Evidence-based neonatal nursing care Trish McInerney, PhD University of the Witwatersrand “Straight From The Heart – Bettering Our Best and Beating the Odds” October 2008 Durban
This presentation will attempt to answer the following questions: • What is evidence based practice? • Joanna Briggs Institute • JBI model of EBP and the neonatal node • Some evidence relating to neonatal care
Perhaps I could ask this question another way – Why do you do things the way you do?
In asking you why you do things the way you do – I could guess at a few of your responses!
Because… • That was how I was taught – how long ago was that? • Because that is the policy in this hospital / clinic – who made that policy decision? And on what information was it based? • That is the way I’ve always done it! – have you thought about what you’re doing? Could it be done better?
Evidence based practice and evidence based health care, have their origins in evidence based medicine
Evidence-based medicine is the conscientious, explicit and judicious use of currentbestevidence in making decisions about the care of individual patients. David Sackett et al (1996)
The randomised controlled trial approach to EBP has severe limitations when we try to apply it to nursing and midwifery.
Today, there is a much broader perspective taken of “evidence”. Evidence does not only come from RCT’s!It is more than “effectiveness” that drives our clinical decision making!
Need for evidence • Health professionals seek evidence to substantiate the worth of a wide range of activities and interventions • This means that the type of evidence we need depends on the activity and its purpose
Five types of evidence • Evidence of feasibility • Evidence of appropriateness • Evidence of meaningfulness • Evidence of effectiveness • Economic evidence
Example of feasibility • By feasibility we mean the extent to which an activity is practical. • What factors impact on the success or failure of introducing evidence-based practice in a neonatal care unit?
Example of appropriateness • This is the extent to which an activity is ethical or apt for that culture. • Is it appropriate to expect fathers to take an active role in caregiving in neonatal units in Africa?
Example of meaningfulness • Refers to the personal experiences, opinions, values, thoughts, beliefs and interpretations of clients. • What are parents’ experiences of being told that their preterm baby has severe abnormalities?
Example of effectiveness • This refers to cause and effect • What effect does prone positioning of the neonate have on sudden infant death syndrome?
Example of economic evidence • There are a number of different study types relating to economics. These are: • Cost description evaluations • Cost minimisation evaluations • Cost effectiveness evaluations • Cost utility evaluations • Cost-benefit evaluations
Implementing EBP • Implementation may be in the form of clinical practice guidelines – “practical procedures” • Policies • JBI CONnect – Neonatal Node
Some current evidence in infant care - from systematic reviews • The effectiveness of interventions for infant colic • Possibly useful • Dietary interventions, eg low allergen diet for B/F mother, low allergen formula milk; behavioural interventions, eg reduced stimulation (Grade B) • No effect • Pharmaceutical interventions, dietary interventions – soy substitute formula milk; behavioural interventions – increased carrying (Grade B) • Possibly harmful (Grade A) • Dietary intervention herbal tea
Current evidence (cont) • Management of asymptomatic hypoglycaemia in healthy term neonates • Early and exclusive B/F is safe to meet the nutritional needs of healthy term newborns worldwide (Grade A) • Healthy term newborns that are B/F on demand need not have their blood glucose routinely checked and need no supplementary foods or fluids (Grade A) • Maintenance of normal body temperature in addition to B/F is necessary to prevent hypoglycaemia (Grade A)
Current evidence (cont) • Early childhood pacifier use in relation to B/F, SIDS, infection and dental malocclusion • As B/F confers an important advantage on all children and the incidence of SIDS is very low, it is recommended that health professionals generally advise parents against pacifier use, while taking into account individual circumstances (Grade B)
Grades of evidence • Grade A: effectiveness established to a degree that merits application • Grade B: effectiveness established to a degree that suggests application • Grade C: effectiveness established to a degree that warrants consideration of applying the findings • Grade D: effectiveness established to a limited degree • Grade E: effectiveness not established
Systematic reviews currently being undertaken • Suctioning children with an artificial airway in a healthcare setting – a systematic review • A systematic review of positioning of preterm infants for optimal physiological development
Current SR’s (cont) • Neonatal hypoglycaemia - the diagnostic accuracy of point-of-care testing methods
Evidence sources • Cochrane Library – www.cochranelibrary.com • Joanna Briggs Institute – www.joannabriggs.edu.au • DARE (Database of Abstracts of Reviews of Effectiveness) - www.york.ac.uk/inst/crd/ • NHS Centre for reviews and dissemination (University of York) • Agency for Healthcare Research and Quality (AHRQ)