EVIDENCE-BASED PRACTICE Author: Debra S. Hall, MSN, RN,C, CCRN Clinical Nurse Researcher Learning Objectives: To understand the concept of Evidence-based practice To understand the importance of evidence-based practice in the clinical setting Performance Objectives: Differentiate between the concepts of quality improvement, performance improvement, research utilization, and evidence-based practice. Describe how Evidence-based practice can be used to improve clinical practice. Identify process for implementation of evidence-based practice within a clinical setting. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital AUTHOR I am currently the Clinical Nursing Researcher for the University of Kentucky Hospital in Lexington, Kentucky, USA. I became interested in Evidence-based practice while in a student in the PhD program at the University of Kentucky College of Nursing, as I tried to evaluate the effects of nursing interventions. I have chaired several clinical evidence-based practice groups, educated nursing staff about the process, and used the process to improve clinical practice and direct further research efforts. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital CONTENT Definition of Evidence-based practice (EBP) Effect of Evidence-based practice Implementation of Evidence-based practice within a clinical setting This lecture reviews the definition of evidence-based practice, its implementation in a clinical setting, and the various projects for which it can be used. 1/17/2019 University of Kentucky Hospital

EVIDENCE-BASED MEDICINE A shift in the culture of providing healthcare away from basing decisions on opinion, past practice, and precedent toward making more use of science, research, and evidence to guide clinical decision-making Evidence-based practice began its life in healthcare as evidence-based medicine. Evidence-based medicine is based on the concept of shifting healthcare away from basing decisions on opinion and past practices. Research has shown that physicians failed to recommend medications up to ten years after they have been shown to be efficacious and continue to recommend treatments up to ten years after they have been shown to be useless. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC: A comparison of results of meta-analyses of randomised control trials and recommendations of clinical experts. JAMA 1992;268:240-8. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital “…Evidence-based practice is a state of mind…a constant process of inquiry. …Why am I doing it this way? Is there evidence that can guide me to a better outcome?…” (Foster, 1999) Evidence-based practice originates with the clinician and focuses on clinical decision-making leading to improved patient outcomes. Foster, R. L. (1999). Evidence-based practice. Journal of the Society of Pediatric Nurses, 4 (1), 4-5. 1/17/2019 University of Kentucky Hospital

EVIDENCE-BASED PRACTICE (EBP) “The conscientious and judicious use of current best evidence to guide health care decisions for improving patient outcomes.” Marita Titler, PhD, RN, FAAN 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital RESEARCH A systematic scientific process that generates new knowledge or validates existing knowledge Research differs from EBP in that research is a specific scientific process of investigating a phenomena. Research includes a research question(s), a review of the literature on the area of interest, a study design to answer the question, interventions with resultant data collection, data analysis, and dissemination of the research results. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital RESEARCH UTILIZATION Research Utilization (RU) differs from evidence-based practice (EBP) in that, although RU also serves to improve the quality of patient care, it utilizes solely research findings as a basis of practice to improve patient care Includes critique of research studies, synthesis of research findings, application/implementation of scientific findings into practice, and evaluating the practice change in relation to resource utilization. It is NOT the same as conducting research. Should grade or evaluate the research or evidence you have available. (A-E) Discuss examples. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital QUALITY IMPROVEMENT The betterment or enhancement of a product or service This can be achieved by EBP, but is not limited to it Quality improvement is a continuous process that builds upon traditional quality assurance methods by emphasizing the organization and focuses on “processes” rather than on the individual; recognizes both internal and external “customers;” promotes the need for objective data to analyze and improve processes; carried out by both employees and managers. Although this may be achieved by EBP, it is often achieved by the collection of raw data on patient outcomes, sentinel events, negative clinical outcomes or errors from an institution or organization. This data is often specific to the institution or organization. 1/17/2019 University of Kentucky Hospital

PERFORMANCE IMPROVEMENT Focuses on the achievement of human performance goals Focuses on the performance of the individual and person-specific goals Performance improvement is similar to quality improvement, but its focus is on the performance of the individual and achieving person-specific goals, instead of reaching organizational or departmental goals. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital Evidence-based practice in the clinical setting requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research 1/17/2019 University of Kentucky Hospital

INDIVIDUAL CLINICAL EXPERTISE The proficiency and judgment that clinicians acquire through clinical experience and clinical practice leading to more effective and efficient patient assessment and diagnoses 1/17/2019 University of Kentucky Hospital

BEST AVAILABLE CLINICAL EVIDENCE Clinically relevant patient-centered research, scientific evidence, empirical evidence, institutional data, and external data that indicate how to achieve patient outcomes that you wish to achieve 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital EBP assists in - practicing based on the evidence (rather than opinion) Accepting clinical guidelines developed by other disciplines Developing indicator conditions in which the management and performance of patient care create a difference in patient outcomes 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital The aim of evidence-based practice (EBP) is to reduce wide variations in individual clinician’s practices, eliminating worst practices, and enhancing best practices, thereby reducing costs and improving quality. Although the other processes, such as research, research utilization, quality improvement, and performance improvement are important and can easily be associated with EBP, their aims are somewhat different. The overall aim of EBP is to standardize practice by maximizing good practice, reduce costs, and improve quality of care. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital OUTCOMES MANAGEMENT Efficacy – the results of an intervention applied under ideal conditions (RCT) Effectiveness – the results of an intervention applied in the real world; fewer controls; lack of random assignment For clinicians, effectiveness is more important than efficacy. Due to its nature, EBP lends itself to outcomes management more so than research. 1/17/2019 University of Kentucky Hospital

EBP CHANGES THE FOCUS FROM PROCESS TO RESULTS What systems or problems are not allowing growth? What barriers are present that prevent you from delivering the quality of care you, and your staff, think is needed? Quality Improvement also identifies issues or problems; however, EBP focuses on finding existing ways of overcoming problems or altering the manner in which outcomes are achieved based on evidence and positive results. What protocols, guidelines, practices do you need that you do not have? 1/17/2019 University of Kentucky Hospital

USE OF EBP IN ANALYSIS OF CARE ISSUES Use of specialty beds in patients for skin care Evidence supports use of some specialty beds only for pulmonary problems 1/17/2019 University of Kentucky Hospital

USING EBP TO EVALUATE THE QUALITY OF CARE Obstructive sleep apnea (Sonnad, et al., 2003) Cardiac Rehabilitation (Bitzer EM, Klosterhuis H, Dorning H, Rose S., 2003) Oncology oral care (Stricker & Sullivan, 2003) These studies used EBP to determine treatment modalities and develop guidelines. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital THE EBP PROCESS Link your use of evidence-based practice to a process May choose an existing process May choose another process commonly used in your organization/institution Clinicians can use the scientific process, Nursing process, or other process found in the literature. Rosswurm & Larrabee (1999) developed a systematic process for the change to evidence-based practice. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital Assess the need for change in current practice by including the stakeholders collecting internal data about current practice comparing internal/external data (benchmark) identifying your problem statement/desired state (Rosswurm & Larrabee, 1999) 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital Link problems, interventions & outcomes by using standardized classification systems & language identifying potential interventions & activities selecting outcome indicators (Rosswurm & Larrabee, 1999) 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital PROBLEM STATEMENT There is an increase in requests for nursing staff to administer unfamiliar anesthetic and sedative agents in the ICU area for procedures which affect patient care and staffing. 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital DESIRED STATE Nursing staff will have guidelines for administration of sedatives during procedures and extended patient treatment and for care of such patients in the critical care area 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital Synthesize the best evidence by searching literature related to major issues critiquing & weighing the evidence assessing the feasibility, benefits, and risks (Rosswurm & Larrabee, 1999) 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital Design practice change by: defining the proposed change identifying needed resources planning an implementation process defining outcomes (Rosswurm & Larrabee, 1999) 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital OUTCOME INDICATORS Data collected on administration of approved IVP drugs by ICU RNs (e.g., frequency) Anecdotal reports from staff on administration of approved drugs No negative patient outcomes with non-approved drugs 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital Implement & evaluate the change in practice by: pilot study demonstration evaluate process & outcome decide to adapt, adopt, or reject practice change (Rosswurm & Larrabee, 1999) 1/17/2019 University of Kentucky Hospital

University of Kentucky Hospital Integrate & maintain change in practice by communicating recommendations to stakeholders staff education on changes in practice integrating changes into standards of practice monitoring the process & outcomes (Rosswurm & Larrabee, 1999) 1/17/2019 University of Kentucky Hospital

WHAT INFORMATION IS AVAILABLE ON THE WEB ON EBP? http://www.ahcpr.gov/ www.cochranelibrary.com http://www.cche.net/usersguides/main.asp http://www.shef.ac.uk/~scharr/ir/core.html http://healthlinks.washington.edu/clinical/guidelines.html www.hml.org/WWW/ebpws.html McMaster University Canadian Centres for Health Evidence 1/17/2019 University of Kentucky Hospital