacnacc2019607Why does evidence matter? Without question, the overarching aim of nurses and organizational leaders in clinical practice settings is to improve patient outcomes through the diligent use of evidence in the delivery of care. However, we fall short of that goal, as first highlighted almost 20 years ago in the Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century.1 This highly publicized report was the first to cite the wide gap in the US health care system between the high cost of care and poor quality of care outcomes. In addition, the report empha-sized the unacceptably long time required to move new evidence into the fore-ground of clinical practice arenas.1,2 To help close the quality gap, the Institute of Medicine partnered with the Robert Wood Johnson Foundation to commis-sion the report Future of Nursing: Leading Change, Advancing Health,3 in which these gaps were explored and specific roles of nurses in improving health care quality were clearly defined. Among the nursing roles articulated in the report were specific opportunities and responsibilities associated with improv-ing the conduct of research and dissemination of research findings in clinical practice settings. Specifically, recommendation 2 in the 2011 report called out nursing’s role in achieving more evidence-based care delivery by 2020, in part through leading interprofessional collaboration in improvement efforts across clinical settings.4 The National Academies of Science, Engineering, and Medicine have since established a committee to assess and report on progress toward the goals established in 2011 for achieving evidence-based clinical practice settings by 2020.5 Findings thus far indicate that most goals set in 2011 have yet to be achieved, particularly those related to evidence-based care.5 Examples cited in the report suggest that although interprofessional education has increased in terms of raw numbers of programs offering courses, the results in terms of collaborative decision-making and use of evidence in practice remain largely unmeasured and difficult to assess. Two studies showed improved safety when nurse-led interprofessional collaboration was effectively employed to improve Bradi B. Granger, PhD, RNDepartment EditorAACN Advanced Critical CareVolume 30, Number 3, pp. 282-286 © 2019 AACNDeimplementation in Clinical Practice: What Are We Waiting For?Mary Beth F. Makic, PhD, RN, CCNS, CCRN-KBradi B. Granger, PhD, RN282https://www.coursehero.com/file/67991989/Deimplementation-in-Clinical-PracticeWhat-are-we-waiting-forpdf/This study resourcewas shared viaCourseHero.comCLINICAL INQUIRYVOLUME 30 • NUMBER 3 • FALL 2019283the use of evidence in practice5,6: one study demonstrated fewer adverse drug events7 and one showed reduced central line–associated infection rates.8 And yet, despite isolated suc-cess in demonstrating improved quality through interdisciplinary work to implement evidence, the findings suggest we have a long way to go. In fact, as described in the National Acad-emies of Medicine progress report on the future of nursing5 and an American Association of Colleges of Nursing report9 (both of which highlight the role of nursing in advancing health care transformation), quality and value can best be achieved through interprofessional col-laboration and thoughtful, team-based consid-eration of the evidence that supports or does not support existing practice. Although both reports focus on improving adoption of evi-dence in practice, an equally essential character-istic of an effective implementation scheme is knowing when to stop implementing. The success of implementation and the appropriate metrics to use to evaluate that success depend on whether the use of evi-dence in practice (adoption) actually improves patient outcomes. Implementation and the outcomes related to it can be measured and evaluated by describing the work in 3 areas: (1) knowledge of existing, relevant evidence at the point of care; (2) innovative strategies used to implement evidence; and (3) evaluation of the adoption of evidence and the extent to which innovative models of evidence adoption are used or cease to be used.10 Although reports of evi-dence adoption, or implementation success stories, are prevalent in journals and profes-sional symposia, we propose that thoughtful, patient-centered deimplementation can also improve patient and health system outcomes and requires broader dissemination in con-temporary literature and public forums.DeimplementationAdvancing nursing practice requires individ-ual nurses to critically examine their practice to ensure practice traditions are challenged and best evidence guides interventions. In addition, nurses, as the largest health care professional body, have the opportunity to advance best practices through adoption of evidence-based practice and deimplementation of practice tra-ditions. Deimplementation is the process of identifying and removing ineffective and pos-sibly harmful interventions from practice.11 Practice traditions, also referred to as low-value care, provide little benefit to the patient, waste resources (material and human), and may cause patient harm.11-13 Low-value interventions have limited evidence to support them, yet the rou-tines are part of practice habits. Questioning practice to identify low-value interventions should be part of all nurses’ clinical inquiry practices. The next steps are to critically evaluate the evidence and remove low-value interventions from practice habits. Through questioning practice traditions and eliminat-ing low-value interventions, nursing practice moves closer to the ideal state—that of fully embracing practice interventions based on current best evidence, which will then help optimize patient outcomes and, often, reduce costs. In a systematic review conducted in the Netherlands,12 66 low-value nursing inter-ventions within 125 clinical practice guide-lines were

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