FANNP 28TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW OCTOBER 17-21, 2017

Transcription

1 How Can NNPs Perform Evidence-Based Practice at the Bedside? Bobby B. Bellflower, DNSc, APRN-BC, NNP-BC Associate Professor, Director of DNP Programs University of Tennessee Health Science Center Neonatal Nurse Practitioner Regional One Health, Memphis, TN A8b The speaker has signed a disclosure statement indicating she has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation. Session Summary Evidence-based practice (EBP) is a buzz word in the literature and we talk about it frequently, but do you really conduct evidence-based practice? Can you do EBP at the bedside? This presentation discusses how to do EBP on the paper towel at the bedside. Session Objectives Upon completion of this presentation, the participant will be able to: define evidence-based practice; identify the steps of EBP; evaluate practice for EBP. References Beyea, S. & Slatterly, M. J. (2008). Evidence-based expert: Quality improvement vs. research: Are they the same? Staff Development Weekly:Insight on Evidence-Based Practice in Education, Retrieved from 975/Evidencebased-expert-Qualityimprovement-vs-research-Arethey-the-same.html Butler, K. D. (2011). Nurse practitioners and evidence-based nursing practice. Clinical Scholars Review, 4(1), The Cochrane Collection (2017). Strategy to 2020 aims to put Cochrane evidence at the heart of health decision-making all over the world. Retrieved from Facchiano, L. & Snyder, C. (2012). Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process. Journal of the American Academy of Nurse Practitioners, 24(10), DOI: /j x Facchiano, L. & Snyder, C. (2012). Evidence-based practice for the busy nurse practitioner: Part two: Searching for the best evidence to clinical inquiries. Journal of the American Academy of Nurse Practitioners, 24(11), DOI: /j x Facchiano, L. & Snyder, C. (2012). Evidence-based practice for the busy nurse practitioner: Part three: Critical appraisal process. Journal of the American Academy of Nurse Practitioners, 24(12), DOI: /j x Page 1 of 11

2 Facchiano, L. & Snyder, C. (2013). Evidence-based practice for the busy nurse practitioner: Part four: Putting it all together. Journal of the American Academy of Nurse Practitioners 25(1), DOI: /j x Greenhalgh, T. (2010). How to read a paper: The basics of evidence-based medicine (4th ed.). Oxford, UK: BMJ. Guyatt, G., Drummond, R., Meade, M. O, & Cook, D. (2008). Users guides to the medical literature: A manual for evidence-based clinical practice (2nd ed.). New York, NY: McGraw Hill. Institute of Medicine (2008). Knowing what works in healthcare: A roadmap for the nation. Retrieved from Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Retrieved from Melnyk B. M., Fineout-Overholt, E., Stillwell, S, & Williamson K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. American Journal of Nursing, 110(1), Melnyk, B. M., Gallagher-Ford, L., Long, L. E. & Fineout-Overholt (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. World Views on Evidence-Based Nursing, 11(1), Melnyk, B. M. & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed., pp. 11). Philadelphia, PA: Wolters Kluwer Health. Newhouse, R. P. (2007). Diffusion, confusion among evidence-based practice, quality improvement, and research. Journal of Nursing Administration, 17(10), Sackett, D., Rosenberg, W., Gray, J., Haynes, R. & Richardson, W. (1996). Evidence-based medicine: What it is and what it isn t: It s about integrating individual clinical expertise and the best external evidence. British Medical Journal, 3(12), Stiffler, D. & Cullen, D. (2010). Evidence-based practice for nurse practitioner students: A teaching competency-based teaching framework. Journal of Professional Nursing, 26(5), Straus, S. E., Glasizou, P., Richardson, W. S. & Haynes, R. B. (2011). Evidence-based medicine: How to practice and teach it (4th ed.). Edinburgh, London: Churchill Livingstone Elsevier. Page 2 of 11

3 What is EBP? Evidenced-Based Practice Bobby Bellflower DNSc, NNP-BC Problem solving approach for clinical practice that integrates Conscientious use of best evidence (internal and external) In combination with a clinician s expertise AND Patient preferences and values to make decisions about the type of care that is provided. (Meinyk & Fineout-Overholt, 2015) What is EBP? Research, QI, and EBP Most widely accepted definition: EBP is the conscienctious, judicious, and explicit use of current best evidence in making decisions about the care of the individual patient Occasional confusion regarding research, QI, and EBP Research: create scientific knowledge that can be generalized to similar clients, populations, and clinical settings EBP does not conduct new research; it uses clinical findings from previous research and applies to individual patients Uses not just one study but uses research from multiple studies Best evidential findings on populations to inform decisions about individuals! Research, QI, and EBP QI: work to improve systems in an attempt to improve overall outcomes Addresses an organization s experiences through the generation of descriptive data unique to that organization. Dissemination of results of a QI project is limited to lessons learned and is not generalizable like a research study Research, QI, and EBP Research and EBP inform QI EBP process can help identify gaps of knowledge thus generating new research Research, QI and EBP may overlap, but all are distinct entities and have important roles to play in health care Page 3 of 11

4 In 2001, IOM called for patient-centered care as a part of interdisciplinary teams with emphasis on: Evidenced-based practice Quality Improvement (QI) Informatics All health care providers must be able to find evidence to answer clinical questions and interpret data. How you acquire knowledge to make decisions is often thought to determine quality of the clinician! In order to stay current may need to read 19 articles every day for 1 year (Straus, et al., 2011). Ways of staying up to date other than reading journal articles: Clinical experience: basing clinical decisions on the collective experience of a much larger population would be much more beneficial (Straus et al., 2011). A well designed clinical trial yields greater information on expected treatment outcomes and adverse events than what is learned from limited anecdotal cases Ways of staying up to date other than reading journal articles: Published clinical guidelines from the numerous clinical specialty organizations to guide clinical decisions The danger in expert opinion guidelines is that they are based on lifelong anecdotal clinical experiences rather than evidence from high-level clinical trials. Ways of staying up to date other than reading journal articles: Web updates (Smart Briefs) Using this approach to inform clinical knowledge runs risk unknown origin of results the characteristics of the population studied disease severity spectrum of adverse events Why EPB? Using EBP appraisal skills: Improve the ability to determine trustworthy guidelines and the application of the guideline to clinical practice One of the first ways that EBP impacted the healthcare profession is through the development of meta-analysis studies Another was the application and dissemination of clinical practice guidelines that are based on evidence from rigorous systematic reviews and synthesis of published medical literature Page 4 of 11

5 Why EBP Values and preferences of patients is a very important knowledge source to the applicability of any evidence and these must supplement each other. EBP as a strategy: Keep knowledge up to date Enhance clinical reasoning and decision-making Cost-effective treatment modalities Nearly 50% of Americans do not receive the identified evidence-based recommendations Practices vary among providers Greater than 20% of care provided is either not needed or may even be harmful EBP steps Practice based on what was always done is no longer acceptable 1. Ask a clinical guiding question. 2. Search for the best evidence. 3. Critically appraise the evidence. 4. Integrate the evidence with one s clinical expertise and client preferences to make best clinical judgment. 5. Evaluate the outcome(s) of the EBP decision or change 6. Disseminate the outcome. EBP enables us to present accurate evidence to patients, while further involving patients and families in the clinical decision-making process EBP: Levels of Information Levels of information: Meta-Analysis: A systematic review that uses quantitative methods to summarize the results Systematic Review: Authors have systematically searched for, appraised, and summarized all of the medical literature for a specific topic Critically Appraised Topic: Authors evaluate and synthesize multiple research studies Page 5 of 11

6 EBP: Levels of Information EBP: Levels of Information Critically Appraised Articles: Authors evaluate and synopsize individual research studies Randomized Controlled Trials: Include a randomized group of patients in an experimental group and a control group. These groups are followed up for the variables/outcomes of interest. Cohort Study: Identifies two groups (cohorts) of patients, one which did receive the exposure of interest, and one which did not, and following these cohorts forward for the outcome of interest Case-Control Study: Identifies patients who have the outcome of interest (cases) and control patients without the same outcome, and looks for exposure of interest. Background Information/Expert Opinion: Handbooks, encyclopedias, and textbooks often provide a good foundation or introduction and often include generalized information about a condition. While background information presents a convenient summary, often it takes about three years for this type of literature to be published. EBP{ Levels of Information EBP steps Animal Research/Lab Studies: Information begins at the bottom of the pyramid: this is where ideas and laboratory research takes place. Ideas turn into therapies and diagnostic tools, which then are tested with lab models and animals. Step I Writing a clinical guiding question: PICO(T) P patient, population or problem (consider age, gender, clinical setting, client symptoms) I intervention or prognostic factor being considered C comparison or intervention (not all questions will have a comparison or the comparison may not be easily identified or apparent O outcome measured (may include improved treatment outcomes, decreased adverse events, decreased cost, or improved quality of life) T time period EBP steps- Step 1 EBS- Step I PICO(T) uses familiar nursing critical thinking standards Well-formulated question: Facilitates efficient literature search Allows filters to be used in search engines Can help define inclusion and exclusion criteria and outcomes of interest More refined the question, the fewer articles required Spell out terms used in search engine ( computed tomography instead of CT) Avoid jargon Clearly define population (newborns, adults over 55, etc.) Page 6 of 11

7 EBS steps- Step I EBS steps- Step I Two other key components of a well-formulated question Type of question being asked Type of study design that will answer the clinical question Type of question Diagnostic Prognostic Therapy Prevention Harm Knowing type of question will help identify the study design best available to answer that question Clinical Question All Clinical Questions Type of questions and studies that may answer the question Therapy Etiology Diagnosis Suggested Research Design(s) Clinical Question Prevention Systematic review, metaanalysis Randomized controlled trial (RCT), meta-analysis Also: cohort study, casecontrol study, case series Type of questions and studies that may answer the question Randomized controlled trial (RCT), meta-analysis, cohort study Also: case-control study, case series Prognosis Suggested Research Design(s) Randomized controlled trial (RCT), metaanalysis Also: prospective study, cohort study, case-control study, case series Cohort study Also: case-control study, case series Meaning Qualitative study Quality Improvement Randomized controlled trial (RCT) Also: qualitative study Randomized controlled trial (RCT) Also: cohort study Economic Cost EBP steps- Step I EBS: Step 2 Search for the Best Evidence Learning to formulate well-built clinical questions written in PICO (T) format takes time considered the first step in the EBP process key to the critical thinking process required to translate evidence into practice Massive amount of info available Knowing which study design can answer a particular type of clinical question helps focus the literature search The more focused the literature search, the easier it is to find the evidence being sought to answer the clinical inquiry PubMed has over 20 million references How do we find the answer to clinical inquiries? Identify information sources Select appropriate sources Search effectively and efficiently Page 7 of 11

8 EBP Step 2 EBP Step 2 Electronic database filters can improve the retrieval of evidence Systematic Reviews (SRs) are the oldest synthesized sources Databases are categorized as synthesized/filtered unfiltered background information/expert opinion resources Started in the early 1980s by Archie Cochran EBS Step 2 EBS Step 2 Systematic Reviews (SRs), meta-analysis, and Point of Care tools Cochrane Database of Systematic Reviews DynaMed: Point of care information and evidenced based reference tool for providers TRIP: Turning Research into Practice- will answer clinical practice inquiries using single term entries Up-To-Date: peer reviewed electronic textbook that provides guidance and recommendations Clinical practice guidelines (National Guideline Clearing House) EBP Step 2 Search vocabulary: Keyword or Natural language- use natural language to type in phrases or sentences Pubmed Google Scholar Cochrane database The more concepts entered, the larger the retrieval size too many to sort through. PICO (T) helps limit the phrases and concepts Gold standard for systematic reviews is the The Cochrane Database of Systematic Reviews Example: Neonatal Unfiltered Resources: Refers to articles found in the primary literature, which were not prescreened/or pre-appraised like filtered resources. Excerpta Medica Database Guide (EMBASE) Cumulative Index to Nursing and Allied Health Literature (CINAHL) Medical Literature Analysis Retrieval System (Medline/PubMED) OVID Google, Google Scholar EBP Step 2 Controlled vocabulary Pubmed In Pubmed, controlled vocab is referred to Medical Subject Heading (MeSH) and is available when natural language is searched. Enter natural language concept and in a separate list MeSH terms are displayed Click on the MeSH terms and several subheading are revealed.very helpful to learn to use MeSH terms Page 8 of 11

9 EBP Step 2 : Critically Appraise the Evidence Use specialized functions of each Database Example: In Pubmed, Clinical Queries button brings up 3 feature headings Clinical Study, Systematic Reviews, and Medical Genetics The process of critical appraisal and judging scientific findings is necessary because even clinical findings from the highest quality evidence are not absolute Ability to judge and interpret the strength or weakness of findings is essential for applicability to clinical practice Learning critical appraisal skills is an essential step in evidence-based practice. Ovid has a drop down box that offers limits or filters to retrieve studies. EBSCO and CINAHL have query filters : Critically Appraise the Evidence Critical appraisal: Can I trust findings for use with my patient? It is not about trashing or finding information as a good or bad scientific trial, but about identifying the strengths of the findings A hierarchy of evidence is used to rank levels or strength of evidence and provide guidance to healthcare providers seeking to answer clinical inquiries Critical appraisal: evaluation of the worth or quality of scientific evidence to clinical practice, not a judgment on the quality of the research design Ability to judge and interpret strength or weakness of findings is essential for applicability to clinical practice (Facchiano and Snyder, 2012). To do this a clinician needs: Working knowledge of statistics Be able to determine if a specific methodology is appropriate or not Step 3 Three essential components of evidence appraisal Validity: are the findings trustworthy Results or reliability: clinical importance of the findings and how important and reliable are they Applicability: is it useable with population or practice Table 1. Critical appraisal tools (CAT) and clinical measures resources Name Web sites Resource BestBets (CAT BANK) CAT templates in PDF format for downloading Center for Evidence-Based Medicine University of Oxford Useful tools and downloads for the critical appraisal of medical evidence. Example appraisal sheets are provided together with several helpful examples Electronic Statistics Textbook (free) An electronic textbook on statistics EBM Working Group University of Alberta This is a collection of tools for identifying, assessing, and applying relevant evidence for better healthcare decision making Page 9 of 11

10 Need a basic understanding of measures of Central tendency(mean, median, mode, and frequency distribution) Measures of variability (variance, standard deviation, and range) p-value Confidence intervals (CI) To decide whether a new therapy or diagnostic test should be used, statistical significance of its effectiveness over current treatment alone is insufficient. Clinical significance measures how large the differences in treatment effects are in clinical practice. EBP Study 3 To avoid over exaggeration of statistical results, the appraiser should look for reporting of more meaningful clinical measurements of effect size number needed to treat (NNT): number of patients who need to be treated to prevent one additional adverse outcome number needed to harm (NNH): number of patients that need to be exposed to a risk factor over a specific period to cause harm in one patient that would not otherwise have been harmed CIs Not all researchers report this data Clinicians as clinical experts need to utilize their expertise to decide whether the outcomes measured in a study were clinically important for their practice population EBP requires the integration of patient values, concerns (benefits, risks, costs), and choices (such as pharmacological vs. nonpharmacological interventions The lower the NNH, the higher the chance an individual exposed to a specific risk factor will be harmed. The NNH is important in EBP as it assists in determining whether to proceed with a particular treatment, which may expose the patient to harm while providing therapeutic benefits EBP Step 4: Integrate the evidence using clinical expertise and patient preferences to make best clinical judgment EBP requires the integration of patient values, concerns (benefits, risks, costs), and choices (such as pharmacological vs. nonpharmacological interventions Page 10 of 11

11 EBP Step 6: Evaluate the outcome(s) of the EBP decision or change EBP Step 6: Disseminate the results PDSA cycles: Analyze the results: Did it make a difference? Plan Do Study Publish In house Posters Manuscript Presentations Act EBP: It is important Evidenced-based Practice is important in the care of our patients Evidenced Based care can be done on a paper towel or the back of an envelope It takes practice and confidence Without EBP we are just doing what has always been done.may be good or bad Page 11 of 11