Transcript Evidence Based Practice C Pacini
Evidence-Based Practice & Outcomes: Transforming Practice at the Point of Care Christine M. Pacini, PhD, RN
Dean & Professor College of Health Professions McAuley School of Nursing University of Detroit Mercy
Objectives
Upon completion of this presentation, the participants will be able to: – Recognize the power of evidence to change practice – Define key “how-to” principles required for utilization of evidence in practice – Identify examples of clinicians using evidence to transform practice in a variety of settings
OMG!
What WERE we thinking?
OMG!
So, NOW what do we do?
It’s Obvious!
When asked about the care that they personally want to deliver or receive, clinicians choose EBP over care that is steeped in legacy and tradition.
– If you were diagnosed with cancer…?
– If your mother was diagnosed with Alzheimer’s disease…?
– If you are caring for a child who was in a MVA…?
An Overview of Evidence-Based Practice
What is EBP?
An early definition of EBP proposed by physician David Sackett (1996) – The conscientious, explicit and judicious use of current best evidence in making decisions about the care of patients.
What is EBP?
Nursing Definition
A problem-solving approach to clinical practice that integrates: – A systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question – One’s own clinical expertise and patients’ preferences and values Melnyk & Fineout-Overholt (2005, p. 6)
What is EBP?
Both definitions emphasize the
essentials
of EBP: – Using current best evidence for the purpose of providing the highest quality patient care
What EBP is NOT
Misconceptions and controversies about EBP: – EBP means doing research – EBP is a new “buzzword” for research utilization – EBP is a “cookbook” approach to health care
EBP is NOT the same as “doing research”
EBP means using the is patient care
BEST AVAILABLE
evidence (typically research evidence) to solve patient care problems – the emphasis Often EBP involves using research findings that have already been generated and published But if no evidence is available to answer one’s clinical problem, EBP may involve conducting research
EBP is NOT a new “buzzword” for Research Utilization
Research utilization means using the results of a research study to address a nursing practice problem Research utilization involves taking existing research findings and making them part of one’s practice Research utilization may be less systematic and formal than EBP – RU could involve one nurse using the results of one study
EBP is NOT a “cookbook” approach to health care
The definition of EBP includes incorporating patients’ values and preferences AND clinicians’ expertise into clinical decisions Modifications in care might be made for individual patient’s needs Clinicians’ judgment is always primary – evidence may not always apply to every patient
History of EBP
Dr. Archie Cochrane in the UK is attributed as the founder of the EBP movement in 1972 Dr. Cochrane’s focus was on developing high quality synthesis of clinical trials The Cochrane Center was established in 1992 in the UK
Why the emphasis on EBP?
Crossing the Quality Chasm
– IOM report in 2001 – U.S. health care practices were fragmented and based on tradition and previous training rather than scientific evidence – Recommendation – health care professionals need to employ
evidence based practice
as a standard of practice
The Basics of EBP: What is evidence?
Dictionary definition: – “Something that furnishes proof”
What is EVIDENCE in EBP?
Traditionally, evidence in EBP = research studies, specifically: – Scientific evidence from randomized clinical trials or experiments
But what if no clinical trials will answer your clinical problem?
Sometimes your problem can’t be answered by a clinical trial Sometimes there is nor clear answer or available research If no research is available, EBP means using the
best available
evidence
Evidence in EBP for Nursing Practice
In nursing,
best available evidence
may include: – Results of qualitative studies – Benchmarking data – Case studies – Clinical reports – Expert opinion – Epidemiologic studies and statistics
EBP Models in Nursing
EBP Models provide roadmaps for the EBP process There are several models of EBP that have been used in nursing: – Rosswurm & Larrabee Model – Stetler Model – Iowa Model – AceStar Model Most have the same fundamental steps
Rosswurm & Larrabee (1999)
Focuses on use of change theory, principles of research utilization and standardized nursing nomenclature.
Six steps include: – Assess the need for change in practice – Link the problem with interventions and outcomes (using standard nursing nomenclature) – Synthesize the best evidence – Design a change in practice – Implement and evaluate the practice – Integrate and maintain the practice change
Stetler Model (1994)
Applies research findings at the individual practitioner level. Critical thinking and decision making are emphasized.
The model has six phases: – Preparation – Validation – Comparative evaluation – Decision making – Translation and application – Evaluation
Iowa Model (1994)
Combines a Quality Assurance model with research utilization Focuses on change for and entire organization Includes 10 steps with 3 key decision points: – Is the topic a priority?
– Is a research base sufficient?
– Is the change appropriate for adoption in practice?
Iowa Model – 10 Steps
“Trigger” to change practice Is this a priority for the institution?* [yes/no] Form a team Assemble research & other evidence Critique & synthesize research Is there sufficient research?* [yes/no] Develop plan/pilot change OR conduct research Is change appropriate for adoption?* [yes/no] Change practice Monitor results
Ace Star Model (2004)
Focuses on the process of transforming new knowledge (research) into practice Five phases of knowledge transformation are illustrated as 5 points on a star: – Discover (generation of new knowledge) – Summary (synthesis of research knowledge on a topic) – Translation (or research knowledge into practice recommendations) – Implementation (integrating knowledge into practice) – Evaluation (of outcomes from EBP)
Six Steps of EBP
Most nursing EBP models have common steps: – State the problem – Search the literature – Appraise and synthesize the literature – Identify and plan practice changes – Implement practice changes – Evaluate practice changes
1. State the Problem
Problems = clinical issues that suggest a need to change practice – The issues could be clinical concerns that emerge from daily practice – OR, they could be the need to address new standards of care in current practice
State the Problem
This is a very important part of EBP The PICO format helps to state the problem clearly: – – – –
P
atient population
I
ntervention
C
omparison intervention (optional)
O
utcome
PICO Format -- Example
One has heard about promoting “family presence” in the ICU and one wonders how well it works for families.
The PICO format helps one to create a problem statement that can guide an evidence-based practice change.
Here is a problem statement, restated in PICO format: – For families of critically ill patients does family presence during invasive procedures reduce family stress and increase satisfaction
[O]?
[P], [I]
2. Search the Literature (Research & other evidence)
The goal is to locate all of the high quality evidence for one’s clinical question The PICO statement guides the literature search and helps one to find the right type of evidence Reference librarians are your best friends!!
Types of Evidence
What’s out there?
There are many types of evidence: – –
Data-based
evidence Research studies Statistical data, etc.
Expert opinion
evidence Experts on a topic write about their experience or opinions
Types of Evidence
For research evidence, one may find: – –
Primary
or
Secondary
research literature
Primary Research Evidence
Original research articles reported by the investigator – e.g., reports of clinical trials in MEDLINE or research articles in CINAHL – Reader must determine the quality of the study, including its methods and conclusions
Secondary Research Evidence
Summary or evaluation of original research – e.g., Cochrane Database of Systematic Reviews Very useful for EBP – experts review multiple studies on a particular topic for design, methods and conclusions, and then synthesize findings and conclusions – saving one from doing own search & synthesis Examples: – Systematic Review – Meta-analysis
Secondary Research Evidence
The
Cochrane Databases of Systematic Reviews
is the premier source of reliable secondary research evidence The Cochrane organization uses a rigorous, standard process to search for and synthesize all of the research on hundreds of health topics such as pressure ulcers and falls prevention
Types of Evidence
Levels of Evidence: – Higher level evidence is considered more reliable –
if
it answers your clinical question – “Hierarchies of evidence” organize different types of research according to reliability
Evidence Hierarchy: Example #1
Systematic reviews of randomized controlled trials Randomized controlled trials Non-randomized clinical trials Systematic reviews of non-experimental studies Cohort studies Case control studies Surveys Case reports (Craig & Smith, 2007, p. 103)
Evidence Hierarchy: Example #2
Level 1
: Systematic review & meta-analysis of RCTs; evidence-based Clinical Practice Guidelines
Level 2
: One or more RCTs
Level 3
: Controlled trial (no randomization)
Level 4
: Case-control or cohort study
Level 5
: Systematic review of descriptive & qualitative studies
Level 6
: Single descriptive or qualitative study
Level 7
: Expert opinion
Where can you find evidence?
A good starting point is publication databases such as Medline or PubMed Another good starting place is the Agency for Healthcare Quality and Research (AHRQ) – a U.S. government resource for EBP AHRQ maintains the National Guideline Clearinghouse (NGC) – a high quality, searchable database of evidence-based practice guidelines www.guidelines.gov
Where can you find evidence?
Peer-reviewed health care journals: – – – Nursing Research Journal of Advanced Nursing Research in Nursing and Health – Specialty nursing journals AORN AJCCN
Where can you find evidence?
Government organizations – CDC evidence summary related to hand hygiene
www.cdc.gov/handhygiene/
National organizations – Policy Statements – Practice Guidelines e.g., Sleep Position and SIDS: Update from the American Academy of Pediatrics
This statement provides an update to the June 1992 AAP policy, “Infant Positioning and SIDS,” which recommended that healthy term infants be placed on their sides or backs to sleep. Recent data show that the original policy appears to have had a positive effect in decreasing the prevalence of prone sleeping significantly. ( www.aap.org
)
3. Appraise & Synthesize Evidence
Upon completion of the ROL, one will have a variety of evidence: – Secondary, primary, data-based, expert opinion, high quality, conflicting, not exactly congruent with patient population of interest One will need to critique the evidence for: – – – Quality Applicability Meaning
Critique the Evidence: Quality
How reliable is the evidence?
– Where does it fall on the evidence hierarchy “pyramid?” – What is the methodological quality?
If research, is the method sound?
If expert opinion, what is the source?
– How much evidence is available and does it agree?
Critique the Evidence: Applicability
Is this evidence relevant to my setting and patients?
Critique the Evidence: Meaning
What are the risks/benefits of the evidence for may patients?
What are my patients’ preferences?
Does the evidence demonstrate clinically meaningful findings?
Synthesize the Evidence
Summarize the overall recommendations from the evidence Weigh the overall risks, benefits and strength of evidence to answer the question: Does most evidence agree?
– Note: EBP recommendations from reliable professional organizations do this step.
Decision Point: Is there sufficient evidence?
In the end, one will need to decide whether there is enough evidence to support a nursing practice recommendation The decision balances the risks, benefits and strengths of evidence – Risks/weak evidence = don’t use – Benefits/strong evidence = do use
4. Identify and Plan Practice Change
Translate evidence into a plan for nursing practice – Identifying outcomes The results that one wants A plan for data collection – Developing written practice guidelines Outline the practice changes, including the details of the practice and the roles of staff
Identify & Plan Practice Change
A
pilot
trial is recommended – Trial practice change on a small scale – Collect data on outcomes, process and user concerns – Engage the skeptics – Refine the change based on results of the pilot trial
5. Implement evidence based practice change
The next step is “whole scale” implementation of the practice change Consider how to inform and educate staff Consider how to sustain the change
6. Evaluate Results of Practice Change
Consider the following types of outcomes: – Patient outcomes/satisfaction – Nurse satisfaction – Cost
Overcoming Barriers: How to Make EBP Happen
Necessary processes and needs: – EBP education – EBP mentors/champions CNSs, NPs, Unit Educators – Computers & internet access – Librarian assistance – Supportive culture – Communication of latest evidence directly to nurses at the point of care
Evidence-based practice tries to bridge the gap between research and clinical practice. The aim is to incorporate patient care practices that are as accurate, safe and effective as possible, based on the best available current evidence.
Our patients deserve evidence-based care!
Exemplars
Non-invasive BP monitoring Family presence during CPR and invasive procedures Management of the child with fever Installation of normal saline before endotracheal suctioning Management of adult depression