Evidence-based Practice

1. Evidence-based Practice Beth Gray, MSN, NP, COHN-S, NE-BC VP of Patient Care and Nursing St. Luke’s McCall

2. Today’s objectives • Describe the elements of evidence-based practice • State at least one method to identify and locate best evidence • Describe a guided evidence-based practice application process • What’s different between urban and rural models when it comes to evidence-based practice?

3. Keystones of Evidence-based Practice • Integration of the best possible research or evidence with clinical expertise and with patient needs.

4. Research Utilization Uses only research evidence Dependent on research publication Evidence-based Practice Uses research (including that not published) as well as other sources of credible information Clinical Experience Patient preference Differentiating RU and EBP Both use the same critical review, recommendation, and implementation process!

5. Why Evidence-based Practice? • Patients benefit when patient care decisions are based on scientific evidence. (Polit, Beck, Hungler, 2001, Asch, McGlynn, Hogan, et al, 2004) • Patients who receive care based on the best and latest evidence experience 28% better outcomes (Heater, Becker, & Olson, 1988) • Healthcare providers who use an EBP approach to delivering patient care experience higher levels of satisfaction (Dawes, 1996) • Without EBP, practice is rapidly outdated, often to the detriment of patients. It often takes as long as 17 years to translate research findings into practice. (Balas &Boren, 2000)

6. Sources of Knowledge • Experiential • Nursing School (avg. time since completing education 18 years) • Workplace Sources • Physician Sources • Intuitions • Literature—rated bottom 5 for frequency Estabrook CA. Will evidence-based nursing practice make practice perfect? CJ Nurs Res 1998; 30:15-36.

7. Five Steps ofEvidence-based Practice • Ask the burning clinical question. • Collect the most relevant and best evidence. • Critically appraise the evidence. • Integrate all evidence with one’s clinical expertise, patient preferences, and values in making a practice decision or change. • Evaluate the practice decision or change.

8. 4. Design practice change 5. Implement & evaluate change in practice 6. Integrate & maintain change in practice Assess need for change in practice 2. Link problem interventions & outcomes 3. Synthesize best evidence • Include stakeholders • Collect internal data about current practice • Compare internal datawith external data • Identifyproblem • Use standardized classification systems and language • Identify potential interventions & activities • Select outcome indicators • Search research literature related to major variables • Critique and weigh evidence • Synthesize best evidence • Assess feasibility, benefits, risk • Define proposed change • Identify needed resources • Plan implementation process • Define outcomes • Pilot study demonstration • Evaluate process & outcome • Decide to adapt, adopt, or reject practice change • Communicate recommended change to stakeholders • Present staff inservice education on change in practice • Integrate into standards of practice • Monitor process & outcomes Model for Evidence Based Practice from Larabee and Rosswurm

9. Observe patients and families for their responses to treatment and for cues that the current plan of care may not be effective. Question current practice and identifies issues amenable to change. PI data Report cards or benchmarks Staff practice concerns New knowledge shared Policies and Procedures Question significance of the clinical issue. Where do the questions come from?

10. What evidence must be gathered? • Literature Search • Standards (Regulatory, Professional, Community) • Guidelines • Expert Opinion • Patient Preferences • Clinical Expertise • Financial Analysis

11. What are your resources? Internal • Policies and procedures • Specialists External • Professional organizations • Medical library • Internet

12. Internet: Use discriminately! • Accuracy • Authority • Objectivity • Content • Currency • (Morris, 2001)

13. Start with guidelines*! • Wound Ostomy & Continence Nurses Society • http://www.wocn.org • Evidence Based Practice Centers • http://www.ahcpr.gov/clinic/epc/ • Cochrane Collaboration • http://www.cochrane.org • National Guideline Clearinghouse • http://www.guideline.gov/ • Agency for Healthcare Research and Quality • http://www.ahrq.gov • University of York Center for Reviews • http://www.york.ac.uk/inst/crd/crddatabases.htm *List not complete

14. PICOT: asking the question • P= Population • I= Intervention • C= Compared to • O= Outcome • T= Timeframe

15. Literature Search Results • Search output--parts • Title • Who ,When, Where and What published • Peer reviewed • Qualitative vs. Quantitative

16. Research Newhouse, Dearholt, Poe et al, 2007

17. Tips for Reading Research • The Title • The Abstract • The Conclusion • The Method • The Results • The Discussion • The Overall Report

18. Grading the evidence • Three Domains: • Quality--extent to which a study’s design, conduct, and analysis has minimized selection, measurement, and confounding biases (internal validity) • Quantity--the number of studies that have evaluated the question, overall sample size across studies, magnitude of the treatment effect. • Consistency--whether investigations with both similar and different study designs report similar findings. • Agency for Healthcare Research and Quality [AHRQ], 2002)

19. Strength of the evidencePerry Mason style Multiple eyewitnesses One sober eyewitness who got a good look Physical evidence at the crime scene Pattern of previous criminal activity Round up the usual suspects

20. Quality Rating Scheme for Research Evidence Newhouse, Dearholt, Poe et al, 2007

21. AACN Levels of Evidence • Level I: Manufacturer’s recommendation only • Level II: Theory based, no research data to support recommendations: Recommendations from expert consensus group may exist • Level III: Laboratory data, no clinical data to support recommendations • Level IV: Limited clinical studies to support recommendations • Level V: Clinical studies in more than one or two patient populations and situations to support recommendations • Level VI: Clinical studies in a variety of patient populations and situations to support recommendations.

22. Staff nurses must “do” and “use” research…. • Staff nurses provide direct patient care and are the link between research and practice, • Staff nurses have the opportunity to identify clinical problems amenable to research, and • The number of nurses with research preparation at the doctoral level will always be small. • Dr. Janelle Krueger, “Promoting Nursing Research as a Staff Nursing Function” 1980.

23. EBP Application • Practice question • Evidence • Translation

24. Clinical DataResearchBest Practice What is our practice based on?

25. PICOT: asking the question • P= Hospitalized patients • I= Prevention Strategies • C= Compared to--none • O= Pressure Ulcers

26. Resources • National Guideline Clearinghouse • http://www.guideline.gov/ • Keast, D., Poarslow, N., Houghton, P., Noton, L., Fraser, C., (2007). Best practice recommendations for the prevention and treatment of pressure ulcers: update 2006. Advances in Skin & Wound Care, 20, 447-60. • Gibbons, W., Shanks, H., Kleinhelter, P., Jones, P., (2006). Eliminating facility-acquired pressure ulcers at Ascension Health. Joint Commission Journal on Quality and Safety, 32, 488-496. • Hart, S., Bergquist, S., Gajewski, B., Dunton, N., (2006). Reliability testing of the national database of nursing quality Indicators pressure ulcer indicator. Journal of Nursing Care Quality, 21, 256-65. • Joint Commission, (2006), Raising the bar with bundles. Joint Commission Perspectives on Patient Safety, 6, 5-6. • Lyder, C., Grady, J., Mathur, D., Petrillo, M., Meehan, T., (2004). Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement. Joint Commission Journal on Quality and Safety, 30, 205-14.

27. Resources • Lyder, C., Preston, J., Grady, J., Scinto, J., Allman, R., Bergestrom, N., Rodeheaver, G., (2001). Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Archival of Internal Medicine, 161, 1549-54. • Reddy, M., Gill, S., Rochon, P., (2006). Preventing pressure ulcers: A systematic review. Journal of American Medical Association, 296, 974-84. Retrieved January 28, 2008, downloaded from http://www.jama.com. • Registered Nurses’ Association of Ontario, (2005). Nursing Best Practice Guidelines: Risk Assessment & Prevention of Pressure Ulcers. Retrieved April 5, 2008, from http://www.rnao.org/bestpractices. • US Department of Health and Human Services, (1992). Clinical Practice Guideline Number 3: Pressure Ulcers in Adults, Prediction and Prevention. AHCPR publication 92-0047. • Wimpenny, P. vav Zelm, R. (2007). Appraising and comparing pressure ulcer guidelines. Worldviews on Evidence-Based Nursing, 4, 40-50.

28. Risk Assessment • Using a risk assessment tool • Applying a risk assessment tool to the patient • Integrating a risk assessment tool with practice

29. Improving care • “Bundle is a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. • It is a grouping of several scientifically grounded elements essential to improving clinical outcomes.” Institute for Healthcare Improvement—check www.ihi.org website

30. Bundle essentials Dr. Carol Haraden, Ph.D. V.P. at IHI • Two things essential to forming a bundle, “first, it has to be irrefutable science (i.e. grounded in research) and second, all elements of the bundle have to be executed in the same space and time to ensure that clinical improvement occurs”. • Other bundles: ventilator care bundle, central line bundle, sepsis bundle. Joint Commission, (2006).

31. Pressure ulcer bundle • Surface • Keep turning • Incontinence • Nutrition As developed by Ascension Health (Joint Commission on Accreditation of Healthcare Organizations, 2006)

32. Clinical Expertise OR What do you add to patient care?

33. Background Information • Understanding of the National Pressure Ulcer Advisory Panel Staging System • Understanding the science of healing • Expertise in products and their application • Clinical Judgment • Educators • Change agents

34. Clinical Resources

35. Patient & Staff Education • Ensure understanding of staff so they can teach patients. • Modifying plan to ensure that if works to achieve goals with patient input. • Bringing together patient concerns and values and your expertise.

36. Patient Concerns/Values What does the patient expect, need and want from their care?

37. Patient Concerns/Values • Knowledge vs. knowledge deficient • Motivation • Goals • Disease process • Medications • Nutrition • Physical Capabilities • Allergies • Cost issues

38. Evidence in Practice • “Knowledge of the research process alone does not ensure translation of that knowledge into practice.” • Seymour et al. 2003

39. Lessons from the field… • Most successful transformation focuses on the needs of the patient. • Most of the successful instances of transformation involved a local change champion. • Local input is important to customize approaches in order to obtain buy-in and create sustainable change. Agency for Healthcare Research and Quality, October 2004

40. Diffusion of Innovations Innovators (2.5%) Venturesome Early Adapters (13.5%) Respect Early Majority (34%) Deliberate Late Majority (34%) Skeptical Laggards (16%) Traditional 40

41. Mechanism of Diffusion 1) Knowledge – person becomes aware of an innovation and has some idea of how it functions, 2)  Persuasion – person forms a favorable or unfavorable attitude toward the innovation, 3)  Decision – person engages in activities that lead to a choice to adopt or reject the innovation, 4)  Implementation – person puts an innovation into use, 5)  Confirmation – person evaluates the results of an innovation-decision already made. 41

42. Measurable improvement in practice • Appropriate use of data is a key element in successful efforts to transform • Outcomes are the most important measures to create transformation • Use PDSA model • Small tests of change Agency for Healthcare Research and Quality, October 2004

43. Piloting the change • Select outcomes to be achieved, • Collect baseline data, • Design evidence-based guidelines, • Implement on a pilot unit, • Evaluate the process and outcomes, • Modify the practice guidelines.

44. Leadership • Leadership/Infrastructure to hold people accountable. Agency for Healthcare Research and Quality, October 2004

45. The British Medical Journal reported in 1995 that to keep up with journals relevant to practice, each practitioner would need to read 17 articles per day, 365 days per year. (Davidoff, Haynes, Sackett, & Smith, 1995)

46. Journal Clubs • Purpose: The purpose of the Journal Club is to foster excellence in practice by promoting evidence-based practice • Goals: • Improve knowledge of current research findings. • Foster the application of clinical research and best practice modules to practice. • Provide a means by which to address clinical issues.

47. Journal Clubs • Format for Presentations • Introduce topic and presenter • Give brief synopsis • Discuss major findings of study • Discuss other relevant research that supports/does not support this study

48. Journal Clubs • Discuss implications of article in terms of impact on practice • What is the relevance of this article to our practice? • Should we change our practice based on this information?

49. “The illiterate of the 21st century will notbe those who cannot read and write, but those who cannot learn, unlearn and relearn.” -Alvin Toffler Questions?