On Low-Value Nursing Care: Part 2, De-implementing Practices in Your Unit

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

Implementing evidence-based practices and de-implementing outdated practices occur on the same continuum. Both align with the culture of safety of high-reliability organizations. Adopting best practices is triggered when new science demonstrates that the procedures are safe and effective. De-implementing practices (ie, removal, replacement, reduction, or restriction) is indicated as evidence no longer confirms the benefit or shows harm of those practices.1–4 High-reliability organizations’ principle of preoccupation with failure (or anticipation of risk) is fundamental to disinvesting in low-value care to attain zero harm.5Much like the implementation of evidence-based practices, de-implementation of outdated practices requires behavior change. As little is known about eliciting behavior supportive of de-implementation, the PICO (patient/population/problem, intervention, comparison, and outcome) question for this synthesis was this: What de-implementation interventions are effective in reducing low-value practices in high-acuity and critical care nursing?The strategy included searching CINAHL, OVID and PubMed. Key words were sacred cows, tradition-based, low-value care, de-implementation, nursing, critical care, and interventions. The search was limited to evidence focused on critical care.Only 2 studies were retrieved (see Table). One report was a case study and the second was a systematic review. Single and multifaceted interventions were used to reduce unnecessary laboratory tests, catheters/drains/tubes, medications, and occlusive chest tube dressings and to replace techniques for bathing and assessing enteral feeding tolerance.The level of evidence for de-implementation interventions ranged from level A (systematic review) to level E (case study). In this sparse evidence base, single educational and multifaceted strategies were influential in decreasing low-value practices, although this range was wide (0.4%-61.9%). Multifaceted interventions like stakeholder support, targeting biases, and decision tools/evidence-based practice guidelines supplemented education. De-implementation research in other settings and disciplines has yielded similar results. In a non-ICU study, inappropriate use of venous and urinary catheters was reduced by 6% via tailored multifaceted strategies such as education about appropriate indications, posters/pocket cards, and competitive unit feedback reports.8 In another systematic review, multicomponent interventions combining education with decision support or feedback effectively reduced overuse of medical services.9 These findings support active multifaceted approaches tailored to context.1,10 Further research on the effectiveness of de-implementation interventions is needed within critical care.In part 2, “De-implementing Low-Value Practices,” we continue the de-implementation process (Figures 1 and 2). In step 4, graded performance is used to initiate dialogue about low-value practices among stakeholders.17,18,27,36 Parch-man et al2 referred to this interchange as “sense-making conversations,” where teams establish shared language to resolve tensions over potential harms and create a shared need to reduce overuse. Thus, appraised evidence needs to be converted into useful information to convey the quality and quantity of evidence to help clinicians break existing practice loyalties and adapt to innovations with stronger evidence or disinvest in certain practices altogether.3,14 Clinical champions have noted that including the patient’s voice by sharing stories of harm also facilitates the discussion about overuse.11Even when clinicians know the evidence, “extra-scientific factors” that often drive tradition-based practices make change difficult13,20 (Figure 1). At the individual level, for example, psychological biases pave the way to contestability of the evidence.18 De-implementation can also threaten professional autonomy, affecting acceptability and resistance.29 Innovation tendency further influences de-adoption. Late adopters and laggards—most likely skeptical of the practice from the onset—may be easier to influence, as are early adopters, who are open to new evidence and become “reappraisers.”1,15,29 At the unit/ organizational level, some climates welcome optimizing resources/efficiencies and reducing practice burdens, whereas others resist change.1,13 Teams whose members gain understanding of human and system barriers and facilitators of de-implementation (Figure 3) increase their likelihood of success.2In step 5, low-value practices are prioritized. Factors to consider include evidence of benefit/ harm, prevalence of use, substitution options, and resource availability.1,21,28 Engaging teams in this process enhances ownership of de-implementation goals. Casting these priorities into a larger patient safety/quality agenda may also improve willingness to disinvest.18Once prioritized, multifaceted interventions (step 6) are delivered at the clinician, team, organization, and/or health care system level.37 Selected interventions should be practice, context, and barrier specific because each type of de-implementation presents unique challenges for learning new knowledge/skills and unlearning what was believed to be effective, replacing it with an alternative practice (except “removals”)1,4,10 (Figure 1). Deeply ingrained practices will be more difficult to de-implement, requiring more intense strategies than would be needed to substitute new or modified practices (unless the new or modified practices require more time, resources, and skills training).1,27,28 Communication tools like huddle boards and gemba rounding, decision aids at the point of care, and audit/feedback are critical to support de-implementation goals.14In steps 7 and 8, low-value practices are de-implemented by using tests of change. The impact of reduced overuse can be assessed with feasibility/cost, fidelity, sustainability, and penetration outcomes25 (Figure 1). Thus, return on investment may be quantified by the human cost of lessened harm (cost avoided for adverse events/complications, patient dissatisfaction) and improved efficiencies in care delivery (less wasted time/resources). To sustain new practice routines, divested practices need accompanying changes in policies/procedures, workflows, documentation and other ongoing reinforcements.4,10,23,29As teams prioritize the next low-value practice (step 9), the cycle repeats (Figure 2). By closing these practice gaps and becoming more mindful of implementing practices that are based on solid scientific evidence, the need for disinvestment diminishes.37 Through these implementation and de-implementation strategies, clinicians contribute to safe, efficient, high-quality patient-centered care in a high-reliability framework.