MODULE 1: Evidence Based Practice and Informatics NURS 736: Technology Solutions for Knowledge Generation in Healthcare

Objectives Provide an overview of the benefits, barriers and steps associated with EBP. Explore the informatics contributions to EBP. Develop a PICO question related to an informatics topic or emerging technology. You will be discussing Evidence Based Practice (EBP) in much more detail in other courses so the focus of this presentation is to provide an overview of the benefits, barriers and steps associated with EBP. This information will be useful for determining your informatics topic and developing your EBP paper. We will also explore the informatics contributions to EBP and revisit many of these items in more detail throughout of course.

Evidence-Based Practice (EBP) “Evidence-Based Practice is the explicit, judicious, and conscientious use of current best evidence from health care research in decisions about the care of individuals and populations” (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2002).

EBP - Benefits Improve patient outcomes Standardize practice Strengthen Nursing as a profession and science Increase patient satisfaction Reduces liability Saves health care dollars Helps providers & facilities meet regulatory requirements

EBP- Steps Ask clinically focused questions. (PICO) Collect the most relevant and best evidence to answer the clinical question. Search the literature. Critically appraise the evidence that has been collected for its validity, relevance, and applicability. Integrate the evidence with your own clinical expertise, assessment of the patient’s condition, and available resources. Refine that to meet your patient’s preferences and values. Evaluate the change resulting from implementing the evidence into practice.

EBP - Resistance Ten most common reasons nurses don’t use EBP: Practice inertia Satisfied with the ways things are always done Don’t like change Organizational politics Don’t really understand what EBP is all about

Inability to understand research findings EBP - Resistance Ten most common reasons nurses don’t use EBP (cont.): Lack skills to find appropriate evidence Lack of relevant research evidence Inability to apply findings (personal and/or organizational) Lack of time to do searches and/or read literature #1 REASON Inability to understand research findings

EBP – Informatics Contribution Improving information access to “evidence” Literature search databases (Medline, PubMed, CINAHL) Supporting access to information in the clinical setting to improve care and care planning Referential links with EBP clinical content Infobuttons (Cimino) EBP InfoBot (Seckman, Fisher & Demner-Fushman) Facilitating communication among healthcare team members E-mail and other communication devices Electronic Medical Record/Electronic Health Record Personal Health Records

EBP – Informatics Contribution Automating surveillance for real-time error detection and prevention (Alerts) Allergy notifications, drug-drug or drug-food interactions Other decision support tools Supporting and maintaining standardization of practice patterns Protocols, SOP, Clinical Guidelines Enhancing educational programs Internet based learning, simulation, gaming etc. Supporting research and the generation of knowledge Tools for data coding and analysis, model building, meta- analysis, qualitative analysis Dissemination of results (email, internet, posters etc.)

Getting Started on your EBP Informatics Paper

Asking a Clinical Question PICO Method: P = What is your population or setting? Be specific. I = Identify an intervention of interest related to this group or setting. C = Compare this with standard treatments (could be no treatment) or a comparison group. O = What is the intended outcome? Polit & Beck (2009) p. 46 One way to craft a clinical question is the PICO method. Start by identifying your population or setting. Then identify an intervention (which is your practice, procedure, or instrument/technology) of interest related to this group or setting. Depending on the intervention you may or may not want to do a comparison to a standard treatment. This may also depend on what you find in the literature on the topic. Finally what is the intended outcome for this intervention. See the next slide for some examples.

PICO Examples Example 1: Example 2: P = Pediatric patients (inpatient) I = Medication barcoding C = Standard (no barcoding) O = Decrease medication administration errors Clinical question: What is the effectiveness of barcoding for decreasing medication errors among hosptialized pediatric patients? Example 2: P = Intubated and sedated patients I = Capnography C = Standard treatment O = Therapeutic effect Clinical question: What is the therapeutic effect of capnography on intubated and sedated patients?

Searching the Literature Use a variety of databases to search your topic Examples: Medline, PubMed, CINAHL Do a preliminary search on your topic using specific keywords If the results are large you need to focus your search If results are too small then your question may be too narrow or there isn’t any recent literature on the topic Based on the preliminary search you may need to refine your topic REMEMBER: Your FINAL topic must be approved by the instructor

Locate Research Sources Start with a Plan! What databases will be searched Commonly used databases in nursing: CINAHL, Medline, PubMed,PsycINFO CINAHL through library Medline through library or through web via Pubmed: http://www.ncbi.nlm.nih.gov/sites/entrez What keywords will be used in your search (don’t forget to truncate & use (*)) Where to locate the relevant literature: use titles & abstracts to help you evaluate relevance. How to store the references A database is a compilation of citations. The idea of the databases is that you can search multiple journals simultaneously for a keyword, author, or subject. Once you have your key words and have identified the databases that you are going to use, you use the key words to search the databases. The next task is to evaluate the references for relevance. NOT ALL of the citations that come up during a search will be relevant and in many cases – even if they were all relevant, there may be too many. To sort for relevance, start with the title - if it seems potentially relevant, you will want to look at the abstract if it’s available to further evaluate relevance. Many of the databases include abstracts from the research papers. Don’t forget to save your references – don’t do it at the end! A word about google – google and google scholar are useful for finding some of the sources that are out there. However searching google is not considered scholarly work and the searching that you do for your literature review must be done within one or more of these databases that contain scholarly sources. NO WIKIPEDIA 14

Performing Complex Searches Combine two or more keywords you have used to conduct simple searches to make your search more inclusive or more specific . In CINAHL & Medline or allows a more inclusive search than searching each term individually. and provides a more specific search by combining keywords not allows excluding concepts that are not of interest. After locating relevant sources in a preliminary search, you are ready to make more complex searches. Select the keywords you have used to perform simple searches And use the or, and, not terms to combine those terms. This can make your search more inclusive or else more specific. 15

Complex Search Examples or example: cardiac or coronary or heart or myocardial returns articles with any one of these terms which may be used interchangeably. and example: depression and risk reduction behaviors. Because both terms include many citations individually, combining the terms in a single search focuses the results. not example: anxiety is often included in research about depression but may not be of interest. By entering depression not anxiety, you limit the search to those articles that relate solely to depression. 16

Limiting a Search Some searches will result in thousands of hits To reduce number of hits while increasing the relevance of citations, try the following strategies: Limit to English language Limit the publication dates to recent years Limit to peer-reviewed Limit to papers that are research Limit to full-text articles (this can be risky) Note: Medline will not automatically limit to peer-reviewed so you will need to check those sources directly. The journal homepage will indicate whether their articles are peer-reviewed. 17 17

Types of Sources Primary sources are written by the person who generated the ideas published In research, written by the person(s) who conducted the research In theory, written by the theorist who developed the theory Secondary sources paraphrase the works of researchers and theorists Someone else’s interpretation of a primary source i.e. books, book chapters, review articles etc. Provides reference lists of primary sources and may present good ideas Prone to bias and misinterpretation The important distinction here is that in primary sources the only interpretations in a primary source belong to the researcher(s). A secondary source is someone else’s interpretation of a primary source. Common secondary sources include books, book chapters, and review articles. Secondary sources are useful in the research process because they provide reference lists composed of primary sources and may also present good ideas. However, the reason that we place so much importance on reading the primary sources is because secondary sources that synthesize and interpret research done by others, are more prone to bias and misinterpretation than primary sources. 18

Recording Search Information DOCUMENT YOUR SEARCH List each keyword (or combinations of keywords) used in a search and include: Name of the database Date of the search Search strategy (the database will record this with the search if prompted to do so) Number of articles found in the search Number of relevant articles found & approach for deciding relevance Author(s) name Limits applied Often useful to save this in a table (See Database Search Form) It is very important that you document your search. There is a form on Blackboard for you to record your search strategy. This information will be helpful in writing the Methods section of your EBP paper. 19