Transcript Leading the Way: Keys to Success for Evidence

Susan Fowler, PhD, RN, CNRN, FAHA
Director of Magnet, Education, Quality, & Research
TRANSLATING EVIDENCE INTO PRACTICE:
USING A CRITICAL EYE
OBJECTIVES

At the end of this presentation, attendees will:
 Define
evidence-based practice.
 Describe critical parts of a critique of evidence.
 Apply critical analysis to infection control practices.
EVIDENCE-BASED PRACTICE





Who does it pertain to?
What is it?
When do I use it?
Why is it important?
How do I go about
evidence-based
practice?
MANDATE FOR EBP

Focus on outcomes and
cost



Unnecessary variations in
practice persist
Gap between evidence
and practice
Unmanageable amounts
of information
EBP ORIGINATED IN MEDICINE.
 Dr.
Archie Cochrane, Epidemiologist
 Crossing
 Studies
the Quality Chasm (IOM, 2001)
in medicine and nursing indicated
that interventions based on evidence have
better outcomes.
EVIDENCE-BASED PRACTICE

Definition

Evidence Based Practice of nursing is the process by
which nurses make clinical decisions using the best
available research evidence, their clinical expertise
and patient preferences.
 Nurse,

Clinical Expertise, Patient, Evidence
Reality



We use evidence everyday without thinking about it
Sources of evidence can be too few or too many
It’s easier to base practice on myths and the way we have always done
things than attempt to understand the evidence and change practice
EBP COMBINES THE ART AND SCIENCE OF
NURSING

Essentials of practice
 Art



Our ability to connect to those around us
We just ‘know’ what to do to meet a patient’s emotional needs: when to hold
a patient’s hand, stroke their brow, crack a joke or even just sit and listen
Calls you to the profession
 Science




Body of knowledge
Uses scientific methods
Generate and test theory, discover meaning, and grow knowledge
A scholarly adventure
THE PROCESS OF EBP
Ask the burning clinical question (PICO).
 Collect the best evidence.
 Critically appraise the evidence.
 Integrate the evidence, clinical expertise, and
patient factors/preferences to implement a
decision.
 Evaluate the outcome.

THE LINK BETWEEN EBP AND RESEARCH

Research



Conducted a systematic &
scientific manner
Follows a series of steps with a
rigorous standard protocol
Purpose is to generate new
knowledge

Evidence-based
Practice

The process by which nurses
make clinical decisions using the
best available research evidence,
their clinical expertise and
patient preferences

Where are the
similarities and
differences?




Both use a process/specific
approach
Both are trying to gain something –
knowledge, a new way of doing
something
Research more ‘rigorous’ with
more steps
Research tries to gain new
knowledge whereas EBP might try
to confirm knowledge
EBP





Ask the burning clinical question
(PICO)
Collect the best evidence
Critically appraise the evidence
Integrate the evidence, clinical
expertise, and patient
factors/preferences to implement
a decision
Evaluate the outcome
RESEARCH








Statement of the Problem; Purpose
of the Study
Significance (WHY is this important
to nursing – SO WHAT??)
Review of the Literature; Research
?
Conceptual Framework
Methods/Design/Data Collection
Data Analysis
Findings
Discussion/implications
COMPARING EBP & RESEARCH
EBP PROCESS
Practice Question, Evidence, Translation
(PET)
Practice
Question
Evidence
Translation
(Newhouse, R.P., Dearholt, S., Poe, S., Pugh, L.C., White, K. 2005)
HOW DO I ASK AN EBP QUESTION?
P – patient population
 I – intervention of interest
 C – comparison intervention or status
 O – Outcome
 In caring for disabled adults, does the use of
level-access showers improve patient hygiene
more than bed bathing???

PICO QUESTION

In adult surgical
patients, does getting
the patient out of bed
ambulating help with
bowel elimination more
than just sitting in the
chair?
PICO QUESTION

In hospitalized elderly,
does brushing their
teeth before every
meal improve the
amount of food eaten
compared to no oral
care?
 Level
l – experimental/RCT/meta-analysis of RCTs
 Level II – quasi-experimental
 Level III – non-experimental or qualitative
 Level IV – opinion of experts and/or reports of
nationally recognized expert committees, evidence
from case reports
 Level V – opinion of nationally recognized experts
based on experience
 Top
to Bottom
 Truffles
 Donnelly
Chocolates
 Ghiradelli Chocolate
bars
 Hershey kisses
 Fannie Farmer
sample
 Nestle’s Quik
STEVENS (2005) ESSENTIAL COMPETENCIES (20)
FROM: STEVENS, K. (2005). ESSENTIAL COMPETENCIES FOR EVIDENCE-BASED
PRACTICE IN NURSING. (1ST ED.). SAN ANTONIO, TX: ACE, UTHSCSA.
Define EBP in terms of evidence, expertise, and
patient values.
 Critically appraise original research reports for
practice implications.
 Classify clinical knowledge as primary research,
evidence summary, or practice guideline.
 Recognize ratings of strength of evidence when
reading literature.

ESSENTIAL COMPETENCIES (CONT.)




Use evidence summary databases to locate
systematic reviews and evidence summaries on
clinical topics.
Participate on a team to develop agency-specific
evidence-based clinical guidelines.
Deliver care using evidence-based clinical practice
guidelines.
Choose evidence-based approaches over routine as
basis for own clinical decision-making.
AACN ESSENTIAL COMPETENCIES (1998)
Related to Critical Thinking
o
Apply research-based knowledge from nursing
and sciences as the basis for practice.
o
Evaluate nursing care outcomes through the
acquisition of data and questioning of
inconsistencies.
AACN ESSENTIALS (CONT.)
Related to Provider of Care
o
Integrate theory and research-based
knowledge from the arts, humanities and
sciences to develop a foundation for
practice.
o
Participate in research that focuses on the
effectiveness of nursing interventions.
o
Utilize outcome measures to evaluate
effectiveness of care.
MODELS

Why pick a model for
EBP?



Provides an organized
approach
Prevents incomplete
implementation
Maximizes nursing time
and resources (Gawlinski &
Rutledge, 2008)
JOHN HOPKINS EBP MODEL & GUIDELINES


Depicts 3 essential cornerstones that form the
foundation for professional nursing
Nursing practice is the means by which a patient
receives nursing care; education reflects the
acquisition of the nursing knowledge and skills
necessary to become a proficient clinician and to
maintain competency; and research provides new
knowledge to the profession and enables the
development of practices based on scientific
evidence.
JHN Evidence-based Practice Conceptual Model
Practice
External
Factors
Internal
Factors
Culture
Environment
Equipment/Supplies
Staffing
Effectiveness
Standards




Research
Experimental
Quasi-experimental
Non-experimental
Qualitative
Accreditation
Core Measures
Legislation
Licensing
Standards
Non-Research
 Organizational experience
- Quality improvement
- Financial data
 Clinical expertise
 Patient preference
Education
Research
 The Johns Hopkins Hospital/ The Johns Hopkins University
STEPS
Step 1: Identify an EBP question
Step 2: Define scope of practice question
Step 3: Assign responsibility for leadership
Step 4: Recruit multidisciplinary team
Step 5: Schedule team conference
MORE STEPS
Step 6: Conduct internal and external search
for evidence
Step 7: Critique all types of evidence
Step 8: Summarize evidence
Step 9: Rate strength of evidence
Step 10: Develop recommendations for change
in processes of care or systems based on the
strength of evidence
IOWA MODEL OF EBP
Guides clinical decision-making; details
implementation of EBP; considers practice &
organizational perspectives
 Examples (at the Univ. of Iowa Hospitals &
Clinics)

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
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Pain in acute care and outpatient settings
Assessment and intervention to decrease patients’ risk for falling while
hospitalized
Facilitating visitation by family pets in acute care
Nurse retention
IOWA MODEL
Successfully implemented since 1994
internationally
 Infuses research into practice to improve
quality of care
 Planned change principles integrate
research and practice
 Utilizes a multidisciplinary team
approach
 Utilizes feed-back loops

Problem Focused Triggers
Consider other
triggers
NO
Knowledge Focused Triggers
Priority for
Organization
YES
Form a team
Assemble Relevant Research & Related Literature
Critique and Synthesize Research for Use in Practice
Sufficient
Research?
Pilot Change in
Practice
Base Practice on other
Types of Evidence
Conduct
Research
Continue to
Evaluate quality
Care and New
Knowledge
No
Should we
Adopt this change
into practice?
Disseminate
Results
Yes
Institute
Change
Monitor and Analyze
Structure, Process, and
Outcome Data
SELECTING A TOPIC
“THE BURNING QUESTION”

Problem Focused Triggers




Risk management data
Identification of a clinical problem
QI or Financial Data
Knowledge Focused Triggers



New research or other literature
Philosophies of Care
Agencies or Organizational Standards and guidelines
SETTING PRIORITIES

3 step process



EBP expert and clinician
Nursing Research Committee
Endorsement by executive leadership
Priority for
Topic
Idea
Nursing
1=low;
5=high
Organization
1=low;
5=high
Likelihood to
Improve
Quality
of care
1=low;
5=high
Decreas
e LOS/
Contain
Costs
1=low;
5=high
Improve
Patient
Satisfactio
n
1=low;
5=high
Improve
Employee
Satisfactio
n
1=low;
5=high
Body of
Science
1=little
5=multiple
studies
ACE STAR MODEL - THE UNIVERSITY OF TEXAS HEALTH
SCIENCE CENTER AT SAN ANTONIO
KNOWLEDGE TRANSFORMATION

-the conversion of research findings from primary research
results, through a series of stages and forms, to impact on
health outcomes by way of EB care




Knowledge transformation is necessary before research results are useable in
clinical decision making.
Knowledge derives from a variety of sources. In healthcare, sources of
knowledge include research evidence, experience, authority, trial and error, and
theoretical principles.
The most stable and generalizable knowledge is discovered through systematic
processes that control bias, namely, the research process.
Evidence can be classified into a hierarchy of strength of evidence. Relative
strength of evidence is largely dependent on the rigor of the scientific design
that produced the evidence. The value of rigor is that it strengthens cause-andeffect relationships.
KNOWLEDGE TRANSFORMATION




Knowledge exists in a variety of forms. As research evidence is converted through
systematic steps, knowledge from other sources (expertise, patient preference) is
added, creating yet another form of knowledge.
The form ('package') in which knowledge exists can be referenced to its use; in the
case of EBP, the ultimate use is application in healthcare.
The form of knowledge determines its usability in clinical decision making. For
example, research results from a primary investigation are less useful to decision
making than an evidence-based clinical practice guideline.
Knowledge is transformed through the following processes:




summarization into a single statement about the state of the science
translation of the state of the science into clinical recommendations, with addition of clinical expertise,
application of theoretical principles, and client preferences
integration of recommendations through organizational and individual actions
evaluation of impact of actions on targeted outcomes
WHY MEASURE EBP OUTCOMES?


Outcomes reflect
IMPACT!!!
EBP’s effect on
patients:


Physiologic, pyschosocial, function
EBP’s effect on the
health system:



Decreased cost, length of stay
Nursing retention/job
satisfaction
Interdisciplinary collaboration
A MODEL FOR EBP (ROSSWURM & LARRABEE, 1999)

1. Assess need for
change in practice




Include stakeholders
Collect internal data
about current practice
Compare internal data
with external data
Identify problem

2. Link problem,
intervention, and
outcome




Use standardized
Classification systems and
language
Identify potential
interventions and
activities
Select outcomes
indicators
MODEL CONTINUED

3. Synthesize best
evidence




Search research
literature related to
major variables
Critique and weigh
evidence
Synthesize best evidence
Assess feasibility,
benefits, and risk

4. Design practice
change




Define proposed change
Identify needed resources
Plan implementation
process
Define outcomes
MODEL CONTINUED

5. Implement and
evaluate change in
practice



Pilot study
demonstration
Evaluate process and
outcome
Decide to adapt, adopt,
or reject practice change

6. Integrate and maintain
practice change




Communicate
recommended change to
stakeholders
Present staff inservice
education on change in
practice
Integrate into standards of
practice
Monitor process and
outcomes
EBP CASE STORY FROM ASU COLLEGE OF
NURSING & HEALTH INNOVATION


A dog bit my mother-in-law three weeks ago. She has known the dog for many years,
but the immunization status of the dog was unconfirmed. Her wound was small, so
she did not seek treatment at that time. The biggest fear after a dog bite is
contracting rabies. Rabies is a zoonotic disease (one transmitted to humans from
animals) caused by a virus.
Last week she went to her primary care provider (PCP) for treatment, two weeks after
the initial bite. Her PCP recommended rabies post-exposure immunization. My
husband, a resident physician, and I were shocked as neither of us has ever
recommended the rabies immunization for post-exposure treatment in a case like
hers. We both quickly consulted our databases of choice for a quick look at what we
thought were the recommendations for rabies treatment. I consulted
www.emedicine.com and found “Human rabies immune globulin and vaccine are
recommended for bites and exposures regardless of the period between exposure
and treatment unless the individual is previously vaccinated and rabies antibodies
can be detected.” (2007, 11).
CASE CONTINUES…

Of note, the average delay in the United States between exposure and
treatment is 5 days, which does not appear to compromise successful
prophylaxis. My husband consulted the Up to Date database and found “for
persons who have never been vaccinated against rabies, post-exposure
antirabies vaccination should always include administration of both passive
antibody (HRIG) and vaccine (human diploid cell vaccine [HDCV] or purified
chick embryo cell vaccine [PCECV])”. Finally we looked at the Centers for
Disease Control (CDC) website and found their recommendation to be “for
persons who have never been vaccinated against rabies previously, postexposure anti-rabies vaccination should always include administration of
both passive antibody and vaccine”. Post-exposure prophylaxis is a series of
multiple injections around the already painful wound and follow-up is
generally poor for patients (Moran, G.J. Talan, D.A. Mower, W. Newdow, M.,
Ong, S., Nakase, J., et al., 2000).
CASE CONTINUES…


We were frustrated and confused. It seemed that all three databases
recommended that the post-exposure vaccine be given. Yet in all of the nine
facilities that we have worked in across three different states, this has never
been standard of care.
Since I have been learning the process of evidence-based practice (EBP)
and how to search the literature for the best evidence, I thought that I would
apply it to this situation. A PICO question was developed to drive the search
of the literature. In (p) patients with animal bites does the (i) administration
of post-exposure prophylaxis (PEP) compared to (c) observation or testing of
the animal only (o) provide the most appropriate treatment?
CASE…THE END



I performed a quick search of the CINAHL, PubMed, and Google Scholar
databases. After rapidly critically appraising the articles I found and
synthesizing my findings, I know that I now have a validated response to my
mother in law when I say that the post-exposure treatment of rabies is not
warranted in her case. I can show her the evidence. There is even an easy
algorithm to follow called the "Algorithm for Determining Appropriateness of
Animal Exposure Treatments" (Moran, G.J. Talan, D.A. Mower, W. Newdow,
M., Ong, S., Nakase, J., et al., 2000).
My “EBP Story” shows how I have taken what I have learned in the last five
months and not only applied it to my practice, but also my personal life.
This week my mother-in-law’s dog drank antifreeze. Perhaps next week I will
do a mini-synthesis of evidence for a recommendation on the treatment for
that issue.
BARRIERS/CHALLENGES TO EBP IN CLINICAL SETTINGS FROM
PRAVIKOFF ET AL., (2005). READINESS OF US NURSES FOR EVIDENCEBASED PRACTICE. AJN, 105.
 Lack
of knowledge about EBP.
 Lack of knowledge about library and
online resources.
 Inconvenient/inaccessible
library/internet.
 Misperceptions or negative views of
research.
 Devotion to traditional care.
BARRIERS (CONTINUED)






Overwhelming patient care load.
Voluminous amounts of literature.
Difficult patient care situations.
Organizational constraints.
Inadequate information in prelicensure
nursing program.
Laziness/lack of motivation/ burnout.
EBP FACILITATORS – ADDS TO SUCCESS

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


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Educational emphasis in nursing schools and
hospitals.
Administrative support and encouragement.
Time to think through patient care situations.
Time to critically appraise studies and implement
findings.
Clearly written, well-done research reports.
Library and internet access in the clinical area.
STRATEGIES TO ADVANCE EBP




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Enhance critical
appraisal skills
Discuss of findings
Journal Clubs
Systematically examine
the stage of adoption of
practice guidelines
Facilitate systematic
reviews





Facilitate primary
research
EBP Grand Rounds
Scholar in Residence
Web Support/Toolbox
Research corner in
newsletter
DIRECTIONS FOR EBP AND RESEARCH

APIC (2000, 2011)
 Behavioral
management science
 Surveillance standards
 Infection prevention resource optimization
 Standardization
in infection prevention practices
and program resource allocation
NATIONAL INSTITUTE FOR NURSING RESEARCH

Strategic Plan
 Enhance
health promotion and disease prevention
 Improve quality of life by managing symptoms of
acute and chronic illness
 Improve palliative and end-of-life care
 Enhance innovation in science and practice
 Develop the next generation of nurse scientists
WHERE ARE THE GAPS IN THE LITERATURE?

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Hand hygiene
Environmental cleaning
PPE
C-diff
Catheter related blood
stream infections
CAUTI
MRSA
Orthopedic site infections
VAP