International Clinical Librarian Conference Implementing Evidence into Practice International Clinical Librarian Conference MB: Need to add in the name of the event

Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC Mark Barragry Introductions Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC Chief Nurse and Publisher Wolters Kluwer Health Lippincott Williams & Wilkins/Ovid Technologies Mark Barragry Senior Director of Strategic Markets and Partnerships Ovid Technologies

Healthcare information is used by researchers, clinicians, faculty, students, patients, caregivers, industry

In the beginning… The Cochrane Model Archie Cochrane, epidemiologist from Britain Care should not be done just because it’s always been done that way Evidence-based care will: ensure quality care improve patient outcomes improves cost efficiencies Record Question Analyze Experiment In the 1970’s Archie Cochrane, an epidemiologist decided to look at healthcare that was being delivered in the United Kingdom. Up until this time, the U.K. was spending a lot of money on health care but people were having poor outcomes. In 1972 wrote a book that was based on studies that looked at how care was being delivered when it was delivered the way it always had been vs. care that was based on evidence. The patients who received care that was based on research “evidence” did much better overall. The evidence based care group had a higher quality care, had better outcomes and their care cost less that the other group. This work by Archie Cochrane followed by the work done at McMaster’s University, became the basis of EBP today.

Defining evidence-based practice (EBP) Evidence-based practice or evidence-based decision-making is based on: External evidence – systematic reviews, randomized control trials, best practice, and clinical practice guidelines that support a change in clinical practice Internal evidence – health care institution based quality improvement projects, outcome management initiatives, and clinical expertise Patient preferences and values – what does the patient really want Evidence-based care improves quality of life McMaster University (canada) was the 1st to push out evidenced practice as the way to determine care What they have found is that research is put into practice many years after first proven or published – 17-20 years after! Point of care tools provide the means for how evidence based information gets into practice. Ie OvidMD

Hierarchy of evidence-based information (adapted from Haynes, 2007) Translated Evidence- Clinical Decision Support Systematic Reviews and Practice Guidelines Original Research and Review Articles Start at bottom & work my way up.

Evidence-based healthcare information and practice Evidence-based medicine Evidence-based nursing Evidence-based allied health Evidenced based research can be conducted by any health provider – though the bulk of the published output comes from medicine.

Why healthcare providers use evidence-based practice Leads to highest quality care and patient outcomes Reduces health care costs Reduces geographic variations in the delivery of care Increases healthcare provider empowerment and role satisfaction Reduces healthcare provider turnover rate Increases reimbursement from 3rd party payers Reduces complications and payment denials Meets the expectation of an informed public The public is becoming more informed and wants the best care. They are doing their own research. More efficient health care professionals, better quality of care, less turnover. Feeling empowered

7 steps of EBP 0: Cultivate a spirit of inquiry 1: Ask the question in the PICOT format 2: Search for and collect the most relevant and best evidence 3: Critically appraise the evidence 4: Integrate the best evidence with the healthcare provider’s experience/ expertise and patient preference 5: Evaluate outcomes of the practice decision 6: Disseminate the outcomes of the EBP decision (Melynk,B., Fineout-Overholt,E. Evidence-based practice in nursing & healthcare. 2010, 2nd Edition) It’s not about going out and conducting fresh research – its about reviewing what has been done and making a practice change based on that evidence. Step 0 is the basis of Melynk and Fineout-Overholt’s work in the U.S. out of Arizona State University. The basis of step 0 is that – if you don’t have a culture that supports a spirit of inquiry, than none of the other steps can happen.

Key initiatives Cochrane Collaboration (http://www.cochrane.org)- systematic reviews focused on medicine and overall healthcare Joanna Briggs Institute – systematic reviews and best practice recommendations focused on nursing and overall healthcare Campbell Collaboration – systematic reviews focused on social sciences Guidelines International Network (G-I-N) – International Guideline Library – 94 organizations World Health Organization (WHO) – focused on public health guidelines Germany - German Agency for Quality Medicine United Kingdom - National Institute for Health and Clinical Evidence (NICE) – guidelines focused on interventional procedures, clinical practice and technology appraisals Netherlands - Dutch Institute for Healthcare Improvement (CBO) Global nature of the EBM/EBP initiative-I’m sure most of you are familiar with these. Obviously while US is late to the party, the worldwide medical community has been focused on this for more than 20 years. Cochrane is in Ovid. Parts of JBI with more to come. Ovid provides resources to NICE

Barriers to implementing EBP in health care institutions Lack of EBP skills or knowledge Misperceptions or negative attitudes about research and EBP Lack of belief that EBP improves outcomes Too much information in journals – information overload Lack of time and resources to search for and appraise evidence Overwhelming patient loads

Barriers to implementing EBP in health care institutions Organization constraints and lack of administrative support Lack of EBP mentors Demands from patients for a certain type of treatment Peer pressure to continue to practice steeped in tradition Resistance to change Lack of consequences for not implementing EBP Lack of autonomy over practices and incentives

How can institutions support EBP? Leaders need to support and encourage a culture of EBP Medical librarians need to teach researchers and healthcare providers how to search Healthcare providers and researchers need the time to critically appraise studies and implement findings Researchers need to be taught how to write clear reports that can be translated into practice EBP mentors need to be readily available and accessible

How can institutions support EBP? Provide proper tools and resources – access to evidence-based journals and databases Provide an adequate number of computers throughout the institution and make sure they have intranet and internet capability Clinical systems need to incorporate EBP information Clinical practice policies and procedures need to be based on evidence Initiate journal clubs Support EBP rounds

Ovid products that support EBP MEDLINE Evidence-Based Medicine Reviews (EBMR) – Cochrane Reviews Transplant Library British Medical Journal Embase PsycINFO Joanna Briggs Institute - PACESetterS OvidMD

OvidMD “Putting Research into Practice” The first clinical tool from Ovid for physicians and other clinicians to find quick answers to clinical questions backed by comprehensive, evidence-based research from trusted sources. A clinical lens based on evidence-based content: Evidence-Based Guidelines A synthesis of best available evidence written by physicians for physicians that recommends a course of action UpToDate Professional Topics Literature-driven updating system; more than 440 journals are monitored by editors and authors. Current Opinion full-text journals Contain peer-reviewed articles on research, techniques and diagnostic methods Evidence Based Guidelines : from Clin-eguide A synthesis of best available evidence on diagnosis, management, and treatment of conditions that occur in primary care, inpatient and emergency department settings. It is written by physicians for physicians, updated quarterly, and recommends a course of action for diagnosis, disease management and drug therapy UpToDate is written by physicians who are experts in their fields, so you have confidence in our recommendations. Over 4,400 physician authors and editors, all experts in their respective fields, write topic reviews that cover all of the major aspects of a particular condition, including symptoms, tests and diagnosis, and treatment options. All topics are also subjected to rigorous peer review. UpToDate is evidence-based, providing information you can rely on. UpToDate is evidence-based and uses a literature-driven updating system; more than 440 journals are monitored by editors and authors, and anytime something of importance is published, it is incorporated into the program. The key word here is "incorporated." UpToDate is not a journal watch. New studies are not simply added; rather they are placed in the context of what has already been published in that field.

In summary… Healthcare practice based on evidence: Improves healthcare practice Improves patient outcomes Lowers healthcare costs Librarians are in a key role to facilitate evidence-based practice by: Leveraging their expertise to teach and assist healthcare providers with search and obtaining the best search results Assisting in appraising the evidence for validity, reliability, and applicability Leading educational opportunities to educate healthcare providers on the importance of evidence-based practice Facilitating a journal club to discuss the latest clinical practice guidelines around specific conditions and diseases Being the “Evidence Mentor” for the institution

References Eddy, D. Evidence-based medicine: A unified approach; Health Affairs, 24, no.1 (2005) Guyatt, G. Evidence-based medicine has come a long way; BMJ, 2004, Oct. 30th. Hemingway, P. What is a systematic review? Hayward Group Ltd; April 2008. Liang, L. The gap between evidence and practice; Health Affairs, 26, no.2 (2007) Melnyk, B. Fineout-Overholt, E. Evidence-based practice in nursing & healthcare. LWW, Philadelphia, June 2010; 2nd edition McClellan, M. McGinnis, M., Nabel, E., et.al. Evidence-based medicine and the changing nature of healthcare: Meeting summary; IOM Roundtable on evidence-based medicine; National Academies Press; 2008.

Questions? Thank You!