Throughout many areas of hospitals, clinical teams are beginning to tap into standardized evidence-based data so that they can implement best practices as a way to supplement the knowledge gained through experience, colleagues, and mentors. At our 302-bed hospital at Berkshire Medical Center, clinical teams have developed protocols for more than 140 different clinical care scenarios based on data from evidence-based clinical decision support (CDS) systems. Use of the CDS system has resulted in improved outcomes. Although there are many CDS solutions available, our clinical team utilizes Zynx Health CDS.
Out With the Old, In With the New
In an effort to replicate successes seen in other clinical care scenarios, my colleagues and I at Berkshire Medical Center collaborated with a clinical team to develop an evidence-based colectomy module. It was designed to address the perioperative management of adults undergoing colon surgery. The module included medical evidence for each stage of surgery. After reviewing the evidence, we realized that we were practicing with old principles and without standardization. For example, it was discovered that several principles needed to be changed based on the current best practice evidence, including perioperative fluid intake, reintroduction of oral antibiotics, and postoperative use of antibiotics.
“The culture of quality initiatives coming from hospital committees and departments has been replaced by an environment where a multidisciplinary team develops and implements best practices.”
These practices were then modified to create a “fast track” colon surgery protocol that included techniques for reducing complications and costs while also decreasing pain, shortening length of stay (LOS), and facilitating earlier returns to everyday activities. Instead of developing committees and spending months building a complete program, we immediately implemented many of the best practices based solely on their medical merit. More difficult changes took place as the program matured. In a matter of week — rather than the months or years that it typically takes to see the fruits of our initiatives — we observed the following enhancements:
Wound infections decreased from 17% to 14%.
Postoperative respiratory complications decreased from 11% to 6%.
Urinary tract infections decreased from 5% to 4%.
Septic shock decreased from 2% to 1%.
In addition, mortality rates decreased from 1% to 0%, and costs were reduced. Moreover, the average surgical LOS dropped from 8.4 days to 5.8 days.
Promoting a Culture of Quality
Our findings have led to greater implementation of these strategies in other surgical areas, including joint replacement, thyroid surgery, robotic prostatectomy, and hip fracture. At our institution, the surgical team is now leading change. The culture of quality initiatives coming from hospital committees and departments has been replaced by an environment where a multidisciplinary team develops and implements best practices. The experience has been positive, as we’re better reaching our goals of delivering the best clinical care in a timely and organized approach.
Readings & Resources (click to view)
Counihan TC, Favuzza J. Fast track colorectal surgery. Clin Colon Rectal Surg. 2009;22:60-72.
Merkow RP, Ko CY. Evidence-based medicine in surgery: t: The importance of both experimental and observational study designs. JAMA. 2011;306:436-437.
Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008;248:189-198.
Baird G, Maxson P, Wrobleski D, Luna BS. Fast-track colorectal surgery program reduces hospital length of stay. Clin Nurse Spec. 2010;24:202-208.
Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72.
Turkelson C, Hughes JE. Why aren’t you doing evidence-based practice? AAOS Bulletin. 2006;54:1-4.
Jennings BM, Loan LA. Misconceptions amongst nurses about evidence-based practice. J Nurs Scholarsh. 2001;33:121-127.
Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust. 2004;180(Suppl):S57-S60.