ACADEMIC EMERGENCY MEDICINE 2010; 17:865–869 © 2010 by the Society for Academic Emergency Medicine
The 2007 Academic Emergency Medicine (AEM) consensus conference “Knowledge Translation in Emergency Medicine” yielded a number of initiatives in both education and research that directly reflected the conference’s published objectives and recommendations. One research initiative, CONCERT, is a national consortium of chronic obstructive pulmonary disease (COPD) investigators who set forth an effort designed to optimize COPD care through the identification of gaps between research and practice in diagnosis and management of the chronic and acute care aspects of this disease. In addition to CONCERT, educational programs designed to identify barriers to evidence implementation and to develop solutions to achieve uptake through multidisciplinary collaboration have emerged that reflect the impact of the consensus conference. This article describes these initiatives and highlights the potential for future innovative opportunities.
In 2007, Academic Emergency Medicine (AEM), with the help of a small conference grant from the Agency for Healthcare Research and Quality (AHRQ; HS017002), sponsored a consensus conference on knowledge translation (KT). This conference had as its objective the articulation of a research agenda and coordinated initiative in the specialty of emergency medicine (EM).1 The conference yielded a series of consensus papers that prioritized research directions and questions in KT as perceived from a myriad of scientific, educational, and policy perspectives.2–14 The objective of this article is to describe one research and two educational enterprises that were either modeled on or arose from the 2007conference.
Approximating the gap between published knowledge of evidence-based interventions and their implementation in practice remains an obstacle to improving patient care and health care delivery.15,16 While the research enterprise in the specialty of EM has matured, advances published in scientific journals and disseminated through traditional continuing medical education meetings often fail to achieve systematic changes in practice.17,18 Addressing this issue has created a scientific and educational domain dedicated to improving the uptake of evidence-based diagnostic and therapeutic strategies. KT, also known as implementation science, seeks to identify gaps between research and practice, to understand barriers to optimal evidence uptake, and to develop optimal strategies for achieving widespread uptake of research-supported interventions.
Among the priority areas for research and education in KT identified by the consensus conference, several have direct bearing on the initiatives that are described here. For example, one consensus paper emphasized the importance of collaboration with other health care disciplines in EM, as well as with other specialty groups, in designing implementation studies.2 Multicenter collaborations for determining optimal routes of implementation for evidence-based interventions were particularly emphasized. Such interventions frequently involve complex interventions, as patients transition from the care of one multidisciplinary team to another. The research collaboration described below has direct bearing on that component of the consensus recommendations.
On the policy front, the consensus conference authors emphasized the importance of widespread uniformity related to the adoption of specific guideline development methodologies.10 A consensus paper that focused on continuing medical education stressed the importance of adopting content and formats that encourage multidisciplinary interaction and exchange on specific aspects of clinical care.6 Specifically, the consensus article recommended that the objectives of such sessions should include an analysis of barriers and facilitators to inform the design of strategies to achieve evidence-based care for topic areas that represent significant gaps in care. Both of the educational initiatives described in detail in this paper reflect the thrust of these consensus conference statements and emphasize the interprofessional education whose value is supported by high-quality educational research.19
Emergency medicine is not the only field of medicine to struggle with gaps between evidence-based care and what actually filters its way through to clinical practice. Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and affects approximately 24 million people in the United States alone.20 COPD is a chronic lung disorder characterized by dyspnea, cough, and limitations in activities of daily living, which, in the developed world, is largely due to tobacco smoke. Unlike other leading causes of death in the developed world, deaths from COPD are rising. In the United States, for example, COPD is expected to surpass stroke and become the third leading cause of death by 2020.
Studies have demonstrated that the care and outcomes of patients with COPD vary substantially and that many patients are not benefiting from advances in research identified in clinical trials of efficacy.21,22 A major contributor to this practice variation is the lack of data about the effectiveness of treatment strategies in “real-world” clinical practice (thereby providing clinicians the information they need to select the most beneficial therapies) and about how to implement best practices across different health care settings.
To address these critical gaps in knowledge, funding from the AHRQ (HS017894) and the National Heart, Lung, and Blood Institute (NHLBI; HL101618) was used to develop a research infrastructure that promotes interactions and collaborations between those who generate, disseminate, and use new knowledge in COPD (COPD Outcomes-based Network for Clinical Effectiveness and Research Translation [CONCERT]). CONCERT includes a multicenter consortium of interdisciplinary investigators with expertise in COPD, clinical medicine, behavioral science, clinical trials and health services research, epidemiology, and implementation science. In May 2009, CONCERT convened a consensus meeting for chronic COPD care and care coordination (“Setting effectiveness and translational research priorities to improve chronic COPD care and care coordination”) to develop a national research agenda for effectiveness and implementation research in COPD. There were 41 participants from the United States and Canada, and they served as representatives of various stakeholder groups, including physician specialties, nurses, respiratory therapists, health care systems, government agencies, patient advocacy groups, and payers. CONCERT investigators were informed by some of the methodologic approaches devised to help establish a KT research agenda in EM,23 including the development of a broad and inclusive base of stakeholders, working groups of stakeholders who met via teleconference to generate and vote on a provisional list of research topics prior to the meeting, and use of a modified Delphi approach to develop a final consensus-based national research agenda.
CONCERT investigators are now developing grant proposals in chronic COPD care and care coordination in collaboration with stakeholders to address priorities established by the research agenda, ensuring that effectiveness and implementation studies conducted by this group provide actionable information to end users. Similar activities are under way to convene a consensus conference in acute COPD care and transitions in care in May 2010, which will include representatives in EM.
Teaching Evidence Assimilation for Collaborative Health
The Teaching Evidence Assimilation for Collaborative Health (TEACH) is a longitudinal workshop exercise that was developed as a model for the next generation of professional development courses in evidence-based care. Funded by AHRQ (HS018607) and sponsored by the New York Academy of Medicine, TEACH posits a vision in which the skills and disciplines pertaining to guideline and health policy development, policy implementation, quality improvement in care settings, and integrated clinical practice skills are developed in a mutually reinforcing fashion. A team of educators emerging from the AEM KT consensus conference, who had expertise in both KT and evidence-based medicine, designed a program aimed directly at linking training experiences to care initiatives within subscribing health care institutions. Within TEACH, organized evidence-based care initiatives and related on-site educational programs become an educational outcome of conference and workshop activities. The workshops are designed for participants from a number of different health science disciplines and clinical specialties, with participant teams recruited from within participating centers.
The first track within the TEACH conference framework deals with the methodology of health policy and guideline development. The content centers around the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, whereby recommendations for care are based on system-atic evaluations of research evidence, juxtaposed on considerations of the value and preferences associated with specific outcomes.24 These statements describe the strength of the recommendations along with a description of the strength of evidence that supports the recommendations. Unique to the GRADE methodology is the explicitness of the process, which leads to a grading of the strength of the evidence and how specific outcomes were prioritized from a values and preferences perspective to achieve clinical guidance. The GRADE approach constitutes a far-reaching initiative in the domain of health care policy and has been adopted by dozens of medical organizations and societies.
In the second track, entitled “Knowledge Translation,” participants, largely from the same institution, draw on the fruits of implementation science and the evidence in support of or against interventions aimed at facilitating evidence uptake for the purpose of developing comprehensive patient care pathways for a particular condition within their home institutions. For example, one of the multidisciplinary groups in this track in 2009 dedicated the workshop experience to developing a program for the care of congestive heart failure informed by best evidence from clinical research, knowledge of KT interventions, and contextual knowledge of the primary challenges to care in their institution.25
The third of the three tracks, entitled “Evidence-Based Individualized Decision-Making,” is dedicated to the challenges of connecting the process of understanding the methodologic strength and limitations of research evidence and the quantitative results of a synthesis of best evidence and matching it to the values and preferences of patients. Inspired by the notion that evidence alone is never sufficient to be the sole guide to clinical decision-making, the participants in this track drew upon the constructs of narrative medicine as one of the tools that can help provide practical substance to the application of research evidence in a shared decision-making model that maximizes patient input.26
Perhaps the most unique aspect of the TEACH project is the longitudinal nature of the program. As a means of sustaining the institution-specific plans for effecting change based on the three tracks, the home-site initiatives are supported by various means, including site visits combined with ongoing facilitation on the part of the TEACH faculty, to assure that the ongoing activity born out of the intensive workshop experience is maintained.
Knowledge Translation Workshops at the American College of Emergency Physicians (ACEP) Scientific Assembly
Continuing medical education (CME) has been dominated by didactic approaches to transmitting information and the latest developments from clinical research in the hopes that the messages will be retained and incorporated into practice. Unfortunately, studies examining the effectiveness of traditional CME have met with generally dismal results.18 Educational formats that have been shown to have positive effects on practice involve small group discussion among clinicians around specific clinical topics with an attempt to problem-solve in a collaborative environment.27 Another limitation of traditional CME is the failure to consider barriers or facilitators to evidence uptake. It may seem reasonable to introduce and advocate for the adoption of new practice patterns based on available evidence; however, without a consideration of the barriers to adopting a given practice in a consistent and potentially systems-level based approach, knowledge may not translate into practice. Similarly, without specifically planning for strategies that will enhance evidence uptake, simple awareness of practice improvement opportunities rarely result in sustained changes over time.28,29
With these limitations in mind, and drawing from the research gaps described in the consensus conference article on KT issues in CME, a series of interactive workshops was devised and executed at the ACEP Scientific Assembly over the past 3 years. These sessions shift the conventional emphasis on didactic presentations of research suggesting potential advances in practice to a discussion of optimal implementation strategies informed by expertise in KT. The KT workshops center on specific clinical topics and focus on practice improvement opportunities identified by gaps between high-quality and robust research evidence and currently limited implementation. The first workshop in the series was dedicated to the use of therapeutic hypothermia (TH) for the comatose survivors of cardiac arrest. While research has shown that TH appears to have a greater effect on survival than any other known therapy in this patient group, widespread implementation is lacking.30,31 Subsequent workshops examined reducing door-to-balloon times in the care of patients with ST-elevation myocardial infarction who undergo primary angioplasty, reducing ED crowding through implementation of an overcapacity protocol, and improving the care of septic patients through the delivery of early goal-directed therapy. Similar practice gaps were identified for each of these interventions.32–34
The format of these KT workshops follows a consistent architecture. Participants who signed up for these sessions receive a preconference survey to determine the extent to which the intervention targeted by the workshop (e.g., TH) is already in place in their institutions. Additional questions are aimed at an exploration of the perceived obstacles to a more consistent and widespread adoption of the practice in question.
At the start of the workshop itself, a short series of plenary presentations given by content experts in the field outlines the evidence for the workshop theme and describes some of the characteristics associated with a successful implementation program. Results of the preworkshop survey are also presented. The next phase of each of the sessions involves dividing the participants into two or three facilitated and focused discussion groups that encompass relevant themes such as nursing issues, critical care perspectives, and practical considerations for adopting the intervention. The group members share experiences around implementation issues and brainstorm about promising solutions to optimize the development and uptake of a clinical protocol in the area of interest. Finally, the discussion groups reconvene and share their collective wisdom with the larger group in a process we described as “rapportage.”
Participants at these workshops are invited to join online discussion forums to continue the exchange and collaboration that was initiated during the workshops. These online forums have met with limited success and technical difficulties. Improving such interactions may serve as an important area for further exploration.
Increasingly, therapeutic and diagnostic interventions in EM, especially those of a complex nature, are inherently multidisciplinary. Specific to the topics that have been selected for the KT workshops described here, interventions related to TH and sepsis care require collaboration with nursing and intensive care medicine just as measures to reduce door-to-balloon times in patients with ST-segment elevation myocardial infarction require input from cardiologists and prehospital providers. Insofar as KT is contingent on this input, the KT workshops have featured faculty and participant contributions from the very disciplines we have described. The compelling nature of multidisciplinary collaboration on these issues has made possible cosponsorship of these sessions by non-EM organizations, including the American Heart Association and the American College of Cardiology, as well as integration of nonemergency and nonphysician faculty in the sessions.
The 2007 Academic Emergency Medicine consensus conference on knowledge translation has spawned and inspired federally funded and nationally sponsored innovative programs in education and research of a nature that conforms to several stated objectives of that project.
Agencies that supported the 2007 Academic Emergency Medicine consensus conference: 1) Agency for Healthcare Research and Quality, 2) National Institutes of Health, and 3) Canadian Institutes of Health Research. The support included funding to travel to Chicago for ESL.