Overcoming challenges with getting current evidence into practice

This is the authors' abstract. We don't add key points for this paper.

Creating a framework for clinical decision-making that considers feasibility, appropriateness, meaningfulness, and effectiveness has been the aim of the JBI Model for evidence-based health care since it was developed in 2005 and revised in 2019.1 This model outlines the steps for moving from original research to robust synthesis, and then transfer and implementation to support global adoption of best practices.1 However, despite many technological advances in the past 20 years and instant access to information, there is still a significant gap between primary research and full adoption of health care innovations into practice. When this knowledge-to-practice gap was studied in 2000, the estimate was an average of 17 years from the conduct of randomized controlled trials to incorporation into practice.2 That number has not been updated through rigorous study in recent years, but the literature is full of references supporting the hypothesis that a significant gap still exists, including in primary care3 and occupational therapy,4 for example. So what is standing in the way of adoption of best practices, as indicated by the available evidence, as the standard of care? Although the transfer and implementation of new knowledge into practice can take several years, evidence synthesis has become much more common in the past 25 years. The exponential rise of systematic reviews is apparent from a basic search of PubMed. From 1996 to 1997, only 270 citations appear when using the search term “systematic review,” but in 2022 alone, nearly 52,085 citations are returned with that same basic search. These sources of secondary data analysis are intended to form the basis for informing practice and policy, yet transfer and implementation of these findings into a format that can be used at the bedside remains a challenge. With the availability of curated and peer-reviewed data online, embedded clinical decision–support tools in electronic medical records, and easy access to the newest information, it would seem that providing care aligned with best practice should be more common. Yet, disparity remains between the best evidence and actual practice in many cases. In an opinion article by Braithwaite et al., 5 it was estimated that only 60% of care was in line with published consensus guidelines and that up to 10% of care could actually be harmful to patients. This rift is at the heart of why evidence transfer and implementation are so important.1 To illustrate the application of the JBI Model as a framework for moving from synthesis to transfer to implementation, consider a clinical scenario of particular interest to our team at Rosalind Franklin University of Medicine and Science. One of the most common complications after surgery is postoperative nausea and vomiting (PONV).6,7 Inadequate management of PONV in the postoperative period can have significant consequences for patients. Outcomes range from mild discomfort to wound dehiscence that requires reoperation and increased hospital length of stay. A multimodal approach to managing this potentially severe complication has been promoted for several years. A combination of intravenous prophylactic medications, including dexamethasone along with another 5-HT3 blocking agent, has shown to be more effective than any single agent alone.6,8 However, concerns remain about the use of dexamethasone for patients with diabetes because of the potential to increase blood glucose levels.9,10 Much of the concern regarding elevated glucose levels is related to the potential for postoperative surgical site infections. Despite this, no studies have shown an increase in surgical site infections related to a small increase in glucose levels.11 Presented in this month’s issue of JBI Evidence Synthesis, our team conducted a systematic review that pooled results from 11 studies that demonstrated a small but consistent increase in blood glucose levels among patients with diabetes who received a single intravenous dose of 4 to 10 mg of dexamethasone.12 The clinical implications of this increase in blood glucose levels is likely negligible and easily managed with exogenous insulin administration if required,13 reinforcing the safety and effectiveness of combination therapy, including dexamethasone. Additional benefits beyond alleviation of PONV to support administration of dexamethasone include reduced systemic inflammation and pain reduction.14 Based on the evidence, providers who care for surgical patients with diabetes may consider administrating dexamethasone to prevent PONV as part of a mutimodal strategy. This is just one example of where the evidence supports a practice change, but clinicians are reluctant to implement it. The proliferation of evidence syntheses in research indicates that researchers continue to see disconnects between what the evidence is indicating and what clinicians are implementing in their practice. Ongoing efforts are required to narrow the gap and increase the focus on evidence transfer and implementation. To guide clinicians toward implementing the best-available evidence, we must focus on how we train clinicians. Instituting an interprofessional curriculum that includes the tenets of implementation science in medical schools, nursing programs, and other allied health professions will provide a foundation for understanding the steps involved in evidence implementation that can proliferate throughout their careers. In addition, investing in the development of clinicians in practice who have an interest in implementation science, through workshops and mentoring by JBI Centres of Excellence and Affiliated Groups, can increase the number of people with the tools and training to overcome barriers to change. At Rosalind Franklin University of Medicine and Science, we have embraced the JBI Model and integrated it throughout the curriculum of our graduate nursing programs. Our JBI center is a resource for all of the various health professions programs at the university. Our aim is to narrow the knowledge-to-practice gap through education, collaboration, and a commitment to lifelong learning.