Review of Evidence-Based Practice and determining clinical questions to address This group of 17 slides provides a nice review of evidence-based practice (EBP). The information is primarily abstracted from your text. Many of you have had experience with EBP but this powerpoint will hopefully put everyone on the same page about EBP.

Definition of EBP (Melnyk & Fineout-Overholt 2011) Problem-solving approach to clinical practice that integrates: External Evidence: Search, critical appraisal, & synthesis of most relevant & best research Internal Evidence: Via own clinical expertise, generated from outcomes management or QI projects, patient assessment, and evaluation Considers patient preferences and values Both external and internal evidence are important for clinical practice. This course spends most time on the “external” and learning and/or perfecting those methods. When you begin synthesizing evidence you’ll also then put your own knowledge of practice into your conclusions and consider patient preferences.

Evidence-Based Practice (EBP) Crucial to: deliver quality healthcare ensure best patient outcome Under utilized: Not the norm in many healthcare systems in US and elsewhere (Melnyk & Fineout-Overholt, 2011)

Why EBP? Best patient outcomes Reduced: healthcare costs geographic variations in care Retention of healthcare workers (Melnyk & Fineout-Overholt, 2011) These are all critical reasons to use EBP.

YOUR Experiences in eBP? Think back to what your experience has been with EBP. Have you had any? If yes, how was it instigated? In your current clinical sites as a NP student or during your hours required for the administration or education track---where do you see EBP? Does it make a difference?

Components of EBP In this slide, we are considering quality patient outcomes. Follow the various pathways noted for this organizational culture.

Initiatives to Advance EBP Institute of Medicine’s Roundtable on Evidence-Based Medicine United States Preventive Services Task Force (USPSTF) Agency for Healthcare Research and Quality (AHRQ) National Consortium for the Advancement of Pediatric and Adolescent Evidence-Based Practice (NCPAEP) Magnet Recognition Program by the ANA Credentialing Center (Melnyk & Fineout-Overholt, 2011) These are just a few of the initiative that have been developed to advance EBP. Depending on where you have practiced or where you are doing clinical hours, some of these may be familiar. For example, the Magnet Recognition Program is really important for patient outcomes, safety etc.

Other disciplines that use EBP? Can you think of other disciplines that use EBP? It’s not just a nursing “thing”!

Medicine (really began here in the 90’s) Cochrane Physical Therapy Dentistry Psychology Speech Therapy Etc. I’ve listed a few other disciplines that use EBP. That says that if you are collaborating with these disciplines, EBP should be familiar and in use!

Steps of the EBP Process (Melnyk & Fineout-Overholt, 2011) 0. Cultivate a spirit of inquiry. 1. Ask the burning clinical question in PICOT format. 2. Search for and collect the most relevant best evidence. 3. Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis). Melnyk and Fineout-Overholt list 7 steps to the EBP process. Here are the first 3. I’ll list the next 3 on the following slide but then individual slides will focus on each step (1-6). Let me just say that step 0 is also critical. You need to have that spark that makes you interested in developing, following, and evaluating EBP. It’s that “How come”, or “I wonder why”, or “Can’t we do something about this”, that one needs to think about. In one of the other components of class this week is listening to Dr. Melnyk’s presentation on EBP. To me that helps address step 0 noted here.

Steps of the EBP Process (cont’d) 4. Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change. 5. Evaluate outcomes of the practice decision or change based on evidence. 6. Disseminate the outcomes of the EBP decision or change. (Melnyk & Fineout-Overholt, 2011) * For our class we go through Step 4. The DNP program continues through Steps 5 & 6

Step 1: Ask the Clinical Question in PICOT Format Patient population Intervention or issue of interest Comparison intervention or group Outcome Time frame Here is how a question can be asked . . . Using the PICOT format. Your readings for today and future weeks will go more into details about this format and soon you will be coming up with your own PICOT question.

Step 2: Search for/Collect the Most Relevant Best Evidence – Hierarchy of Evidence (Melnyk & Fineout-Overholt, 2011) Level I: Systematic reviews or meta-analyses of RCTs Level II: RCTs Level III: Controlled trials without randomization Level IV: Case-control and cohort studies Level V: Systematic reviews of descriptive and qualitative studies Level VI: Single descriptive or qualitative studies Level VII: Opinion of authorities and/or reports of expert committees Here are the levels of evidence of the work that you will be searching this semester (and later on throughout your career)! Melnyk and Fineout-Overholt use VII levels where I is the highest level because it deals with examining multiple RCT’s (randomized control trial) and coming to a conclusion about all of them using a statistical procedure. This just tells the level but then clinicians and researchers need to determine the quality of this evidence and that is part of what you’ll be doing this semester.

Step 3: Critically Appraise the Evidence Validity Reliability Applicability This is the step that focuses more on quality. One would look at a study and appraise these (and other things) to know quality.

Step 4: Integrate the Best Evidence with Clinical Expertise and Patient Preferences This is the “implementation” step EBP is not based solely on research and published evidence Patients’ hx/circumstances have a significant bearing on choice of intervention Availability of resources also considered Melnyk & Fineout-Overholt, 2011)

Step 5: Evaluate Outcomes of the Practice Decision or Change Based on Evidence Measurement of outcomes to determine and document impact of the EBP change on healthcare quality and/or patient outcomes Essential in determining whether the change based on evidence resulted in the expected outcomes when implemented in the real-world clinical practice setting (Melnyk & Fineout-Overholt, 2011) This is a critical step but in your capstone course you won’t be doing this part or step 6. Keep in mind it is the next step, though and it may be in the future you will do step 5 and 6 in your practice setting or if you go on for a DNP!

Step 6: Disseminate Outcomes of EBP Decision or Change positive and negative outcomes Via various methods personal communication to conference presentation (Melynk & Fineout-Overholt, 2011)