Evidence-based Practice What Does it Mean for Nursing?

Definition of EBP What is evidence-based practice?

Evidence-based Practice Process by which clinical decisions are made using: Best available research evidence Clinical expertise Patient preference

Three Areas of Research Competence Interpreting & using research Evaluating Practice Conducting Research

Evidence Based Practice To carry out EBP, the following factors must be considered: Has sufficient research been published on the specific topic ? Does the nurse have skill in accessing and critically analyzing research? Does the nurse’s practice allow him/her to implement changes based on EBP?

Historical Perspective Variation in practice leads to: Variable quality of care Higher cost of care Potential for errors that may cause harm

Translating research into practice

Clinical Decision Making Drawing conclusions based on EBP, clinical expertise, patient preference, and other factors such as cost-benefit analysis, availability of alternatives, etc.

Skills Required for EBP Clearly identify practice problem or new knowledge ( innovation) Search/find relevant research literature Critically evaluate research findings using established criteria regarding scientific merit Choose interventions/justify selection with the most valid evidence Apply to practice through change process

Research Utilization Transfers research findings to nursing practice Carried out by individual nurses, groups of nurses working together to solve problems, by interdisciplinary teams, and by institutions and organizations seeking to make system-wide improvements in care outcomes

Identifying Practice Problem Why are we doing this? Why are we doing it this way? Can we produce better outcomes with greater consistency?

Clinical practice problems in your setting?

Critically Evaluating Research Literature review: scholarly analysis of a body of research about a specific issue Integrative literature review: integration of a body of research findings (including theory, statistics) which concludes by addressing issues for future research

Critically Evaluating Research Systematic literature review: comprehensive, unbiased analysis of findings which use strict scientific design. Meta-analysis: merged statistical results from a number of related studies which combines various research studies with the goal of discovering consistencies and differences between studies

Strength of the Evidence Level I – systematic review, met-analysis, well-designed RCTs Level VII - opinion

Resources for Reviews Nursing journals Clinical work station sites Up-to-date Zynx Eskind Digital Library Cochrane Reviews

Clinical Practice Guidelines Agency for Healthcare Research & Quality (AHRQ) Early examples Skin integrity Acute pain guideline Urinary incontinence

AHRQ Evidence-based Reports Examples of reports available Cancer symptom management (2002) Coronary heart disease in women, systematic review (2003) Mechanical ventilator criteria for weaning (2000) Wound healing, laser treatment and vitamin-assisted closure (2004)

Evidence-based Nursing Practice AHRQ clinical nursing practice guidelines To be released in December Joanna Briggs Institute (JBI) JBI Connect National Guideline Clearinghouse Guidelines.gov

Application to Practice Does the research apply to my patient population? Would this practice change improve process of care? Patient outcomes? Is there support for this practice change?

EBP Models CURN project  Research utilization Review, synthesis, application, evaluation Stettler Model of Research Utilization Critical thinking & decision making Iowa Model of Research in Practice Quality assurance meets research utilization

Planned Change Assess current practice (processes and outcomes) Identify and implement changes to modify processes Evaluate effects on processes and/or outcomes

Evaluation Processes of care Outcomes of care

Documentation of Groin Sites Investigators: Stacy Sherrard, Grace Vincente & Felicia Lowe 1 month trial of education and coaching to improve documentation of groin sites post-catheterization

Groin Site Documentation

Summary of Purposes Reduce variations in practice Improve the quality of care provided Maintain or improve patient outcomes

Barriers to use of EBP Accessibility of research findings Anticipated outcomes of using research Organizational support/lack of support to use research Support from others to use research

EBP Talking Points EBP is a way of thinking and practicing that requires discipline and practice to continually asse4ss, “where is the evidence for this?”, and to weight the validity and reliability of daily practice activities.

EBP Talking Points Ongoing skill building is required once a basic understanding is acquired Nurses and other health professions daily confront questions about assessment, treatment, prevention, and cost-effectiveness of care.

EBP Talking Points The principles of critical appraisal span health professions and disciplines and overlap with epidemiology and science in general Our patients expect nursing care based on best practice evidence

EBP Talking Points The art of nursing, never to be underestimated, also needs to be studied to validate those contributions to quality care. In the future, Qualitative research will be included

EBP: A Practical Approach Step 1: formulating a well-built question Step 2: Identifying articles and other evidence based resources that answer the question Step 3: Critically appraising the evidence to assess its validity Step 4: Applying the evidence Step 5: Re-evaluating the application of evidence and areas for improvement

Step 1: Formulating the Question Clinical cases often present many details in putting the case together It is important to first decide what details are most important to the question at hand in order to effectively search the literature

Step 1: Formulating the Question Components of a well-built clinical question: PICO acronym: P=patient/problem(disorder or disease) I=intervention (or finding under review) C=comparison intervention (if applicable) O-outcomes T=timeline

Example of Clinical Question A 55-year-old patient with a 35 year history of chronic smoking. Would the administration of bupropion as compared to a nicotine replacement therapy (NRT) be a better therapy in causing long-term abstinence from smoking? Disorder/disease? Intervention or finding under review? Comparison intervention? What is the outcome?

PICOT continued Use of PICOT is a state of mind Applying it systematically helps to identify important concepts in a case It also helps to formulate a question for searching Often, you will not have a comparison intervention, so may not use all components in your search at all times Always start with PICOT, as it helps to think strategically

Forming Good Questions Describe the subject of the questions Example: “How would I describe a group of patients similar to this one?” Define the intervention y9ou are thinking about. Possibly think of another intervention to compare it to the first (e.g. a traditional x-ray vs MRI) Define the outcome you wish to assess. Examples: changes in physical sign, prognostic indicator, outcome of diagnostic test, response to therapy, cost effectiveness

Practice Scenario A 9-year-old patient presents to the ED with diffuse abdominal pain and loss of appetite. The nurse suspects appendicitis and needs to decide which imaging modality is best for making the diagnosis (CT vs ultrasound) Write your clinical question in PICOT format

Example of Good Question P=child with suspected appendicitis I=CT C=ultrasound O=reliable diagnosis of appendicitis

Data Base/Resource Searching Find the relevant evidence Major categories of information sources -General information or background resources -Filtered resources -Unfiltered resources Many are subscription based

Search Decisions Would background information on topic answer your question? Then use background resources: -UpToDate, Stat!Ref, or MD Consult (Examples: differential diagnosis list, types of therapies, presentation information)

Search Decisions Are you trying to decide on best course of action for diagnosis or treatment and want recent reliable evidence for decision-making? Consult filtered resource: Cochroane, National Guideline Clearinghouse, InfoPOEMS, ACP PIER, MD Consult (Fist Consult), National Standard, etc.

Search Decisions Are you unable to find your answer in a filtered resource? Do you want to check journal literature for original research studies? Try unfiltered resource such as: medline/PubMed, PsychINFO, BIOSIS, or CINAHL, OVID MEDLINE

Critical Appraisal Must read articles and look at information critically In the study from a primary source providing original data with no commentary-should do a validity check. Ask questions r/t diagnosis, therapy, harm and prognosis.

Applying the Evidence Next, decide how the study or other information applies to your question Consult questions related to diagnosis, therapy, harm, prognosis May need to confer with others depending on criteria, skill and experience in interpretation

Applying the Evidence Appendicitis Example: Ask from a diagnosis perspective: 1. Is the test affordable and available in my hospital? 2. What is the estimate or probability of appendicitis in the patient (pre-test) 3. Will the post test information affect my management of the patient?

Re-evaluating the Evidence Continuously monitor the decision made for patient care Ask: was the diagnosis and/or treatment successful? Is there new information/data in the literature? How can I improve and/or update my clinical decisions?

Resources EBP.www.biomed.lib.umn.edu Cathy Thompson, University of Colorado, Denver, College of Nursing Nancy Wells, Vanderbilt Medical Center