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Celebrating a decade of evidence-based care

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On the 10th anniversary of the Registered Nurses’ Association of Ontario’s (RNAO) Best Practice Spotlight Organization (BPSO) initiative, nurses share their successes implementing evidence-based guidelines into daily practice.

Gordon’s* foot ulcer was just not healing. The toonie-sized wound, located below the 50-year-old’s ankle, had been growing steadily for months. Gordon, who was uncomfortable and at risk for developing an infection, was diabetic, which meant the limited flow of blood to his foot was hampering his recuperation. His physician was fairly certain the wound was not going to get any better, and prepared Gordon for the worst: a possible below-the-knee amputation.

The wound care team at Saint Elizabeth, a national home health-care organization based in Markham, was asked to step in. Using best practice standards, they performed an assessment of the wound and its underlying causes. They instructed their new client to take pressure off his foot whenever possible, selected dressing materials that would enable the wound to heal, and offered advice on foods rich in protein that would help him to better manage his condition, and help heal his stubborn sore.

All of these evidence-based nursing practices can be found in the Registered Nurses’ Association of Ontario’s (RNAO) Best Practice Guideline (BPG) Assessment and Management of Foot Ulcers for People with Diabetes. The nurses talked to Gordon about his options, and because they could articulate best practice recommendations that were backed by research, he was receptive to the lifestyle changes they recommended.

Gordon defied the prognosis offered by his doctor and, in five months, his foot ulcer was healed. He had a much better understanding of his diabetes and how to prevent future wounds from forming. His case is not unique, says clinical resource nurse Kay McGarvey, who works with the wound care team and nursing staff to ensure patients receive care that reflects best practice recommendations. In fact, she can think of several instances when RNAO’s BPGs have contributed to more effective wound healing, and have potentially saved limbs.

“I’ve seen too many cases where (a clinical situation) has gone poorly,” she says, adding that because nurses have adhered to and advocated for use of recommendations in RNAO’s BPGs, patients’ care has improved, in some cases, dramatically. Outcomes collected by Saint Elizabeth back McGarvey’s claim. The organization has successfully reduced the average time it takes nurses to complete lower leg assessments on clients with diabetic foot ulcers. The organization has also seen an increase in the percentage of clients who meet its 30-day wound healing target.

Before implementing 19 of RNAO’s guidelines, nurses mostly relied on anecdotal evidence with outcomes that were not tracked. The BPGs now help nurses structure client care and “articulate what we’re trying to do and why,” explains McGarvey. They also boost nurses’ confidence when talking to patients and other practitioners, she adds. These are some of the reasons Saint Elizabeth is proud to have implemented so many of them.

This year, the home-care organization celebrates its 10th anniversary as an RNAO Best Practice Spotlight Organization (BPSO®). Designation as a BPSO involves a competitive application process, and is reserved for health-care organizations and academic sites that successfully implement a minimum of five clinical BPGs in the first three years of the formal agreement, and commit afterwards to ongoing uptake of new guidelines and evaluation of their impact on outcomes.

“To see the evolution of our organization as one that uses evidence from the bedside to the boardroom to give the best care possible to get the best care outcomes for our clients, and to engage our staff in that process…that’s why we continue to be a BPSO,” says Nancy Lefebre, the home care organization’s chief clinical executive and senior vice-president of knowledge and practice.

Saint Elizabeth is not alone in witnessing a transformation. Sixty eight BPSOs, representing 298 sites across Ontario, Quebec, and outside Canada, have formally joined the BPSO program and are systematically implementing numerous BPGs, and engaging in outcomes evaluation.

RNAO began developing guidelines in 1999. Today, there are 48 clinical and healthy work environment BPGs. Thanks to continued support from the provincial government, more are on the way. The association also maintains a rigorous guideline review and revision cycle, and robust implementation strategies such as institutes and the Best Practice Champions Network.

The latter was developed in 2002 to support nurses and other health-care professionals who are passionate about implementing BPGs. Through this program, well over 10,000 volunteer champions access tools and strategies such as workshops and teleconferences to help support use of BPGs in their workplaces.

By 2003, RNAO’s Chief Executive Officer Doris Grinspun wanted to take BPG implementation a step further, and worked with the association’s staff to create a structured approach for organizations to use BPGs and evaluate their impact. Thus the BPSO program was born. Looking back, Grinspun couldn’t be more pleased: “My vision was that we would contribute to demonstrating how nursing care, based on evidence contained in our BPGs, can improve patients’ health, and organizational and system outcomes,” she says, adding “we have seen outcomes that are nothing short of formidable, and we are not done yet.”

Though the program is based in Ontario, its influence and reach is international. BPSOs have been established in Chile, Colombia, and the United States. RNAO has also partnered with two large BPSO Host organizations in Spain (government) and Australia (nursing union). Both act as RNAO satellite sites, ensuring BPG implementation in several health-care organizations in their countries, using RNAO educational materials and methodology.

Apart from the sheer growth of the program, Grinspun is also extremely proud that it has ignited passion for the profession at the clinical level. “This has brought the focus back to where it matters most: the patient and the front-line care provider who is trying to deliver the best possible care.”

Currently, 14 organizations from Sarnia to Tavistock to Burlington to North Bay are hoping to become BPSO designates, having been accepted into the initiative last year. If they meet the requirements, they will become designates in 2015.

This is an excerpt from a longer feature published in the March/April 2013 issue of Registered Nurse Journal, the Registered Nurses’ Association of Ontario’s (RNAO) bi-monthly magazine. To read some of the other success stories featured in the magazine, including stories from hospitals in Windsor, Toronto and Sudbury, visit www.RNAO.ca/resources/rnj/back-issues.  To access information about evidence-based practice, the BPG and BPSO initiatives, or for a complete list of RNAO’s clinical and healthy work environment BPGs, visit www.RNAO.ca/bpg



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