Evidence-based Practice

Evidence-based Evidence-based PracticePractice

Beth Gray, MSN, NP, COHN-S, NE-BCBeth Gray, MSN, NP, COHN-S, NE-BCVP of Patient Care and NursingVP of Patient Care and Nursing

St. Luke’s McCallSt. Luke’s McCall

Today’s objectivesToday’s objectives

Describe the elements of evidence-based Describe the elements of evidence-based practicepractice

State at least one method to identify and locate State at least one method to identify and locate best evidencebest evidence

Describe a guided evidence-based practice Describe a guided evidence-based practice application processapplication process

What’s different between urban and rural models What’s different between urban and rural models when it comes to evidence-based practice?when it comes to evidence-based practice?

Keystones of Keystones of Evidence-based PracticeEvidence-based Practice

Integration of the Integration of the best possible best possible research or evidence research or evidence with clinical expertise with clinical expertise and with patient and with patient needs.needs.

Clinical Experience

Clinical DataResearch

Best Practice

Patient Concerns

Differentiating RU and EBPDifferentiating RU and EBP

Research UtilizationResearch Utilization Uses only research Uses only research

evidenceevidence Dependent on Dependent on

research publicationresearch publication

Evidence-based Evidence-based PracticePractice Uses research Uses research

(including that not (including that not published) as well as published) as well as other sources of other sources of credible informationcredible information

Clinical ExperienceClinical Experience Patient preferencePatient preference

Both use the same critical review, recommendation,

and implementation process!

Why Evidence-based Why Evidence-based Practice?Practice?

Patients benefit when patient care decisions are based Patients benefit when patient care decisions are based on scientific evidence. (Polit, Beck, Hungler, 2001, Asch, on scientific evidence. (Polit, Beck, Hungler, 2001, Asch, McGlynn, Hogan, et al, 2004)McGlynn, Hogan, et al, 2004)

Patients who receive care based on the best and latest Patients who receive care based on the best and latest evidence experience 28% better outcomes (Heater, evidence experience 28% better outcomes (Heater, Becker, & Olson, 1988)Becker, & Olson, 1988)

Healthcare providers who use an EBP approach to Healthcare providers who use an EBP approach to delivering patient care experience higher levels of delivering patient care experience higher levels of satisfaction (Dawes, 1996) satisfaction (Dawes, 1996)

Without EBP, practice is rapidly outdated, often to the Without EBP, practice is rapidly outdated, often to the detriment of patients. It often takes as long as 17 years detriment of patients. It often takes as long as 17 years to translate research findings into practice. (Balas to translate research findings into practice. (Balas &Boren, 2000)&Boren, 2000)

Sources of KnowledgeSources of Knowledge

ExperientialExperiential Nursing School (avg. time Nursing School (avg. time

since completing since completing education 18 years)education 18 years)

Workplace SourcesWorkplace Sources Physician SourcesPhysician Sources IntuitionsIntuitions Literature—rated bottom Literature—rated bottom

5 for frequency5 for frequency

Estabrook CA. Will evidence-based nursing practice make practice perfect? CJ Nurs Res 1998; 30:15-36.

Five Steps ofFive Steps ofEvidence-based PracticeEvidence-based Practice

Ask the burning clinical question.Ask the burning clinical question. Collect the most relevant and best evidence.Collect the most relevant and best evidence. Critically appraise the evidence.Critically appraise the evidence. Integrate all evidence with one’s clinical Integrate all evidence with one’s clinical

expertise, patient preferences, and values in expertise, patient preferences, and values in making a practice decision or change.making a practice decision or change.

Evaluate the practice decision or change. Evaluate the practice decision or change.

Model for Evidence Based Practice from Larabee and Rosswurm

Assess need for change in practice

2. Link problem interventions & outcomes

3. Synthesize best evidence

4. Design practice change

5. Implement & evaluate change in practice

6. Integrate & maintain change in practice

•Include stakeholders•Collect internal data about current practice•Compare internal data with external data•Identify problem

•Search research literature related to major variables•Critique and weigh evidence•Synthesize best evidence•Assess feasibility, benefits, risk

•Define proposed change•Identify needed resources•Plan implementation process•Define outcomes

•Pilot study demonstration•Evaluate process & outcome•Decide to adapt, adopt, or reject practice change

•Communicate recommended change to stakeholders•Present staff inservice education on change in practice•Integrate into standards of practice•Monitor process & outcomes

•Use standardized classification systems and language•Identify potential interventions & activities•Select outcome indicators

Where do the questions come from?Where do the questions come from?

Observe patients and Observe patients and families for their families for their responses to responses to treatment and for treatment and for cues that the current cues that the current plan of care may not plan of care may not be effective.be effective.

Question current Question current practice and identifies practice and identifies issues amenable to issues amenable to change.change.

PI dataPI data Report cards or Report cards or

benchmarksbenchmarks Staff practice concernsStaff practice concerns New knowledge New knowledge

sharedshared Policies and Policies and

ProceduresProcedures Question significance Question significance

of the clinical issue.of the clinical issue.

What evidence must be gathered?What evidence must be gathered?

Literature SearchLiterature Search Standards Standards

(Regulatory, (Regulatory, Professional, Professional, Community)Community)

GuidelinesGuidelines Expert OpinionExpert Opinion Patient PreferencesPatient Preferences Clinical ExpertiseClinical Expertise Financial AnalysisFinancial Analysis

What are your resources?What are your resources?

Internal Internal Policies and Policies and

proceduresprocedures SpecialistsSpecialistsExternalExternal Professional Professional

organizationsorganizations Medical libraryMedical library InternetInternet

Internet: Use discriminately!Internet: Use discriminately!

AccuracyAccuracy AuthorityAuthority ObjectivityObjectivity ContentContent CurrencyCurrency

(Morris, 2001)(Morris, 2001)

Start with guidelines*!Start with guidelines*!

Wound Ostomy & Continence Nurses SocietyWound Ostomy & Continence Nurses Society http://www.wocn.orghttp://www.wocn.org

Evidence Based Practice CentersEvidence Based Practice Centers http://www.ahcpr.gov/clinic/epc/http://www.ahcpr.gov/clinic/epc/

Cochrane CollaborationCochrane Collaboration http://www.cochrane.orghttp://www.cochrane.org

National Guideline ClearinghouseNational Guideline Clearinghouse http://www.guideline.gov/http://www.guideline.gov/

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality http://www.ahrq.govhttp://www.ahrq.gov

University of York Center for ReviewsUniversity of York Center for Reviews http://www.http://www.yorkyork.ac..ac.ukuk/inst//inst/crdcrd//crddatabasescrddatabases..htmhtm

*List not complete

PICOT: asking the questionPICOT: asking the question

P= P= PopulationPopulation I= I= InterventionIntervention C= C= Compared toCompared to O= OutcomeO= Outcome T= T= TimeframeTimeframe

Literature Search ResultsLiterature Search Results

Search output--partsSearch output--parts TitleTitle Who ,When, Who ,When,

Where and What Where and What publishedpublished

Peer reviewedPeer reviewed Qualitative vs. Qualitative vs.

Quantitative Quantitative

ResearchResearch

Newhouse, Dearholt, Poe et al, 2007

Distinctive Features of Research Studies

Design Distinctive Features Examples

Experimental Randomization Manipulation Control

Randomized controlled trial

Quasi-experimental No randomization Some manipulation Some control

Non-equivalent control group: posttest only or pretest-posttest

One group: posttest only or pretest-posttest Untreated control, repeated measures Repeated treatment where subjects serve as their

own controls Crossover design Time series

Non-experimental No randomization No manipulation Little control

Descriptive Exploratory Survey Descriptive comparative Time dimensional Correlational

Qualitative No randomization No manipulation Little control

Historical research Grounded theory Ethnographic Phenomenological

Tips for Reading ResearchTips for Reading Research

The TitleThe Title The AbstractThe Abstract The ConclusionThe Conclusion The MethodThe Method The ResultsThe Results The DiscussionThe Discussion The Overall ReportThe Overall Report

Grading the evidenceGrading the evidence

Three Domains:Three Domains: Quality--extent to which a study’s design, conduct, and analysis Quality--extent to which a study’s design, conduct, and analysis

has minimized selection, measurement, and confounding biases has minimized selection, measurement, and confounding biases (internal validity)(internal validity)

Quantity--the number of studies that have evaluated the Quantity--the number of studies that have evaluated the question, overall sample size across studies, magnitude of the question, overall sample size across studies, magnitude of the treatment effect.treatment effect.

Consistency--whether investigations with both similar and Consistency--whether investigations with both similar and different study designs report similar findings.different study designs report similar findings.

Agency for Healthcare Research and Quality [AHRQ], 2002)Agency for Healthcare Research and Quality [AHRQ], 2002)

Strength of the evidenceStrength of the evidencePerry Mason stylePerry Mason style

Multiple Multiple eyewitnesseseyewitnesses

One sober One sober eyewitness who got eyewitness who got a good looka good look

Physical evidence Physical evidence at the crime sceneat the crime scene

Pattern of previous Pattern of previous criminal activitycriminal activity

Round up the usual Round up the usual suspectssuspects

Quality Rating Scheme for Quality Rating Scheme for Research EvidenceResearch Evidence

Grade Research EvidenceA. High Consistent results with sufficient sample, adequate control,

and definitive conclusions; consistent recommendationsbased on extensive literature review that includes thoughtfulreference to scientific evidence

B. Good Reasonably consistent results; sufficient sample, somecontrol, with fairly definitive conclusions; reasonablyconsistent recommendations based on fairly comprehensiveliterature review that includes some reference to scientificevidence

C. Low/Major flaw Little evidence with inconsistent results; insufficient samplesize; conclusions cannot be drawn

Newhouse, Dearholt, Poe et al, 2007

AACN Levels of EvidenceAACN Levels of Evidence

Level I: Manufacturer’s recommendation onlyLevel I: Manufacturer’s recommendation only Level II: Theory based, no research data to support Level II: Theory based, no research data to support

recommendations: Recommendations from expert recommendations: Recommendations from expert consensus group may existconsensus group may exist

Level III: Laboratory data, no clinical data to support Level III: Laboratory data, no clinical data to support recommendationsrecommendations

Level IV: Limited clinical studies to support Level IV: Limited clinical studies to support recommendationsrecommendations

Level V: Clinical studies in more than one or two patient Level V: Clinical studies in more than one or two patient populations and situations to support recommendationspopulations and situations to support recommendations

Level VI: Clinical studies in a variety of patient Level VI: Clinical studies in a variety of patient populations and situations to support recommendations. populations and situations to support recommendations.

Staff nurses must “do” Staff nurses must “do” and “use” research….and “use” research….

Staff nurses provide direct patient care and are Staff nurses provide direct patient care and are the link between research and practice,the link between research and practice,

Staff nurses have the opportunity to identify Staff nurses have the opportunity to identify clinical problems amenable to research, andclinical problems amenable to research, and

The number of nurses with research preparation The number of nurses with research preparation at the doctoral level will always be small.at the doctoral level will always be small.

Dr. Janelle Krueger, “Promoting Nursing Research as a Staff Dr. Janelle Krueger, “Promoting Nursing Research as a Staff Nursing Function” 1980.Nursing Function” 1980.

EBP ApplicationEBP Application•Practice questionPractice question

•EvidenceEvidence

•TranslationTranslation

Clinical DataClinical DataResearchResearch

Best PracticeBest PracticeWhat is our practice based on?What is our practice based on?

PICOT: asking the questionPICOT: asking the question

P= P= Hospitalized Hospitalized patientspatients

I= I= Prevention Prevention StrategiesStrategies

C= C= Compared to--Compared to--nonenone

O= Pressure UlcersO= Pressure Ulcers

ResourcesResources

Keast, D., Poarslow, N., Houghton, P., Noton, L., Fraser, C., (2007). Best practice recommendations for the prevention and treatment of pressure ulcers: update 2006. Advances in Skin & Wound Care, 20, 447-60.

Gibbons, W., Shanks, H., Kleinhelter, P., Jones, P., (2006). Eliminating facility-acquired pressure ulcers at Ascension Health. Joint Commission Journal on Quality and Safety, 32, 488-496.

Hart, S., Bergquist, S., Gajewski, B., Dunton, N., (2006). Reliability testing of the national database of nursing quality Indicators pressure ulcer indicator. Journal of Nursing Care Quality, 21, 256-65.

Joint Commission, (2006), Raising the bar with bundles. Joint Commission Perspectives on Patient Safety, 6, 5-6.

Lyder, C., Grady, J., Mathur, D., Petrillo, M., Meehan, T., (2004). Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Joint Commission Journal on Quality and Safety, 30, 205-14.

National Guideline ClearinghouseNational Guideline Clearinghousehttp://www.guideline.gov/

ResourcesResources Lyder, C., Preston, J., Grady, J., Scinto, J., Allman, R., Bergestrom, N., Rodeheaver, G.,

(2001). Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Archival of Internal Medicine, 161, 1549-54.

Reddy, M., Gill, S., Rochon, P., (2006). Preventing pressure ulcers: A systematic review. Journal of American Medical Association, 296, 974-84. Retrieved January 28, 2008, downloaded from http://www.jama.com.

Registered Nurses’ Association of Ontario, (2005). Nursing Best Practice Guidelines: Risk Assessment & Prevention of Pressure Ulcers. Retrieved April 5, 2008, from http://www.rnao.org/bestpractices.

US Department of Health and Human Services, (1992). Clinical Practice Guideline Number 3: Pressure Ulcers in Adults, Prediction and Prevention. AHCPR publication 92-0047.

Wimpenny, P. vav Zelm, R. (2007). Appraising and comparing pressure ulcer guidelines. Worldviews on Evidence-Based Nursing, 4, 40-50.

Risk AssessmentRisk Assessment

Using a risk Using a risk assessment toolassessment tool

Applying a risk Applying a risk assessment tool to assessment tool to the patientthe patient

Integrating a risk Integrating a risk assessment tool with assessment tool with practicepractice

Improving careImproving care

““Bundle is a collection of Bundle is a collection of processes needed to processes needed to effectively and safely care effectively and safely care for patients undergoing for patients undergoing particular treatments with particular treatments with inherent risks. inherent risks.

It is a grouping of several It is a grouping of several scientifically grounded scientifically grounded elements essential to elements essential to improving clinical improving clinical outcomes.”outcomes.”

Institute for Healthcare Improvement—check www.ihi.org website

Bundle essentialsBundle essentials

Dr. Carol Haraden, Ph.D. V.P. at IHIDr. Carol Haraden, Ph.D. V.P. at IHI Two things essential to forming a bundle, “first, it Two things essential to forming a bundle, “first, it

has to be irrefutable science (i.e. grounded in has to be irrefutable science (i.e. grounded in research) and second, all elements of the bundle research) and second, all elements of the bundle have to be executed in the same space and time have to be executed in the same space and time to ensure that clinical improvement occurs”.to ensure that clinical improvement occurs”.

Other bundles: ventilator care bundle, central Other bundles: ventilator care bundle, central line bundle, sepsis bundle. line bundle, sepsis bundle.

Joint Commission, (2006).

Pressure ulcer bundlePressure ulcer bundle

SurfaceSurface Keep turningKeep turning IncontinenceIncontinence NutritionNutrition

(Joint Commission on Accreditation of Healthcare Organizations, 2006)

As developed by Ascension Health

Clinical ExpertiseClinical Expertise

OR OR What do you add to patient care?What do you add to patient care?

Background InformationBackground Information Understanding of the Understanding of the

National Pressure Ulcer National Pressure Ulcer Advisory Panel Staging Advisory Panel Staging SystemSystem

Understanding the Understanding the science of healingscience of healing

Expertise in products and Expertise in products and their applicationtheir application

Clinical JudgmentClinical Judgment EducatorsEducators Change agentsChange agents

Clinical ResourcesClinical Resources

Product Mfg Description Photo

Tegaderm (clear film)

3M Not good for wounds that are draining; will not absorb drainage.Apply over skin tears leave on until dressing falls off.

Tegaderm Foam 3M Plain side – skin side.Can cut to size or shape.Does not include adhesive.Absorbs drainage.Secure with tape, Tegaderm, or wrap gauze.

Tegaderm Foam Adhesive

3M Good on rounded or folded body parts.Clean wound with MicroKlenz in between dressing changes.Does not relieve pressure.

Patient & Staff EducationPatient & Staff Education Ensure understanding Ensure understanding

of staff so they can of staff so they can teach patients. teach patients.

Modifying plan to Modifying plan to ensure that if works to ensure that if works to achieve goals with achieve goals with patient input. patient input.

Bringing together Bringing together patient concerns and patient concerns and values and your values and your expertise. expertise.

Patient Patient Concerns/ValuesConcerns/Values

What does the patient expect, What does the patient expect, need and want from their care?need and want from their care?

Patient Concerns/ValuesPatient Concerns/Values

Knowledge vs. Knowledge vs. knowledge deficientknowledge deficient

MotivationMotivation GoalsGoals Disease processDisease process MedicationsMedications NutritionNutrition Physical CapabilitiesPhysical Capabilities AllergiesAllergies Cost issuesCost issues

Evidence in PracticeEvidence in Practice

““Knowledge of the Knowledge of the research process research process alone does not alone does not ensure translation of ensure translation of that knowledge into that knowledge into practice.”practice.”

Seymour et al. 2003Seymour et al. 2003

Lessons from the field…Lessons from the field…Most successful Most successful transformation focuses transformation focuses on the needs of the on the needs of the patient.patient.

Most of the successful Most of the successful instances of instances of transformation involved transformation involved a local change champion.a local change champion.

Local input is important Local input is important to customize approaches to customize approaches in order to obtain buy-in in order to obtain buy-in and create sustainable and create sustainable change.change. Agency for Healthcare Research

and Quality, October 2004

QuickTime™ and a decompressor

are needed to see this picture.

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Diffusion of InnovationsDiffusion of InnovationsInnovators (2.5%)Innovators (2.5%)

Venturesome Venturesome Early Adapters (13.5%)Early Adapters (13.5%)

RespectRespectEarly Majority (34%)Early Majority (34%)

DeliberateDeliberateLate Majority (34%)Late Majority (34%)

SkepticalSkepticalLaggards (16%)Laggards (16%)

TraditionalTraditional

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Mechanism of DiffusionMechanism of Diffusion

1) 1) Knowledge – person becomes aware of an innovation Knowledge – person becomes aware of an innovation and has some idea of how it functions,and has some idea of how it functions,

2)  Persuasion – person forms a favorable or unfavorable 2)  Persuasion – person forms a favorable or unfavorable attitude toward the innovation,attitude toward the innovation,

3)  Decision – person engages in activities that lead to a 3)  Decision – person engages in activities that lead to a choice to adopt or reject the innovation,choice to adopt or reject the innovation,

4)  Implementation – person puts an innovation into use,4)  Implementation – person puts an innovation into use,5)  Confirmation – person evaluates the results of an 5)  Confirmation – person evaluates the results of an innovation-decision already made.innovation-decision already made.

Measurable improvement in practiceMeasurable improvement in practice

Appropriate use of data is Appropriate use of data is a key element in a key element in successful efforts to successful efforts to transformtransform

Outcomes are the most Outcomes are the most important measures to important measures to create transformationcreate transformation

Use PDSA modelUse PDSA modelSmall tests of changeSmall tests of change

Agency for Healthcare Research and Quality, October 2004

Piloting the changePiloting the change

Select outcomes to be achieved,Select outcomes to be achieved,Collect baseline data,Collect baseline data,Design evidence-based guidelines,Design evidence-based guidelines, Implement on a pilot unit,Implement on a pilot unit,Evaluate the process and outcomes,Evaluate the process and outcomes,Modify the practice guidelines.Modify the practice guidelines.

LeadershipLeadership

Leadership/Infrastructure Leadership/Infrastructure to hold people to hold people accountable.accountable.

Agency for Healthcare Research and Quality,

October 2004

The The British Medical JournalBritish Medical Journal reported in 1995 that to keep up reported in 1995 that to keep up

with journals relevant to practice, with journals relevant to practice, each practitioner would need to each practitioner would need to

read 17 articles per day, 365 days read 17 articles per day, 365 days per year.per year.

(Davidoff, Haynes, Sackett, & Smith, 1995)(Davidoff, Haynes, Sackett, & Smith, 1995)

Journal ClubsJournal Clubs Purpose: The purpose of the Journal Club is to foster Purpose: The purpose of the Journal Club is to foster

excellence in practice by promoting evidence-based excellence in practice by promoting evidence-based practicepractice Goals: Goals:

Improve knowledge of current research findings.Improve knowledge of current research findings. Foster the application of clinical research and best Foster the application of clinical research and best

practice modules to practice.practice modules to practice. Provide a means by which to address clinical Provide a means by which to address clinical

issues. issues.

Journal ClubsJournal Clubs

Format for PresentationsFormat for Presentations Introduce topic and Introduce topic and

presenterpresenter Give brief synopsis Give brief synopsis Discuss major findings of Discuss major findings of

studystudy Discuss other relevant Discuss other relevant

research that research that supports/does not supports/does not support this studysupport this study

Journal ClubsJournal Clubs

Discuss implications of Discuss implications of article in terms of impact article in terms of impact on practiceon practice

What is the relevance of What is the relevance of this article to our this article to our practice?practice?

Should we change our Should we change our practice based on this practice based on this information? information?

““The illiterate of the 21The illiterate of the 21stst century will not century will notbe those who cannot read and write, be those who cannot read and write,

but those who cannot but those who cannot learn, unlearn and relearn.”learn, unlearn and relearn.”

-Alvin Toffler -Alvin Toffler Questions?Questions?