Barbara Raymond Maura Ricketts (presenting) Jess Rogers Lisa Paddle Valerie Palda Jill Skinner

Barbara RaymondMaura Ricketts (presenting)Jess RogersLisa PaddleValerie PaldaJill Skinner

PHPC CPD Event

9 June 2013

2

Research Funding

1. National Collaborating Centre for Infectious DiseasesM. Ricketts

2. Public Health Agency of Canada PHACCentre for Effective PracticeCanadian Medical Association

3

• PH response successful– Health care system strained– Front line health care provider planning did not

advance as far as PH post-SARS• Post H1N1 need to establish strategies &

processes– guidance development

• rapidly & despite limitations of evidence– knowledge translation for front-line clinicians

• clinically relevant– communication with front-line clinicians

• information designed for clinical care providers

Lessons Learned: 2009 H1N1 pandemic

4

• Strategy needs to be established now, in “peacetime”, to ensure an effective response during a PH emergency

• Strategy could be tested during inter-pandemic periods e.g. seasonal influenza, novel corona virus etc.

• Strategy should serve all-hazards response

Lessons Learned: 2009 H1N1 pandemic

5

Goal of Project 1

• Evidence Review of Health Systems Strategies to Respond to 2009 pH1N1– Literature review– Synthesis report

6

Health Systems Strategies1. Linkages between Primary Care and PH (PH Lead)

– Create processes, governance & capacity during inter-pandemic period

– Integration of HC provider needs into pandemic planning – Health care system oriented surveillance

2. Diversion (Health Care Lead)– of the public away from the formal HC system through

self-screening, expanded anti-viral access etc.

3. Triage (Health Care Lead)– Tools used in clinical settings to separate urgent from

non-urgent

4. Medical Surge Management (Health Care Lead)– Emergency response plans, extension of HCP roles,

human resources management etc.– Duration of surge management is extended

7

Goal of Project 2 Maximize HCP clinical knowledge about how to effectively treat their patients by …

Improving the quality and timeliness of clinical guidance provided to Canadian health care providers (HCP) …

during an influenza pandemic/PH emergency…

through the development of a strategic plan describing1. infrastructure2. processes & 3. products

for clinical guidance1. creation (guidance development) 2. communication, Dissemination and Implementation3. evaluation

made for Canada’s social, political, geographical and economic realities & …

using what we already have | not “reinvent the wheel”

8

What is “Guidance”

•Guidance includes but is not confined to Clinical Practice Guidelines (CPG)

• CPGs are distinguished by practice of limiting the recommendation based on evidence

• Some guidance is relatively stable e.g. respiratory precautions

• Some guidance will be based on rapidly evolving and changing information, iterative and unstable

9

Guidance Development Working Group (GDWG)

4 Meetings 10-12 Members

Guidance Development Process and Tools1.Pre-Pandemic2.Intra Pandemic

Communication and Dissemination 1.Strategy 2.Plan (tactical)

Communication and Dissemination Working Group (CDWG)

4 Meetings 10-12 Members

Evaluation Framework

Output

Output

Structure Advisory Committee

4 Meetings + attending Consultation Workshop15-18 Members (TBC)

– Dr. Bonnie Henry (BCCDC)– Dr. Adam Steacie (CMA– Madeleine Ashcroft (CNA)– Susan Bowles (CPharmA)– Dr. David Allison (CPHA)– Dr. Val Rachlis– Kristin Stewart (CHNC)– Dr. Allison McGeer– Dr. Cecile Tremblay

(INSPQ)– Dr. Brian Schwartz (PHOn)– Dr. Barbara Raymond

(PHAC)– John Wooton (SRuralPhysC)– Dr. Reka Gustafson (UPHN)

Advisory Committee

CEP Team– Dr. Valerie Palda – Jess Rogers– Caroline Higgins

WG members– Dr. Todd Hachette (AMMI)– Dr. Daniel Kollek (CAEP)– Dr. Michael Christian (CCS)– Yvone Burland (Nursing, FNIHB)– Alfred Gin (Pharmacy, CPhA)– Dr. John Maxted (CFPC)– Patty Lindsay (guidance

specialist)– Michael Bingley (nurse

practitioner)– Irmajean Bajnok (RNAO)– Dr. Eliana Castillo (SOGC)– Althea House (PHAC)

Guidance

12

Guidance Development WG

• Modifications to existing guideline methodology to adapt to the needs of a guidance process used during a pandemic

• Products1. Guidance Inventory

2. Search & AGREE II assessment

3. Inter-Pandemic Guidance Process (Handbook)

4. Pandemic Expedited Guidance Process (Handbook)

CMA Team– Dr. Maura Ricketts– Jill Skinner– Marion Fuller

Supported by Survey Group

– Lynda Buske– Anna Murphy Dow

WG members– Dr. Bonnie Henry (BCCDC)– Dr. Jane Brooks (CMA)– Coleen Brooks (CNA)– Elizabeth Moreau (CPS)– Eric J Mang (CFPC)– Dr. Ada Bennet (PHPC)– Erin Henry (FNHIB)– Dr. Lee Donohue (OMA)– Cecilia Van Egmond (PHAC)– Nicole Kain (researcher)– Natalie Wright (SOGC)– Jess Rogers (CEP)

Communications, Dissemination & Implementation

Goal1. Develop a strategy for the effective delivery

of clinical guidance to HCPs providing front-line clinical care during influenza pandemics.

2. Make recommendations regarding 1. the structure and processes needed to

efficiently deliver clinically-relevant knowledge products (HCP-adapted clinical practices) to front-line HCPs

2. identify and propose solutions for the management of communication barriers to the adoption of the knowledge products by end-users

Framework Development• Examine the ‘lived experience’ of HCP using

published information from pH1N1

• Identify strategies used during pH1N1, implemented after pH1N1 or recommended following pH1N1

• Identify strategies (of known effectiveness) to address those barriers

• Information sources– In principle, using peer-reviewed KT/implementation

literature– In practice, using published reports – Surveys

K2A: Evidence-based input

Lavis et al. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Quarterly, 2003

17

If we know what clinicians prefer in general, what would they have preferred to have during pH1N1? What worked?

Framework for Report

(1) Products(1.1) Tailored communications products(1.2) Evaluation

(2) Processes(2.1) Joint planning and collaboration(2.2) Delegation of clinical decisions to HCPs(2.3) Improved intergovernmental communication

(3) Infrastructure(3.1) Creation of structures to serve HCPs(3.2) Improve PH’s capacity to link with the acute-care system

Preliminary Data from Stakeholder Surveys

Jill Skinner (Public Health Group, CMA)

Lynda Buske & Anna Murphy Dow (Surveys Group, CMA)

20

Stakeholder Organization Survey

48 Surveys sent

68 Responses (140% response rate!)

Respondents

MedicineNursingPH

Preliminary Results

• 71% produce guidance

• 62% developed guidance during pH1N1

• 94% willing to distribute guidance

• 72% could distribute emergency guidance in <24 hr

• 70% prefer email channel

21

Stakeholder Organization Survey

Structured queries What do they want?

Emerging Clinical Information (98%)Expert Review (90%)

Infection Control (84%) interventions /treatment (82%)special populations (68%)

Algorithms (90%)Email bulletins (94%)Summary Guidance in 2-5 pages (92%)Web-based updates (90%)

Email (86%)Websites (73%)

Important Supports

Guidance for

Preferred formats

Preferred routes

22

Survey of Individual HCP

Based on 559 Responses

Direct

Pat

ient

Car

e

Group

Pra

ctice

Urban

set

ting

use

EMR

0

200

400

Respondents

Distribution

• Survey distributed through 6 national HCP organizations, FNIHB, Centers for Effective Practice newsletter

• Target audience:– Physicians– Nurses– Pharmacists

23

Survey of Individual HCPWhat do they

want?Preferences

(74%) Interventions/treatment (71%) Infection Control(67%) For special populations

(94%) Email bulletins (92%) Summary guidance in 2-5 pages (90%) Web-based advisories

(79%) Decision trees or algorithms(77%) Point form

(89%) Email(55%) Dedicated website(9%) Social media

(58%) PHAC or HC(50%) Prov/Terr (50%) International(48%) Local PH

Most requested guidance

Top 3 formats

Preferred layouts

Preferred Channels

Where would they look?

24

Thanks to the Project Team

CEP

• Jess Rogers• Valerie Palda• Caroline

Higgins

CMA• Maura

Ricketts• Jill Skinner• Marion Fuller• Emilia

Nowakowska

PHAC• Barbara

Raymond• Althea House• Cecilia Van

Egmond• Lisa Paddle

Maura RickettsDirector, Public Health GroupHealth Policy & Research DirectorateMaura.Ricketts@cma.ca

25

26

Critical to achieving our goal

• Broad range of health care professionals providing influenza care (e.g. family physicians, nurses, ER physicians, pharmacists, intensivists)

• Engage stakeholders throughout the project to understand needs, identify capacity and build from expertise

• Identify solutions for Canada

• Identify role/considerations for stakeholder organizations and individuals in the final deliverables

27

Draft Deliverable: Handbook Overview

• Proposing a literature-based process modified to reflect pandemic needs o Building from existing, validated methods to ensure broad

acceptance

• Guidance vs. Guidelineso “Guidance” is an umbrella term used to describe clinical

recommendation documents of which a subset fit into the category of “guidelines”. The Handbook uses the broader term “guidance” so as to be inclusive of relevant prior work and potential future products that may not meet criteria for the term “guidelines”.

28

Draft Deliverable: Handbook Overview

Assumptions [from CEP meeting on Apr 17]• Vaccines and antivirals are always separate• Teleconferencing is a webinar• Pandemic and Inter-pandemic processes are

different but similar• Pandemic evidence is always very low quality• Faster is more expensive [from Handbook]• A secretariat is required • To meet sorter timelines, resources are

available to provide facilitated relay of information to the Guidance Panel

• Commitment from Panel members to complete work between meetings

29

Draft Deliverable: Handbook Section 1: Guidance Inventory: Preparing the Way

Purpose:• Assists [future Guidance Panel?] members to reflect on the quality

of guidance developed • These tables would become an inventory of recommendations –

Consider that it become a searchable database (not static spreadsheet)

• Lays foundation for the development of a workplan that is efficient and responsive to the inter-pandemic and pandemic needs

30

Draft Deliverable: Handbook Section 2: Inter-Pandemic Guidance Process

Purpose:• Through a cyclical workplan, a Panel reviews, maintains, updates,

discards existing guidance in inventory of recommendations, and identifies novel topics which require evidence-based recommendations

• Guidance Panel undergoes a similar but different guidance development process that will be used in pandemic timeso Benefits include: developing capacity of Panel members to

develop guidance; building a reserve of individuals that can be called upon to develop guidance in pandemic situation; maintenance of relevant guidance that can be readily disseminated in [first wave?] pandemic situation

31

Draft Deliverable: Handbook Section 3: Pandemic Expedited Guidance Process

Purpose:• A parallel process to the Inter-pandemic process that builds from

European CDC technical report that addresses developing guidance when (1) timelines are short, and (2) required to use low quality evidence.

• Explicitly outlines the logistics of developing guidance for influenza care in a time of pandemic.

32

33

Scope for Project 2

• Will not develop, communicate or disseminate clinical guidance

• Will describe infrastructure needs, process requirements and products

• Will produce value for stakeholders (organizations and individuals) by describing – their guidance needs (content, channel &

presentation) e.g. knowledge translation and knowledge transfer (KT)

– the characteristics of processes that lead to seeking, trusting and using guidance e.g. implementation principles of fidelity & uptake

Section One: Principles of Communication

Activities of Knowledge to Action (K2A)

1. Engagement & Communication– Identify the barriers– Brainstorm on solutions– Figure out how to maximize impact

2. Dissemination– Identify the target audience– Tailor the message and the medium

3. Implementation– Develop practical solutions that improve behavior

oriented ‘access’ to the communication– Maximize Fidelity &Uptake

Step-wise Approach

• Use Knowledge to Action frame to identify the barriers to the effective dissemination and uptake of clinical guidance to front-line HCPs before, during and after a pandemic.

• Identify strategies of known effectiveness to address those barriers.

• Recommend a process, in sufficient detail and reflecting the realities of the Canadian health care system, that identifies effective communication channels and required resources for optimal guidance dissemination to the targeted populations.

• Provide recommendations regarding inter-pandemic strategies to engage stakeholders in the dissemination process, so that these individuals and groups may be ready in the event of a pandemic.

• Recommend a procedure to secure standing agreements for the activation of these channels of communication in the event of a pandemic.

Section One: Principles of Communication

Knowledge to Action (K2A)

K2A: Implementation

Elements in Action Plan1.Target audience for the guidance

2.Key messages that explain why they should care

3.Categories of engagement to identify what are you asking them to do e.g. adopt a practice, promulgate and champion a practice, developer, owner, create a community of practice, practitioner etc.

4.Methods/tactics e.g. videoconferencing, teleconferences, website, grand rounds, mentoring, toolkit for providers, toolkit for patients, accredited CME etc.

5.How will you measure success? Plan to measure and measure in order to plan

6.Potential partners for producing products, developing and managing processes, and adapting or developing infrastructure

7.Where is the ‘home’ for your guideline and related materials? Who will take care of it until it is needed?

37

Awar

enes

s

of guidance, practice, innovation etc

Agre

emen

t

with guidance, practice , innovation, etc

Adop

tion

try out the guidance etc in your setting

Adhe

renc

e

abide by the new practice on all appropriate occasions

Model for Change

K2A: Engagement

Barriers & Facilitators

• “Knowledge translation for healthcare professionals and consumers is more likely to be successful if the choice of knowledge translation strategy is informed by an assessment of the likely barriers and facilitators”

• Grimshaw, 2012

Barriers can be identified from the literature and our experiences e.g. (Légaré, 2010) Confusion about roles and

expectations of HCPs, PHP Stodgy financial instruments Legislation, regulations, policies,

practices and standards that cannot respond to an emergency

Overestimating the availability, capacity and ability of individuals to respond

Underestimating the need for pre-pandemic ‘testing’ of ethics, training, and agreements with unions and licensing bodies

38

TABLE III Barriers (Légaré, 2010)

Confusion about roles and expectations of HCPs, PHP

Stodgy financial instruments Legislation, regulations, policies,

practices and standards that cannot respond to an emergency

Overestimating the availability, capacity and ability of individuals to respond

Underestimating the need for pre-pandemic ‘testing’ of ethics, training, and agreements with unions and licensing bodies

“During the H1N1 pandemic, there was a need for rapid, clear and authoritative clinical advice”. Dame Deidre Hines

THEMECharacteristics of desired products:Trusted sourceReliable qualityReliable processTimelyBriefTargeted to audience Clinically relevant

THEME: Establish plans “well ahead of any crisis”

Alternate care site for remote regions

Priority setting mechanisms for policies

Negotiate data gathering requirements with clinicians ahead of time

THEME: Clinical protocols are needed in order to preserve a consistent level of care

THEME: Clinicians should guide clinical care

The content of the Report will be used in Strategic Planning Table and Flow Diagrams:

Organization of the ReportSection 1: Principles of Communication

– an overview of the existing evidence about how to communicate with health care providers

– KT, KTA and the emerging field of Implementation Science will be a source of evidence-based processes and methods

Section 2: Environmental Scan: What was said?– Understand HCP communication requirements through

the recorded experiences of pH1N1 2009 – Survey to test thesis

Section 3: Environmental Scan: What was done and recommended?

– Structured catalogue of products, processes and infrastructure that were used during pH1N1 or recommended post-pH1N1