Evidence-Based Practice Pulling the pieces together. Lynette Savage, RN, PhD, COI March 2017

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1 Evidence-Based Practice Pulling the pieces together Lynette Savage, RN, PhD, COI March 2017

2 Learning Objectives Delineate the differences between Quality Improvement (QI), Evidence Based Practice (EBP), and Research Look at IOWA Model Describe a PICO(T) question Search for evidence Describe the levels and quality of evidence 2

3 Why is EBP important? 1. Assures patient receives most up-to-date care possible 2. Assists practitioner in dealing with increasing volume of healthcare literature 3. Allows patient and practitioner to work together to make informed decisions 4. Clinical decisions can be clearly explained and justified to patients and their families 3

4 Keep the patient in the center of the conversation 4

5 Why we do what we do QI (improve processes) Patient Care EBP (change practice) Research (generate new knowledge) 5

6 Tool #1: Comparison Method QI Improve processes PDCA (Plan-Do- Check-Act) Rapid Cycle EBP Change practice Levels of Evidence Research Generate new knowledge Qualitative Quantitative Mixed Methods Sample Unit level Patient population Representative Human Subject IRB* Rarely IRB -?? IRB - Yes Data Collection Evaluation Search and appraise Validity Results Improve process Impact Add to body of knowledge Implications Process change Practice change Understanding change Dissemination Unit Practice standards Scientific community * Institutional Review Board (IRB) (Dimitroff, 2011; Shirey et al., 2011) 6

7 IOWA Model 1. Look at Triggers or Opportunities for Improvement 2. Is this a top priority? 3. Form a Team 4. Find, critique, and synthesize evidence 5. Is the evidence sufficient? 6. Design and trial the practice change 7. Develop localized protocol; engage stakeholders 8. Create implementation and evaluation plans 9. Integrate and sustain practice change 10.Share Learnings - Publish 7

8 First Decision Point Identify Triggers/Opportunities Clinical issue/data State, national initiative New evidence Accrediting organization requirements/regulations State the Question or Purpose Is this topic a priority? No Consider another trigger (Steelman, 2015) Yes

9 Tool #2 PICO(T) A clinical question should incorporate at least three of the elements P I C O T Population, problem, program, patient: Age, sex, ethnicity, inpatient, community based, condition, diseases, general health status Intervention: Education, diagnostics, treatment plan, self-care Comparison: Placebo or alternative intervention, no intervention Outcomes: Expected and actual effects on patient Time 9

10 PICOT In (P), how does (I) compared to (C) affect (O) within (T)? In surgical patients, does pre-op bathing with chlorhexidine compared to bar soap reduce infections post operatively? 10

11 Example In adult patients with total hip replacements (P) how effective is IV PCA pain medication (I) compared to prn IM pain medication (C) in controlling post operative pain (O) during the perioperative and recovery time (T)? 11

12 SEARCH FOR THE EVIDENCE 12

13 Find Us! 13

14 Library Resources 14

15 Additional Nursing Info 15

16 Library Resources Databases: Medline (Ovid or PubMed) largest health sciences database CINAHL largest nursing database Cochrane Library home of the Cochrane Systematic Reviews Other Health Business Elite, etc. 16

17 Library.providence.org (sign in with NT Login and Password) 17

18 18

19 Search Steps Start with a focused topic Develop your PICO/T Identify keywords/subject headings you want to search and plan how you are going to connect the terms Search each keywords/subject separately Use filters and limits to narrow your search (Leonardelli, 2013) 19

20 Evaluate the information The process of making a decision about whether a study can help to answer a clinical question. 20

21 Second Decision Point Form a Team Assemble, critique and synthesize evidence Reassemble Is there sufficient evidence? No Generate new knowledge through research or quality improvement Yes (Steelman, 2015)

22 There are two parts. There are two parts to reading and understanding if the research study you found is appropriate or right for your hospital, nursing unit, or patient(s). Part 1: Grade (or strength) of recommendation (often referred to as Levels of Evidence) Part 2: Quality of the research

23 Tool #3: Levels and Quality of Evidence

24 Level of evidence (LOE) Level I Level II Level III Level IV Level V Level VI Level VII Description Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results. Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT). Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental). Evidence from well-designed case-control or cohort studies. Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis). Evidence from a single descriptive or qualitative study. Evidence from the opinion of authorities and/or reports of expert committees. (Ackley, Swan, Ladwig, & Tucker, p.7)

25 How do you assess the quality of a study? High quality Good quality Low quality or major flaws 25

26 Quality of the Evidence (Johns Hopkins Nursing EBP Evidence Rating Scale, 2005) High Research Consistent results with sufficient sample size, adequate control, and definitive conclusions; consistent recommendations based on extensive literature review that includes thoughtful reference to scientific evidence. Summative reviews Well-defined, reproducible search strategies; consistent results with sufficient numbers of well defined studies; criteria-based evaluation of overall scientific strength and quality of included studies; definitive conclusions. Organizational Well-defined methods using a rigorous approach; consistent results with sufficient sample size; use of reliable and valid measures Expert Opinion Expertise is clearly evident Good Research Reasonably consistent results, sufficient sample size, some control, with fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence Summative reviews Reasonably thorough and appropriate search; reasonably consistent results with sufficient numbers of welldefined studies; evaluation of strengths and limitations of included studies; fairly definitive conclusions. Low quality or Major flaws Organizational Expert Opinion Research Summative reviews Organizational Well-defined methods; reasonably consistent results with sufficient numbers; use of reliable and valid measures; reasonably consistent recommendations Expertise appears to be credible Little evidence with inconsistent results, insufficient sample size, conclusions cannot be drawn Undefined, poorly defined, or limited search strategies; insufficient evidence with inconsistent results; conclusions cannot be drawn Undefined, or poorly defined methods; insufficient sample size; inconsistent results; undefined, poorly defined or measures that lack adequate reliability or validity Expert Opinion Expertise is not discernable or is dubious. (Johns Hopkins Nursing EBP Evidence Rating Scale, 2005; Newhouse, Dearholt, Poe, Pugh, & White, 2005)

27 Reading a research article Review of Literature Is the literature current within the last five years? (Y/N) Does authors make a case with the literature about why the study was conducted? (Y/N) Does the literature support the aims? (Y/N) 27

28 Reading a research article Abstract Does it cover the topic you want? (Y/N) Background/objective/purpose/aim Methods Results Conclusions 28

29 Reading a research article Discussion Look for implications for practice Does this fit your problem or population? (Y/N) Does the discussion answer the aims? (Y/N) 29

30 Reading a research article Methods How large was the sample size? What type of study? If quantitative (counting or comparing something) Randomized Control Trials is the gold standard to evaluate interventions If qualitative (asking about feelings or perception) what methodology did they use? Be careful if it is a case study (usually have small sample size and are unique) 30

31 Words of Wisdom Consider the individualize patient needs and preferences Age, language, literacy needs, health knowledge, cultural perspectives, and familiarity with technology all impact the patient s ability and willingness to participate The results of a single study should never be used alone to make practice changes or decisions; look to multiple sources before making a change 31

32 Nurses Role in Using Research Evidence Read widely and critically Attend professional conferences Learn to expect evidence that a procedure is effective Become involved in a journal club Pursue and participate in EBP projects 32

33 Never be afraid Never be afraid to try something new. Remember, amateurs built the ark. Professionals built the Titanic. (Anonymous) 33

34 Keep the patient in the center of the conversation 34

35 References Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. St. Louis, MO: Mosby Elsevier. Dimitroff, L. (2011). Comparing and contrasting nursing research, evidencebased practice, and quality improvement: A differential diagnosis. Capital District Nursing Research Alliance 7th Annual Conference. Leonardelli, A. (2013). How to find and evaluate pertinent research. AACN Advanced Critical Care, 24(4), DOI /NCI.0b013e3182a2004f Johns Hopkins Hospital (2015). JHNEBP research evidence appraisal. Retrieved from 35

36 References Newhouse, R., Dearholt, S., Poe, S., Pugh, L., & White, K. (2005). The Johns Hopkins nursing evidence-based practice rating scale. Baltimore, MD: The Johns Hopkins Hospital; Johns Hopkins University School of Nursing. Shirey, M., Hauck, S., Embree, J., Kinner, T., Schaar, G., Phillips, L., McCool, I. (2011). Showcasing differences between quality improvement, evidencebased practice, and research. The Journal of Continuing Education in Nursing, 42(2), DOI: / Steelman, V. (2015). The 2015 Revised Iowa Model for infusing evidencebased practices globally. Retrieved from 36

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