UNPACKING THE PIECES FOR EVIDENCE BASED PRACTICE

1. UNPACKING THE PIECES FOR EVIDENCE BASED PRACTICE LuAnn Tandy, RN, PhD Student LuAnn Tandy 2009

2. Today’s Goal EBP EBP LuAnn Tandy 2009

3. We went to school to be….. LuAnn Tandy 2009

4. But its more like…. LuAnn Tandy 2009

5. 7 Days Worth of Stuff • It used to be that patients stayed in the hospital about 7 days. • So….we taught nurses how to do 7 days worth of stuff. • Now patients stay 2-3 days • We continue to hold nurses to providing the same standard of care we gave patients when their stays were 7 days. • Dr. Tim Porter-O’Grady 2007 LuAnn Tandy 2009

6. Evidence-based Medicine • The Institute of Medicine defines evidence-based practice (EBP) as “the integration of best research, clinical expertise, and patient values in making decisions about the care of individualized patients” LuAnn Tandy 2009

7. Evidence-based Nursing Practice • Sigma Theta Tau definition: “Integration of the best evidence available, nursing expertise, and the values and preferences of individuals, families and communities who are served” Sigma Theta Tau International Evidence-Based Nursing Position Statement, 2005 LuAnn Tandy 2009

8. What is EBNP? • EBP is a problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences and a clinician’s expertise in making decisions about patient care. Melnyk & Fineout-Overholt, 2005 LuAnn Tandy 2009

9. You might be practicing EBP if you… • question your practice • go to the literature to determine best practice rather than a peer • Embrace change and let go of old practices • Quit saying “because that’s the way I was taught” (30 years ago) LuAnn Tandy 2009

10. Ways to Use EBP • Improve outcomes • Increase efficiency • Improve patient satisfaction • Improve nurse satisfaction • Improve physician satisfaction • Lower costs LuAnn Tandy 2009

11. List the Following… • Everything you have added to your practice in the last 5 years (i.e.. VAP protocol, two patient identifiers) • List things you have given up in the last five years (i.e.. Changing IV sites every other day) LuAnn Tandy 2009

12. Interdisciplinary EBP ……different points of view Nurse Physician Dietician Patient Therapist Administrators Case Manager LuAnn Tandy 2009

13. Why EBP?THE QUALITY OF CARE LAGS BEHIND KNOWLEDGE AND EBP IS SEEN AS THE SOLUTION LuAnn Tandy 2009

14. So Why are We Behind? • Knowledge Explosion • Every 9 years the number of journals increases by…… • Time it takes to move research into practice?.......... • Research is not always able to be translated into practice • EBP is a way to bundle that knowledge and put it into usable interventions LuAnn Tandy 2009

15. History of EBP • Evidence Based Practice was used by Florence Nightingale years ago. • Observation informed her on what worked and what didn’t • 1990’s EBP became a viable framework for positive clinical outcomes • Driven by cost-containment efforts that were initiated by health administrators and payers. LuAnn Tandy 2009

16. History of EBP • Educated health care consumers expect their health care providers to be on the cutting edge and they demand high quality care and outcomes. • With the coming of the web health care consumers do their research and they may know the best treatment before the physician or the nurse. LuAnn Tandy 2009

17. EBP: We’ve Come A Long Way Baby • In 1977 the standard of care for a patient post-op open heart surgery was to give pain medications as needed. • In 2008 our standard of care is to schedule pain medication with dosages based on the patient’s pain rating. • In 1977 family visits were restricted to 5 minutes every hour and only 2 people at a time. • In 2008 family members have unrestricted visiting privileges LuAnn Tandy 2009

18. EBP: Then and Now • In 1977 only patients with diabetes had their blood glucose levels monitored and controlled • In 2008 all open-heart surgery patients glucose levels are maintained between 80 and 110 mg/dL. Sendelbach, S.E. (2008) Evidence Based Practice:Then and Now, AJN, 108:10, 75-76. LuAnn Tandy 2009

19. UNC-Chapel Hill EBP Process LuAnn Tandy 2009

20. Evidence Based Process • ASK • Define the question • AQUIRE • Find the evidence • APPRAISE • Evaluate the evidence • APPLY • Apply the evidence • ASSESS • Assess the outcome LuAnn Tandy 2009

21. Evidence Based Process • ASK* • AQUIRE • APPRAISE • APPLY • ASSESS LuAnn Tandy 2009

22. ASK :Questions arise out of our daily practice and daily life. These are a few real life examples…. • Janey’s story • Sister in the hospital was febrile and shivering • Blankets or no blankets? • Jennifer’s story • Noticed several standards of practice in the ICU regarding tube feedings • When should tube feedings be held? LuAnn Tandy 2009

23. ASK • Mary Ann’s story • Heard on CNN that you no longer need to apply alcohol to a newborn’s umbilical cord • Is this true? • You need to define the question in order to find the evidence • PICO is one strategy LuAnn Tandy 2009

24. PICO • P is for patient for population • I is for intervention • C is for conventional treatment • O is for outcome LuAnn Tandy 2009

25. Patient or Population • How would you describe a group of patients that are similar to yours? • Primary problem, disease or co-existing condition • Sex, age or race • Socio-economic situation • Country they live in LuAnn Tandy 2009

26. Intervention • What main intervention are you considering • What do you want to do to the patient? • What are the co-existing issues? • Age • Addictions • Mobility • Socio-economic concerns LuAnn Tandy 2009

27. Comparison • What is the main alternative to compare with the intervention? • Is it better to instill normal saline into the trachea before you suction or not? • You do not always need a comparison LuAnn Tandy 2009

28. Outcomes • What are you trying to measure? • What are you trying to improve? • What are you trying to do for the patient? LuAnn Tandy 2009

29. Janey’s Story • Janey’s sister was in the hospital and had a fever and she was shivering. The nurse wanted to take away the blankets and Janey felt bad for her sister and fought to keep them. After that situation she wondered what really was the best thing to do in that situation. What is Janey’s PICO LuAnn Tandy 2009

30. Janey’s PICO • P = In post-op patients who are febrile and shivering • I = is taking away the patient’s blankets • C = or allowing them to keep the blankets • O = more effective in reducing the fever? LuAnn Tandy 2009

31. Mary Ann’s Story • Mary Ann was driving to work one day to her job in the labor and delivery department. On the radio she heard that it was no longer necessary to apply alcohol to the newborn’s umbilical cord, you could just use soap and water. • What is Mary Ann’s PICO? LuAnn Tandy 2009

32. Mary Ann’s PICO • P = In newborn’s • I = is soap and water • C = better than alcohol • O = in preventing infection of the umbilical cord? LuAnn Tandy 2009

33. PICO Think of your EBP question and write it down LuAnn Tandy 2009

34. Evidence Based Process according to UNC-Chapel Hill • ASK • AQUIRE* • APPRAISE • APPLY • ASSESS LuAnn Tandy 2009

35. ACQUIRE: Selecting the Resources and Conducting the Search • Locating the highest quality and relevant information from the medical literature to answer your question • How do you find the literature? • How do you know the literature is of the highest quality? • By determining the levels of evidence. LuAnn Tandy 2009

36. DETERMINING THE LEVELS OF EVIDENCE Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence based clinical practice guidelines based on systematic reviews of RCTs. LuAnn Tandy 2009

37. Systematic Reviews • A summary of evidence on a particular topic that uses a rigorous process for retrieving, critically appraising, and synthesizing studies in order to answer a question about a burning clinical question Melnyk, 2004 LuAnn Tandy 2009

38. Meta-analysis • A systematic review that uses quantitative methods to summarize the results of multiple studies. • It produces a summary statistic LuAnn Tandy 2009

39. Where to find Systematic Reviews • Cochrane Database • Worldviews on Evidence-Based Nursing by Sigma Theta Tau • Peer reviewed journals LuAnn Tandy 2009

40. Levels of Evidence • Level II: Evidence obtained from at least one well-designed RCT • Experimental study in which subjects are randomly assigned to experimental and control groups. • Randomized trial is an opportunity for anyone that fits the criteria for inclusion to have a chance to be in the study. • Pointing to names in the phone book LuAnn Tandy 2009

41. Levels of Evidence • Level III: Evidence obtained from well-designed controlled trials without randomization • Without randomization you can’t assume that subjects in the study are equal on demographic and clinical variables. LuAnn Tandy 2009

42. Levels of Evidence • Level IV: Evidence from well-designed case-control and cohort studies • Case control study compares certain characteristics of an individual such as a person with diabetes to the characteristics of another individual without the disease. • This type of study is used to identify variables that might predict the condition. • A cohort study gathers two groups on individuals, one with exposure to a disease and one without and follow them over time to measure outcomes of the disease. LuAnn Tandy 2009

43. Levels of Evidence • Level V: Evidence from systematic review of descriptive and qualitative studies • This is similar to meta-analysis only using qualitative studies LuAnn Tandy 2009

44. Levels of Evidence • Level VI: Evidence from a single descriptive study • Level VII: Evidence from the opinion of authorities and/or reports of expert committees LuAnn Tandy 2009

45. Issues with Evidence • Too much • Too little • Same author publishes all the studies • Only vendor research LuAnn Tandy 2009

46. Interpreting the Results: Statistics • Sample size • Reliability • Validity • Significance • Clinical significance LuAnn Tandy 2009

47. Sample Size=n • Number of people in the study • The larger the better • Determining a good sample size depends upon the size of the population that is being studied. • Sometimes it’s a small sample size but if the whole population is in the study, then that means you sampled 100% LuAnn Tandy 2009

48. Significance = p • A good significance level is between <.01 and .05 in most cases • Significance is the risk of error we are willing to accept and still say our results are correct • .05 means that 95 times out of 100 “IT” works • .01 means that 99 times our of 100 “IT” works LuAnn Tandy 2009

49. Reliability • Reliability means that the tool you used to measure results in your research study will measure the same way every time. • You wouldn’t want to use a tape measure that stretches. • You might stretch it more one time than you do the next. • Look for clues that they didn’t measure things the same way every time LuAnn Tandy 2009

50. Validity • When research is valid it means that the tool used to measure the results measures what it is supposed to measure. • You don’t want to use a tape measure to weigh a baby. It measures inches not pounds. • Look for clues that they didn’t use the right tool to measure their results. LuAnn Tandy 2009