lesson 14 - translational research

8/6/2019 Lesson 14 - Translational Research

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Translational Research:

Generating Evidence for Practice


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Objectives

Clarify the differences between

evidence based practice andtranslational research.

Describe models for introducing

research findings into practice.

Identify barriers to research

utilization in practice.


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Introduction Evidence-based practice, translational

research and research utilization are all

words which have been used to describe

the application of evidential knowledge toclinical practice.

In evidence-based practice, the goal is to

decrease practice variability, increase

patient safety and eliminate unnecessarycost.


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Clarification ofTerms

Research utilization is a subset ofevidence-based practice.

Translational research is used todescribe the translation of medical,biomedical, informatics and nursingresearch into bedside clinical

interventions. Research results are crucial to

furthering evidence-based practice.


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Clarification ofTerms Discussion abounds in the area of what

constitutes evidence.

Considered the most reliable, the randomizedcontrol trial (RCT) is often termed the goldstandard for evidence.

Evidence includes standards of practice,codes of ethics, philosophies of nursing,

autobiographical stories, esthetic criticism,works of art, qualitative studies and thepatient and clinical knowledge.


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Clarification ofTerms In order to use evidence in practice,

the weight or validity of the researchmust be determined.

An example of an evidential hierarchyby Stetler et al. (1998) prioritizesevidence into 6 categories:

Meta-analysis

Individual experimental studies

Quasi-experimental studies

Non-experimental studies

Program evaluations such as quality improvementprojects

Opinions of experts


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Clarification ofTerms

The hierarchy identifies meta-analysis asthe best quality evidence since it utilizes

multiple individual research studies tocome to consensus.

Qualitative research allows us tounderstand the way in which theintervention is experienced to theresearcher and to the participant as wellas the value of the interventions to bothparties.


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Bridging the gap between

research and practice

Bridging the gap between research

and practice requires an

understanding of the key concepts and

barriers, accessibility to research

findings, access to clinical mentors for

research understanding, a reinforcing

culture and a desire on the part of the

clinician to implement best practices.


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Bridging the gap between

research and practice In an observational study of the

information seeking behaviors of on-

duty nurses, McKnight (2006) notedthat nurses did not feel ethicallycomfortable with taking time frompatient care to read publications, norwas much time available.

Nurses may see the job of interpretingresearch as too complex or may seethe organizational culture as a barrier toimplementation.


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The role of informatics The collaborative component of

research is supportive of informatics

science. Technology has become so important

to research that the National Institutes

of Health has invested in re-

engineering of the clinical researchenterprise as part of its roadmap

initiative for medical research

(National Institutes of Health, 2007).


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The role of informatics

An informatics infrastructure is critical to

supporting a clinicians access to

information in a clinical setting. As an example of the integration of

informatics and the medical record, Matter

(2006) describes the positive effects of a

successful integration of referential linkswith EBP clinical content in the clinical

pathway on patient outcomes.


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The Cochrane Collaboration showedan increasing need to improve on the

speed of knowledge acquisition andaccess to evidence.

With the goal of promoting the use ofresearch findings, and tool use basedon these findings, the Agency for

Health Care Research (AHRQ)became an active participant inpushing evidence forward intopractice.


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The AHRQ is a government sponsored

organization with the mission of

reducing patient risk from harm,

decreasing healthcare cost and

improving patient outcomes through

the promotion of research and

technology applications focused on

evidence-based practice.


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As part of an AHRQ initiative, theNational Guideline Clearinghouse

(NGC) was developed. NGC is a comprehensive database of

evidentially based clinical practiceguidelines and related documentswhich are regularly published throughthe NGC listserv and are available onthe NGC website(http://www.guideline.gov/).


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The role of informatics The NGC website allows users to browse the

website for the clinical guidelines, view

abstracts and full text links, download full textclinical guidelines to personal digital assistive(PDA) devices, obtain technical reports andcompare guidelines.

There are a growing number of written and

electronic resources available to assist increating guidelines and offering informationabout evidence-based practice.


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Developing evidence based

practice guidelines

Careful analysis and discussion of the

research and/or other forms of

evidence in this scenario may reveal

that given the context, implementation

may not be practical.

Information technology is important insynthesizing the research regardless

of the model.


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Meta-analysis and

Generation of knowledge

The strength of the systematic

review is its ability to corroboratefindings and reach consensus.

Systematic reviews show the

need for more research by

revealing the areas where

quantitative results may be

lacking or minimal.


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Meta-analysis and

Generation of knowledge

Meta-analysis, a form of systematic

review, uses statistical methods to

combine the results of several studies.

Meta-analysis is the statistical

analysis of a large collection of

analysis results from individual studiesfor the purpose of integrating the

findings.


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Meta-analysis and

Generation of knowledgeSteps of a meta-analysis are:

1. defining the problem followed by protocol

generation2. establishing study eligibility criteria followed by

literature search

3. identifying the heterogeneity of results ofstudies

4. standardizing the data and statisticallycombining the results

5. sensitivity testing to determine if the combinedresults are the same


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Meta-analysis and

Generation of knowledge The often sited criticism of meta-analysis

is that emphasis is on quantitative studies,not qualitative.

The analysis is only as good as thestudies used in the analysis.

Collection and dissemination of thesemeta-analysis and systematic reviews are

available in paper and on-line through theinternet, although many such databasesrequire a subscription.


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Meta-analysis and

Generation of knowledge There are two vehicles for Open Access:

archives

journals

Open Access journals are generally peer-reviewed and freely available.

The publishers of open access do notcharge the reader but obtain funds for

publishing elsewhere. Open access journals may charge the

author for publishing.


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Thought Provoking Questions1. Twelve hour shifts are problematic for patient and

nurse safety and yet hospitals continue to keep the12-hour shift schedule. In 2004, the Institute ofMedicine (Board on Health Care Services & Instituteof Medicine, 2004) published a report which referredto studies as early as 1988 which discussed thenegative affects of rotating shifts on interventionaccuracy. Workers with 12 hour shifts realized morefatigue than workers on 8 hour shifts. In anotherstudy done in Turkey by Ilhan et al(Ilhan, Durukan,Aras, Turkcuoglu, & Aygun, 2006), factors relating toincreased risk for injury were: age of 24 or less, lessthan 4 years of nursing experience, working in thesurgical intensive care units and working for morethan eight hours. As a clinician reading thesestudies, what would your next step be?


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Thought Provoking Questions2. The use of heparin versus saline to maintain the

patency of peripheral intravenous catheters hasbeen addressed in research for many years. TheAmerican Society of Health System recently

Pharmacists (ASHSP) published a position paper inJanuary 2006 (American Journal of Health SystemPharmacists, 2006) advocating their support of theuse of 0.9% saline in the maintenance of peripheralcatheters in non-pregnant adults. It seemssurprising that their position paper references

articles that advocate the use of saline over heparindating from 1991. What do you feel are some of thebarriers which would have caused this delay inimplementation?

lesson 14 - translational research

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