Transcript Evidence-Based Practice

Nursing
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Advantages
◦ Ensure that patients receive best care.
◦ Mechanism to improve the quality of care.
◦ Part of change management within the
organisation.
◦ Nursing Professional Development.
◦ Enhance communication with other health
professionals.
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Train the Trainers in EBP
Introduction within under-graduate training
and graduate year programs.
◦ Formulating research questions introduced within
specific clinical contexts
◦ Computer searching and accessing evidence-based
research introduced with the clinical ward
environment.
Train the Trainers
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Introduction to the principles of EBP
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Formulating questions in a PICO format
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Database Searching
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◦ MeSh Heaings
◦ Medline
◦ Cochrane
◦ Cinahl
Introduction to systematic reviews, & meta-analysis.
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Introduction to Evidence-Based Guidelines.
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Perceived as too time-consuming
Question
◦ Applicability
◦ Relevance
◦ Practicality
Nurses may not feel that they are in a position to
change practice within their ward.
Perception that robust high-level evidence for
nursing interventions does not exist.
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Train Nurses in Educational & Leadership
Roles.
Incorporate summaries of the evidence into
tools and documentation currently used
within the ward area.
Need for tool-kits that summarise the
evidence.
◦ EG: Delirium Management Guidelines
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Incorporate into educational sessions given to
graduate year nurses.
Example:
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Non-invasive ventilation for management of
hypercapnic respiratory failure secondary to
exacerbation of COPD.
Level II Evidence
 Safe alternative to Critical Care,
 Cost-effective,
 Decreased inpatient mortality.
 Keenan, S. 2003 Annuals of Internal Medicine,
 Plant, PK. 2003 BMJ.
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Not used at RMH outside critical care / high
acuity beds before Sept 2004.
◦ Lack of staff expertise.
◦ Lack of equipment.
◦ No specialised beds
◦ Perception that use of NIV in general ward
areas would be unsafe.
Opening Respiratory Care Unit to provide an
environment in which
Non-invasive Ventilation could be used outside
high-dependency areas.
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EBP as part of the Quality Improvement Cycle
Acknowledgement of projects that have
improved practice & quality of care.
Raise awareness that implementation of high
quality care is about implementing current
evidence.
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Staff Education Program
Patient Empowerment
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Identification of CO2 retainers
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◦ Alert at ED triage, “Second screen” in ED and clinical
p’way
◦ Alert in front of history
◦ Coloured arm band in hospital
◦ Sign over bed
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Written oxygen order on RCU forms
?prescription of O2
All patients with lung disease and CO2 reported to
resp reg or CNC for resp med.
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Repeat audit next year
Hope to demonstrate ongoing change
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Important to demonstrate that
implementation of evidence-based best
practice requires input from all members of
the multi-disciplinary team.
One mechanism to increase a sense of
ownership and involvement in improving
care.
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Development of Clinical Nurse Consultant and
Clinical Nurse Practitioner Roles within the
organisation.
Need for focused interventions that improve
patient outcomes.
Need for interventions to be cost-effective.
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Based upon systematic review of the
literature.
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Identification of current best practice and
evidence.
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Identification of gaps in the evidence.
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Support to formulate research to address
gaps in the evidence.
Does Exacerbation Mx Training
Acute Health Care Utilisation
Negative Outcome
RCT conducted in Tasmania 139 participants
Use of Written Action Plans increased appropriate care of
Exacerbations
Intervention group more likely to have treatment with
antibiotics or short course oral corticosteroids.
No impact on health care utilisation (GP consultations,
Emergency attendances or hospitalisations).
McGeoch, GRB (2006 Respirology 11, 611-618).
Chronic Care Model for COPD
…….including self management training
Level -1
Evidence
Systematic Review of 8 Studies
(1) An Extensive Self-management Program
(2) Advanced Access to Care ---- Advanced Trained Health Care Providers
(3) Guideline–Based / Evidence –Based Therapies
(4) Clinical Registry / or Information Management System.
Programs with > 2 elements had an impact on health care utilisation
Emergency Visits (RR 0.58 [0.42 to 0.79];
Hospitalisations
(RR 0.78 [0.66 to 0.94]).
Limitations:
1. Self management in isolation did not reduce Acute Health Care Utilisation .
2. Limited application of evidence–based & effective interventions
• Intensive Smoking Cessation Programs
• Management of Anxiety & Depression
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World-wide EBP Education for Nurses is becoming
standard practice.
Need for EBP to become part of the nursing culture at
Melbourne Health.
Need for Applied Evidence for Nursing Interventions
to be readily available in the clinical setting.
Need for greater support for senior nurses to
contribute to the development of evidence – based
practice for nurses.
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Nursing Literature
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Qualitative & Quantitative Research
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Evidence-Based Clinical Practice Guidelines
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Medical & Scientific Literature
Controlled chronic disease
Established disease
Disease management and 3o prevention
Prevent acute exacerbations
Optimise HRQoL
Treatment Management of
complications
Continuing care
Maintenance
Rehabilitation
Self- management
Specialist services
Hospital care
Primary care
Health Promotion
Primary care
Community care
Health Promotion
N Spearing. University of Queens land
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Individual Client outcomes
 Behavioural change
 Changes in quality of life
 Client & carer satisfaction
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Systems-Based outcomes
 Re-admission rates
 Inpatient Length of Stay
 Adherence with follow-up
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Health Economic outcomes
 Cost-effectiveness
 Models of Cost Reduction
Does Exacerbation Mx Training
Acute Health Care Utilisation
Level II Evidence
All Re-admissions
57%
P = 0.01
COPD Re-admissions
40%
P = 0.01
41%
P = 0.02
Emergency Attendances
Unscheduled Physician Visits
59%
P = 0.003
% Exacerbations that Require Inpatient Care
Bourbeau (2003)
Chronic Disease Management Programs
Education Interventions in the Context of a Multi-disciplinary
Program
Level II Evidence
New Zealand Study ----Randomization of GP Practices
Intervention:
Provision of Educational materials\
• Development of an Individualized Care Plan
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Achievable Goals for Life-style Change
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Action Plan / Initial Treatment Options / When to contact the GP
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Patient Education about inhaler techniques, smoking cessation
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Recommend Immunisation & Exercise Rehabilitation
At 12-month follow-up:
hospitalisations over 12 months (P = 0.03)
Rea H. (2004) Internal Medicine Journal; 34: 608-614.