Applying the Iowa Based Model

1. Applying the Iowa Based Model Allison Williams, Pharm D Ashleigh Mouser, Pharm D, BCPS Tyra Hodge, RN

2. The Iowa Modelat Ephraim McDowell Health • Ephraim McDowell Health adopted The Iowa Model as its model for promoting evidence-based practice • Provide an organized systematic approach using current research-based evidence to implement new practices and policies • Promote quality care at the unit level • Validate current practice

3. Promoting Quality Care with the Iowa Model Evidence-based practice is initiated when a practitioner pinpoints a clinical question or “trigger.” • Types of Triggers • Problem Focused Triggers • Knowledge Focused Triggers

4. Knowledge Based Trigger • New guidelines published on Treatment of Pain, Agitation and Delirium in January 2013: Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (Crit Care Med 2013; 41:263–306)

5. Knowledge Based Trigger

6. Knowledge Based Trigger • Medication Use Evaluation completed in October 2013 • Provide information on current practice at EMRMC • Compare with consensus recommendations to identify areas for improvement • Pain assessed at EMRMC ICU less than recommended • Analgesia administered pre-procedurally, less than recommended • Benzodiazepine most common sedative used • No routine delirium assessment

7. Is This A Priority For EMRMC YES • Lower pain scores • Lower ICU days • Lower mechanical ventilation days • Better patient care/satisfaction

8. Multidisciplinary Team • Primary Team • 2 Nurses with experience in ICU practice • 2 Pharmacists with experience in protocol/order set development • Also input from Nursing Director, Respiratory Therapy Director and Rehabilitation Services and Information Services

9. Additional Research • Guidelines served as primary source of research • Additional literature search in areas of ICU pain, sedation, delirium, early mobilization, sedation interruption, spontaneous breathing trials • Sufficient evidence (primary literature) published to move into policy development

10. Project Development • Team meetings: • Review literature • Determine which parts of the guidelines were practical to implement at this time and which were not*** • Compiled list of implementation goals: new nursing assessments, new physician order set, new policy • Determined those things outside the scope of this project: early mobilization protocol, spontaneous breathing trials

11. Nursing Changes • Selection of Bedside Assessment Tools for Monitoring Pain (communicative and non-communicative) , agitation and delirium • Validated Assessment Tools (as recommended by guidelines) • Critical Care Pain Observation Tool (CPOT) • Riker Sedation Agitation Scale • Intensive Care Delirium Screening Checklist (ICDSC) • Unit Based Council (CCU nurses) provided feedback on assessment tools • Assessments must be built in Meditech and tested

12. Policy Development • Review of current policies • Determined that no current approved policy covered this topic • Developed policy for Critical Care Pain, Agitation and Delirium Assessment and Management • Purpose of policy – to guide nurses in assessing and managing PAD and discussing options/recommendations with providers • Used guidelines as tool • Exceptions: Pain assessment frequency, more general guidelines for treating pain, early mobilization

13. Order Set Development • Research – search for order sets from similar institutions to use as a tool • Developed order set to guide physician order entry for managing PAD in ICU • Order set balance: Provide enough available pharmacologic options to suit physician preference while still guiding therapy as recommended in evidence (it has to be approved!) • CPOE • Need for individual provider education and addition to “favorites” to encourage routine use

14. Approval • Critical Care Committee • Medical Executive Committee • Pharmacy and Therapeutics (Informational)

15. Implementation • Education – nursing, pharmacists, providers • All CCU nurses attended required update on new guidelines • Newsletter article • Meditech Messengers – assessments • Order set build in CPOE • Policy/Order set bar code and add to Compliance 360

16. Post-implementation • Follow up Medication Use Evaluation to reassess progress • Possibly add Performance Improvement data to CCU dashboard after appropriate time post-implementation

17. Potential Barriers • Lack of Physician Champion • Creating time for Interdisciplinary Meetings • Convincing providers/nurses of the need for change in practice • Effective Education

18. Taking Evidence to the Bedside • Iowa model serves as tool for implementing evidence- based guidelines into practice at EMRMC • Multidisciplinary Approach • Practical approach to protocol and order set development • Front line care providers