Evidence-Based Practice: A Tool for Clinical and Managerial Decision Making

Objectives Define what is evidence based practice (EBP). Discuss the history of EBP. Implementing Evidence-Based Practice: The Iowa Model. Discuss the Determination of Clinical Relevance in EPB. Discuss how to Framing a Clinical Question using the PICO model. Discuss the Literature Review and Search Techniques. Define the AHRQ.

What is EBP? The use of evidence-based practice (EBP) and national guidelines to improve the quality of patient care. EBP closes the gap between research outcomes and practice (Newhouse, Dearbolt, Poe, Pugh, & White, 2005)

The importance of evidence

The importance of evidence

What is EBP? EBP uses current research evidence combined with clinical expertise and patient values to formulate sound interventions (DiCenso, Guyatt, & Clinska, 2005).

History of EBP FFCM (1909-1988) in 1972. Dr. Cochran, a British epidemiologist, identified a gap between current practices and evidence-based guidelines.

Implementing EBP: The Iowa Model The Iowa Model of EBP was developed by Marita G. Titler, PhD, RN, FAAN, Director Nursing Research, Quality and Outcomes Management, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa Iowa Model: Considers the entire health care system: Provider Patient Infrastructure

Iowa Model Identify a trigger – problem focused or knowledge focused Determine clinical relevance – is it important to the organization or culture

Framing the Clinical Question What to include what to exclude?

PICO Model P = Who is the Patient Population? I = What is the potential Intervention or area of Interest? C = Is there a Comparison intervention or Control group? O= What is the desired Outcome? Your question drives your research!

The Literature Review Cochrane Library Clinical Practice Guidelines Cumulative Index to Nursing and Allied Health Literature (CINAHL); and PubMed. http://www.hsclib.sunysb.edu/

Types of Literature Reviews Systematic Review: Looks for similar Studies (Critiquing an Article) Meta Analysis: Statistical technique for averaging an effect of treatment across studies (Cochrane Data Base)

DEFINITION OF NURSING RESEARCH Research is a process of systematic inquiry or study to build knowledge in a discipline. The purpose of research is to validate and refine existing knowledge and develop new knowledge. The results of research process: provide a foundation on which practice decisions and behaviors are laid create a strong scientific base for nursing practice and application of results demonstrates profes­sional accountability to insurers and health care consumers.

Research is a process that takes place in a series of steps: Formulating the research question or problem Defining the purpose of the study Reviewing related literature Formulating hypotheses and defining variables Selecting the research design Selecting the population, sample, and setting Conducting a pilot study Collecting the data Analyzing the data Communicating conclusions

Levels of Evidence

Hierarchy of Evidence

Hierarchy of Evidence Levels of Evidence Category I:  Evidence from at least one properly randomized controlled trial. Category II-1: Evidence from well-designed controlled trials without randomization. Category II-2: Evidence from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. Category II-3: Evidence from multiple times series with or without intervention or dramatic results in uncontrolled experiments such as the results of the introduction of penicillin treatment in the 1940s. Category III: Opinions of respected authorities, based on clinical experience, descriptive studies and case reports

Hierarchy of Evidence

Hierarchy of Evidence

SUNY Downstate Medical Center, 2003 Evidence Pyramid MEDLINE and the other online medical literature databases try to be as comprehensive as possible in their coverage. As a result, indexed material may have little direct application to present-day medical practice. The different types of material indexed in MEDLINE are labelled in the pyramid diagram, with the least clinically relevant at the bottom and the most clinically relevant at the top. The four layers above case reports and case series represent actual clinical research; the layers below are least clinically relevant and can be useful as background resources. SUNY Downstate Medical Center, 2003

Evidence Based Resources Models So taking our previous equation, Search Protocol: The pyramid above is a graphical representation of how to search efficiently for the best evidence. The examples of EBM information sources in this pyramid are placed from top to bottom according to the "Usefulness of Medical Information" equation illustrated below: Usefulness =Relevance x Validity  Work This model suggests that you start your search at the top of the pyramid with systematic reviews from the Cochrane Database of Systematic Reviews. Cochrane is small in the amount of information it currently contains, making it easier to search, but large in the validity and relevance of the information it contains for answering therapeutic questions. Depending on the success of your search in Cochrane, you would work your way down the pyramid of resources in order of decreasing relevance/validity and increasing work, until you find an answer. Journal articles form the base of the pyramid because they represent large amounts of "unrefined" information, and the burden of determining the validity and relevance is up to the user. The work part of the "Usefulness Equation" is also very high for journal articles as it may require a lengthy MEDLINE database search to locate them. Searching and Alerting Tools: With the ever-growing number of pre-validated information sources available, clinicians now need two tools to help them identify information that is highly relevant and valid: an Alerting Tool and Searching Tool. A good Alerting Tool would notify the clinician whenever new relevant information becomes available. An example of such a tool would be Daily InfoPOEMs - a companion product to InfoRetriever (a searching tool) from the company InfoPOEMs: The Clinical Awareness System. A good Searching Tool would search multiple databases or sources of information simultaneously and present the results in an easy-to-use format based on relevance and validity. The pyramids below illustrate several such Searching Tools. Not all search tools are equal, and when using one it helps to evaluate it by asking the following questions: Does it search information sources that have a high usefulness score (higher on the pyramid)? Does it search multiple information sources simultaneously? Does it rank its search results according to usefulness (top of pyramid sources listed first)? Does it answer the highest percentage of questions in the least amount of time? Claude Moore Health Sciences Library, 2003

Evidence Based Resources Models Here is how the tool applies to some of the Ovid databases. We have Cochrane at the top and Medline/CINAHL at the bottom. Claude Moore Health Sciences Library, 2003

The cognitive continuum. This diagram is an analysis of something called the cognitive continuum, in this instance based on research among nurses in the UK. It shows 6 steps of information used in decision making, from using intuition on the left, to the most highly analytic and structured information: the scientific experiment, on the right. In this study they followed nurses around and kept track of their decision making processes. What determines whether a nurse uses intuitive decision-making (or NOT evidence based practice) or a more rational decision making (EBP) depends on where the decision task lies on this chart. So, the more structured the decision is, such as through forming a PICO question, by learning how to search in a structured way, the more likely the nurse will use rational decision making. Short time frames for decision turn around encourage intuitive decision making, so learning how to search databases efficiently reduces that time and makes nurses more likely to use EBP. Other factors that increase the likelihood that a nurse will use EBP: whether the information has been broken down into components The need to demonstrate decision making reasoning to others, such as developing a policy or budget rationale to administrators. Thompson, C. et al. Evid Based Nurs 2004;7:68-72 Copyright ©2004 BMJ Publishing Group Ltd.

Evaluating Evidence

STUDY DESIGNS Are plans that tell a researcher how data are to be collected, from whom data are to be collected, how data will be analyzed to answer specific research questions.

Research studies are classified into two basic methods: Quantitative research is a formal, objective, systematic process in which numeric data are used. Qualitative research is a systematic approach used to describe and promote understanding of human experiences such as pain

EBP (Medicine) United States: Agency for Health Care Policy and Research (AHCPR) Department of Health & Human Services http://www.ahcpr.gov/ Developed many clinical guidelines to direct the EBM movement.

GUIDELINE TITLE Evidence-based practice guideline GUIDELINE TITLE Evidence-based practice guideline. Exercise promotion: walking in elders. BIBLIOGRAPHIC SOURCE(S) Jitramontree N. Evidence-based practice guideline. Exercise promotion: walking in elders. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2007 Jun. 57 p. [95 references] GUIDELINE STATUS This is the current release of the guideline. This guideline updates a previous version: Jitramontree N. Evidence-based protocol. Exercise promotion: walking in elders. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2001 Feb. 53 p. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10948&nbr=5728

References Ackermann, R.T. & Williams, J.W. (2002). Rational treatment choices for non-major depressions in primary care: an evidence-based review. Journal of General Internal Medicine, 17, 293-301. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (Rev. ed.) (4th ed.). (DSM-IVTR). Washington, DC: American Psychiatric Association. Balas, E. & Boren, S. (2000). Managing clinical knowledge for health care improvement. In J. Bemmel & A.T. McCray (ed.). In Yearbook of Medical Informatics: Patient Centered Systems (pp. 65-70). Stuttgart, Germany: Schattauer Verlagsgesellschaft. Cliliska, D., Ciliska, D. , Pinelli, J., DiCenso, A., Cullum, N. (2001). Resources to enhance evidence-based nursing practice. American Association of Critical Care Nurses: Advanced Practice in Acute and Critical Care, 12(4), 520-528.

References Collins, S., Vothe, T., DiCenso, A., Guyatt, G. (2005). Finding the evidence. In DiCenso, A., Guyatt, G., Clinska, D. (Eds). Evidence-Based Nursing: A Guide to Clinical Practice. PA: Elsevier; 2005 DiCenso, A., Guyatt,G., & Clinska, D. (Eds.). (2005). Evidence-Based Nursing: A Guide to Clinical Practice. PA: Elsevier. Fineout-Overholt E., Melynk, B. , Schultz, A. (2005). Transforming health care from the inside out: Advancing evidence-based practice in the 21st century. Journal of Professional Nursing, 21, 335-344. Glass, G.V. (Ed.) (1976). Evaluation Studies Review Annual, Vol. 1. Beverly Hills: SAGE Publications.

References Gordis L. (2008). Epidemiology (4th ed.). PA: Elsevier-Saunders. Lang, N.M., Hook, M.L., Akre, M.E., et al., (2006). Translating knowledge-based nursing into referential and executable application in an intelligent clinical information system. In Weaver, C., Delaney, C., Webber, P., Carr, R. (Eds.). Nursing and Informatics for the 21st Century: An International Look at the Trends, Cases, and the Future (pp. 291-304). Chicago: Healthcare Information and Management Systems Society. Malloch, K., Porter-O'Grady T. (2006). Introduction to Evidence-Based Practice in Nursing and Health Care. Boston: Jones and Bartlett. Melnyk, B. & Fineout-Overhold, E. (2005). Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. PA: Lippincott, Williams, & Wilkins.

References Newhouse, R., Dearbolt, S., Poe, S., Pugh, L., & White , K. (2005). Evidence-based practice: A practical approach to implementation. Journal of Nursing Administration. 35, 35-40. Pignone, M.P., Gaynes, B.N., Rushton, J.L., et al., (2002). Screening for depression in adults: a summary of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine,136, 765-776 Simon, G.E. (2000). Long-term prognosis of depression in primary care. Bull World Health Organization, 78:439-445. Titler, M.G., Kleiber, C., Steelman, V.J., et al. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nurse Clinical North America. 13, 497-509.

References Theroux, R. (2006). How to bring evidence into your practice. Association of Women's Health, Obstetric and Neonatal Nurses Lifelines. 10, 244-249 US Preventive Services Task Force (May, 2002). Screening for Depression: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved August 13, 2008, from http://www.ahrq.gov/clinic/pocketgd/gcps2c.htm

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