Implementing Evidence-Based Practice: Strategies for Success Erin Kyle, DNP, RN, CNOR, NEA-BC Perioperative Practice Specialist AORN

Objectives Define evidence-based practice EBP Describe two barriers for implementing evidence-based practice in the perioperative setting Describe two strategies that can be used to facilitate implementing evidence-based practice Discuss experience with implementation of evidence based practice in your facility

Evidence-Based Experiences Imagine a time…. When you tried and either succeeded or failed at implementing EBP Get into small groups (among teams that you regularly work with if possible) Take 6-7 minutes to discuss your experiences – where you tried and succeed or failed at implementing evidence-based practice in your work place. (during this time, I can observe interactions among the group and pick up some stories, guage the energy in the room to direct the path of the remainder of the presentation.)

EBP is …conscientious use of current best evidence in making decisions about patient care. Sackett DL, Straus S, Richardson S, Rosenberg W, Haynes RB. (2000) Evidence-based medicine: how to practice and teach EBM. 2d ed. London, U.K.: Churchill Livingstone Stable datum – Share stories, and focus on the definition of evidence based practice that we use at AORN. If a standout story exists among the group, ask that person to share the story and tie it to this definition. Use an example from the room to illustrate the definition here and on the next slide.

EBP Elements Problem-solving approach to practice Problem-solving Systematic search for and critical appraisal of most relevant evidence to answer a burning question Takes into account one’s own clinical expertise & the patient’s preferences and values Clinical expertise, Patient values Evidence search & appraisal EBP is not merely taking an article and blindly taking the recommendations and placing into practice. It is also not creating a NEW research study. It is a combination of these major elements. It can begin at any point in this triad, but includes all three. For example, the impetus for pursuing evidence-based practice could be a problem that emerges in practice that one nurse or a group of nurses notices and causes him or her to look to the literature for potential solutions (reactive). On the other hand, a nurse may read an article that causes him or her to consider a better way to practice before a problem emerges (proactive). In some circumstances, evidence-based practice changes may occur as a result of patient initiated ideas.

Barriers & Strategies for Success Systematic search how to find relevant evidence? how to identify reputable sources? Critical appraisal How is this done? Implementation in the practice setting Asking the right question Engaging the right people at the right time

Systematic Search for Evidence Finding reputable sources Is Google considered reputable? Not for scientific evidence! First, how not to search……

How to search? Use reputable sources Choose keywords wisely .gov, .org, .edu Choose keywords wisely (use PICOT terms) Generally speaking, websites ending with .gov, .org, .edu are considered reputable sources for scientific or reliable information. Many of these organizations have funding that is subject to changes. Therefore, some sources could change or even go away when funding changes. An example is the Clinical Practice Guideline Clearinghouse, which I will show you on the following slide.

Reputable Sources Each of these is hyperlinked to the website. AORN GUIDELINES AORN JOURNAL AHRQ AHRQ EVIDENCE-BASED PRACTICE CENTERS JOANNA BRIGGS INSTITUTE COCHRANE CINAHL EMBASE NATIONAL GUIDELINE CLEARINGHOUSE SCOPUS PUBMED

Critical Appraisal of Evidence What is it? How good is it? Value Quality In order to critically appraise the evidence, you should determine what kind of study or review it it (identify “what is it?”) and then determine the quality of the study (evaluate “how good is it?”) There are multiple methods and nuances in achieving evidence appraisal. For our purposes today, I will focus on AORN’s methods. This will do two things for you. it will give you a very good and accessible model to achieve evidence appraisals yourself and it will help you understand evidence ratings and what they mean in the AORN Guidelines. It is a win-win situation!

What is it? Identify the type of study or review to determine strength of evidence.

What is it? Value A rigorous synthesis of research findings on a particular research question, using systematic sampling and data collection procedures and a formal protocol where all included studies are randomized control trials (RCT). A full experimental test of an intervention, involving random assignment to treatment groups

What is it? Value A design for an intervention study in which subjects are not randomly assigned to treatment conditions; also called nonrandomized trial or a controlled trial without randomization. A rigorous synthesis of research findings on a particular research question, using systematic sampling and data collection procedures and a formal protocol.

What is it? Value The investigation of phenomena, typically in an in-depth and holistic fashion, through the collection of rich narrative using flexible research design. Used for the purpose of discovering important underlying themes, categories, and patterns of relationships. A rigorous synthesis of research findings on a particular research question, using systematic sampling and data collection procedures and a formal protocol where included studies are mixed. Studies in which the researcher collects data without introducing an intervention; also called observational research

What is it? Value Systematically developed recommendations from recognized experts based on consensus opinion that guides members of a professional organization in decision making related to practice or a particular issue of concern. Practice guidelines that are evidence-based, combining a synthesis of appraisal of research evidence with specific recommendations for clinical decisions.

What is it? Value Initiative with a goal to improve the processes or outcome of care being delivered within a particular institution or organization A critical summary of research on a topic of interest, often prepared to put a research question into context. Advice or statements from individual(s) with knowledge and expertise on a particular topic or issue In-depth analysis of an individual, group, or other social unit issue or event.

AORN Appraisal Tools https://www.aorn.org/guidelines/about-aorn-guidelines/evidence-rating

How good is it? Quality – RESEARCH Study

How good is it? Quality – RESEARCH Summary

How good is it? Quality – NONRESEARCH - Literature Review, Expert Opinion, Case Report

How good is it? Quality – NONRESEARCH - Organizational Experience

Appraisal Score Evidence Rating in AORN Guidelines

Implementing EBP Reactive, Proactive, or a Way of practicing? Reactive: in response to a poor outcome or near miss Proactive: Improvement project, noticed practice variation Way of practicing: you approach every clinical decision by asking yourself “what does the evidence suggest?” If there is time, discussion and reflection from group about experiences with EBP in these areas.

Focused effort: PICOT Question Intervention Outcome Patient or Problem Comparison Timeframe Clearly defining this question makes it easier to communicate with your team as you progress in your evidence-based practice improvements.

PICOT Question – where does it come from? Wide variations in same clinical practice? Poor patient outcomes? Challenges in nursing care delivery

PICOT format and example In _______________(P), how does _________(I) compared with _________________(C) affect __________________ when _______________ (T)? In neurosurgery for lumbar spine instrumented cases, how does prone positioning with a mirrored face cradle compared with a non-mirrored face cradle affect airway management when cases are longer than 3 hours?

PICOT format and example In _______________(P), how does _________(I) compared with _________________(C) affect _________________ when _______________ (T)? In pediatric surgery, how does use of warm blankets compared with forced warm air affect normothermia when patient is admitted to PACU after cases using general anesthesia?

PICOT format and example Among ____________(P), how does _________(I) compared with _________________(C) affect _________________ when ________________ (T)? Among OR RNs, how does a full lunch break compared with no lunch break affect morale when it is time for shift end?

Activity In/among __________(P), how does _______(I) compared with _______(C) affect _____when/after/during ____ (T)? (Already in groups) by hospital/teams (5-6 per team) Discuss past failure or Identify a topic to explore Poor patient outcomes Wide variations in same clinical practice Problematic process Challenges in nursing care delivery Clinical practices that have no basis in science Things you have heard coworkers discuss as concern in lounge Form PICOT question and search keywords If time, share with group

Implementation in the Practice Setting 6 Steps Develop PICOT question; gather & appraise evidence Synthesize evidence; communicate findings Recommend practice changes (or not) depending on your findings Engage leaders in efforts Acquire needed resources and permissions for policy changes if required Implement change within your team

Certificate in the Fundamentals of Evidence-Based Practice AORN education online education course. Pretest 10 learning segments including review of evidence types, search strategies, appraisals, implementation steps. Posttest LINK

Resources https://www.aorn.org/guidelines/about-aorn-guidelines https://www.aorn.org/guidelines/clinical-resources/nursing-research https://www.aorn.org/aorn-journal https://www.aorn.org/about-aorn/aorn-newsroom/or-exec-newsletter/2016/2016-articles/making-evidence-based-changes-stick Back to Basics: Implementing Evidence-Based Practice (2014) Implementing Evidence-Based Practice: Real-Life Success Stories (2012) AORN Certificate in the Fundamentals of Evidence-based Practice

References Huang, X., Lin, J., & Demner-Fushman, D. (2006). Evaluation of PICO as a Knowledge Representation for Clinical Questions. AMIA Annual Symposium Proceedings, 2006, 359–363. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995 Nov–Dec;123(3):A12–3. Sackett DL, Straus S, Richardson S, Rosenberg W, Haynes RB. (2000) Evidence-based medicine: how to practice and teach EBM. 2d ed. London, U.K.: Churchill Livingstone. Spruce, L. Back to Basics: implementing evidence-based practice. AORN J. 2015:101(1):106-114. Spruce, L, Van Wicklen, SA, Wood, A. AORN’s Revised Model for Evidence Appraisal and Rating. AORN J. 2016:103(1):60-72. Spruce, L, Mellinger, E, Bakewell, S. Certificate in the Fundamentals of Evidence Based Practice. AORN, Inc. https://www.aorn.org/education/individuals/continuing-education/online-courses/individual-modules/fundamentals-of-evidence-based-practice. Accessed 4/11/2018

AORN Perioperative Practice Specialists (800) 755-2676 AORN Perioperative Practice Specialists 2170 South Parker Road, Suite 400 Denver, CO 80231 www.aorn.org