5/12/2014. Making a Science Out of Your Art. Objectives. State of EBP.

Transcription

1 Making a Science Out of Your Art Carlton G. Brown, RN, PhD, AOCN, FAAN Director, Professional Services Oregon Nurses Association Objectives Identify models of evidence-based practice that are useful in guiding evidence translation. Identify barriers to evidence based-practice. Differentiate the important steps in the process of implementing a possible intervention based in evidence into practice. State of EBP 1

2 What is Evidence Based Practice (EBP)? Evidence is a collection of facts that are believed to be true The conscientious, explicit, and judicious use of current best evidence in making decisions regarding patient care Practice based on research evidence is more likely to achieve quality patient outcomes What is Evidence Based Health Care? The integration of best research evidence with clinical expertise and patient values. Types of Evidence External Evidence Generated through rigorous research such as a randomized clinical trial or cohort study Internal Evidence Generated through practice initiatives (QI Projects) Patients Preferences and Values Quality Patient Outcome 2

3 Why Evidence Based Practice (EBP)? Despite an aggressive research agenda, majority of findings from research are not integrated into practice Leads to highest quality care and best outcomes, reduces health care costs Without current best evidence, practice becomes rapidly out of date Empowers nurses and creates a sense of satisfaction Bad News for EBP Interventions in health care which have substantial evidence but are not routinely used. 322 patients with advanced cancer randomized to Usual care group (no palliative care) Enable Educate, Nurture, Advise, Before Life Ends Intervention Those who received the intervention had: Survival 14 months vs. 8 months (p=0.14), lower symptom intensity (p=0.06), lower depressed mood (p=0.02) Those patients who died during the study but received the intervention had: Higher QOL (p=0.02), lower depressed mood (p=0.03) Bakitas et al., 2009, JAMA Test the effectiveness of a 6 week walking program in Taiwanese women newly diagnosed with breast cancer 65 women assigned to either a exercise or usual care group Fatigue, QOL, Sleep Exercise and Fatigue QOL Evidence Level 2 Wang, J.J. et al.,

4 Fatigue Sleep Wang, J.J. et al., 2011 Models of EBP Stetler Model individual nurse or organizational level Rosswurm and Larrabee s Model organizational level Johns Hopkins Nursing Model organizational level Iowa Model of EBP organizational level Iowa Model 4

5 Iowa Model for EBP 1. Trigger: Problem or new knowledge 2. Organizational priority? 3. Team formation 4. Evidence gathered 5. Research base critiqued and synthesized 6. Sufficient? 7. Pilot change 8. Decision? 9. Widespread implementation with continual monitoring of outcomes 10. Dissemination Evidence Based Practice Asking answerable clinical questions: PICO format: Patient or Problem Intervention Comparison intervention Outcome Ask A well developed PICO question has the following advantages. 1) It helps to clarify in our mind the clinical problem and the information required to solve it. 2) It helps to define the type of evidence needed (type of study). 3) It helps to provide terms to make searching for evidence more effective. 5

6 Key Clinical Question What is the effectiveness of cognitive behavioral therapy (CBT) compared to anti-depressant therapy in decreasing depression in people with a cancer diagnosis? Key Clinical Question What is the effectiveness of cognitive behavioral therapy (CBT) compared to anti-depressant therapy in decreasing depression in people with a cancer diagnosis? Population Key Clinical Question What is the effectiveness of cognitive behavioral therapy (CBT) compared to anti-depressant therapy in decreasing depression in people with a cancer diagnosis? Intervention 6

7 Key Clinical Question What is the effectiveness of cognitive behavioral therapy (CBT) compared to anti-depressant therapy in decreasing depression in people with a cancer diagnosis? Comparison Key Clinical Question What is the effectiveness of cognitive behavioral therapy (CBT) compared to anti-depressant therapy in decreasing depression in people with a cancer diagnosis? Outcome Steps 1 & 2 1. Trigger: Problem or new knowledge What is the impetus for change? Risk Management Data? PI Data? Financial Data? Clinical Problem? 2. Organizational priority? High volume or high cost issue? (FALLS) Garners interest from hospital administration Garners interest from nursing Titler et al.,

8 Steps 3 & 4 3. Team formation Form a team, perhaps those who have been doing the work New team members Always consider Multi-Disciplinary Approach 4. Evidence gathered Retrieving literature Pay attention to Systematic Reviews, Metaanalysis, Clinical Studies Titler et al., 2001 Sources of Search PUBMED CINAHL MEDLINE Cochrane Database National Guideline Clearinghouse (NGC) PsycINFO EMBASE 8

9 PubMed Ovid CINAHL (Cumulative Index to Nursing & Allied Health) Provides authoritative coverage of the literature related to nursing and allied health. Virtually all English-language publications are indexed along with the publications of the American Nurses Association and the National League for Nursing. PsychLit Provides citations with abstracts to the scholarly literature in the psychological, social, behavioral, and health sciences. Useful for quality of life-related literature, among others. Ovid 9

10 Ovid (CINAHL) Cochrane Library Systematic reviews Provides reliable and up-to-date information from seven different databases on the effects of interventions in health care Published on a quarterly basis and designed to provide information and evidence to support decisions taken in health care and to inform those receiving care Cochrane Library 10

11 Search Terms Concise, clear words or phrases Consider synonyms and related terms Learn to speak the database s language Use a controlled vocabulary or thesaurus MeSH National Library of Medicine's controlled vocabulary thesaurus Other databases have similar tools Troubleshooting Too Few Results? Did you spell your term(s) correctly? Did you use the Expand/Explode command to verify spelling and check for variations in a word or author name? Did you use truncation to retrieve all possible variations of a term or name? Did you use synonyms or related terms? Did you search in appropriate fields? How many concepts did you use? Did you use the right search syntax? Did you use AND when OR was meant? Did you have a typing error? Did you space around words or connectors? Did you use the incorrect set number when ANDing or ORing together the concepts or terms? Could another database be more useful? Troubleshooting Too Many Results? Did you search in all fields rather than a specific field or group of fields restrict term to title or keyword? Did you truncate too soon in a word? Are the terms you searched too common? Did the terms you searched have alternative meaning? Should you combine terms with connectors to be more specific? Would a narrower term be more appropriate? Too few concepts? Did you use OR when AND was meant? Did you use the appropriate set number when combining? 11

12 Step 5 5. Research base critiqued and synthesized Just because it is published doesn t mean it is good science. Important critique questions? Why was the study done? Was the sample size sufficient? Were measures reliable and valid? Were there any untoward events during the study? How was data analyzed? What were the results? What does this research mean to a clinical person? Levels of Evidence System Used For Grading the Evidence* Grade Ia Ib IIa IIb III IV Category of Evidence Evidence from systematic reviews of randomized controlled trials Evidence from at least one randomized controlled trial Evidence from at least one controlled study without randomization Evidence from at least one other type of quasi-experimental study, such as time series analysis or studies in which the unit of analysis is not the individual Evidence from nonexperimental descriptive studies, such as comparative studies, correlation studies, cohort studies and case-control studies Evidence from expert committee reports or opinions or clinical experience of respected authorities * Amended with permission of the British Medical Journal (BMJ) Publishing Group from Shekelle and colleagues (Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. Brit Med J 1999;318 [7183]:593-6., from 12

13 Step 6 6. Sufficient? Take into consideration the level of evidence and if the research results are sufficient If the results are insufficient, one may accept lower levels of evidence or conduct their own study If the results are deemed sufficient, a pilot change can be implemented Titler et al., 2001 Always Ask Three Questions Are the results valid? What are the results? Will the results help me care for my patients? Are the Results Valid? Look for sources of bias: Randomization? Blinding? 13

14 What are the Results? Size of the effect Confidence intervals around the effect seen Will the results help me care for my patients? Similar populations Outcomes important and all considered Patient preferences and values Steps 7 & 8 7. Pilot change Just because results were found to be supportive in research doesn t mean the same results will occur when you implement them. Therefore, piloting to a small group of patients or in one particular area is important as opposed to an entire area. 8. Decision? Titler et al.,

15 Pilot the Change in Practice 1. Select outcomes to be achieved 2. Collect baseline data 3. Design EBP guidelines 4. Implement EBP on pilot units 5. Evaluate the process or outcome 6. Modify the practice guideline AND Decide if Change is Appropriate for Adoption in Practice?? Steps 9 & Widespread implementation with continual monitoring of outcomes Environment Staff Cost Patient and Family 10. Dissemination of results Titler et al., 2001 Barriers to EBP Lack of knowledge and skills for EBP in clinicians EBP takes too much time and is burdensome Lack of organizational culture to support EBP Lack of mentors to help with EBP Melnyk et al.,

16 Pain Perhaps the most common symptom for patients with cancer 20-75% of patients have pain Acute and chronic pain Common in symptom clusters Extensive knowledge in EBP Miaskowski, 2010 Massage and Pain 72 Taiwanese patients with metastatic cancer Randomized to either Massage Therapy Group or Social Attention Group Patients evaluated on pain, mood, muscle relaxation, and sleep quality Evidence Level 2 Sui-Whi et al., 2011 Pain Mood Sui-Whi et al.,

17 Evidence Around Nurse Staffing Aiken et al., (2014) 422,730 patients >50 underwent common surgeries in 300 hospitals in nine European countries An increase in a nurses workload by one patient increased the likelihood of dying within 30 days of admission by 7% 10% increase in bachelor s degree nurses was associated with a decrease in death by 7% Aiken et al., (2014) cont. Patients in hospitals in which 60% of nurses had bachelor s degrees and cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor s degrees and nurses cared for an average of eight patients Useful? 17

18 Tubbs-Cooley et al., (2013) Readmissions of children (90K) in 225 hospitals Each one patient increase in a hospital's average pediatric staffing ratio increased a medical child's odds of readmission within days. Children treated in hospitals with pediatric staffing ratios of 1:4 or less were significantly less likely to be readmitted within days. Cimotti et al., (2012) Investigated hospital infections Significant association between patient-to-nurse ratio and urinary tract infection (0.86; P =.02) and surgical site infection (0.93; P =.04) Nurse burnout remained significantly associated with urinary tract infection (0.82; P =.03) and surgical site infection (1.56; P <.01) Hospitals in which burnout was reduced by 30% had a total of 6,239 fewer infections, for an annual cost saving of up to $68 million Needleman et al., (2011) Examine the association between mortality and patient exposure to nursing shifts Significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level The association between increased mortality and high patient turnover was also significant Study suggests that staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care 18

19 Aiken et al., (2002) Researched 10,184 staff nurses and 232,342 general, orthopedic, and vascular surgery patients discharged from 168 hospitals in PA Each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission Suggested the likelihood of both overall patient mortality (in-hospital death) and mortality following a complication increased by 7% for each additional patient added to the average registered nurse workload Conclusion Use a model for EBP Critique the literature before you change practice Pilot your work before going organization wide Find good research to make your case for improved practice Be cautious of barriers Types of Evidence Again!! External Evidence Generated through rigorous research such as a randomized clinical trial or cohort study Internal Evidence Generated through practice initiatives (QI Projects) Patients Preferences and Values Quality Patient Outcome 19

20 Carlton G. Brown, RN, PhD, AOCN, FAAN 20