Susan Fowler, PhD, RN, CNRN, FAHADirector of Magnet, Education, Quality, & Research

At the end of this presentation, attendees will: Define evidence-based practice. Describe critical parts of a critique of

evidence. Apply critical analysis to infection control

practices.

Who does it pertain to?

What is it? When do I use it? Why is it important? How do I go about

evidence-based practice?

Focus on outcomes and cost Unnecessary

variations in practice persist

Gap between evidence and practice

Unmanageable amounts of information

Dr. Archie Cochrane, Epidemiologist

Crossing the Quality Chasm (IOM, 2001)

Studies in medicine and nursing indicated that interventions based on evidence have better outcomes.

Definition Evidence Based Practice of nursing is the

process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences.

Nurse, Clinical Expertise, Patient, Evidence Reality

We use evidence everyday without thinking about it Sources of evidence can be too few or too many It’s easier to base practice on myths and the way we have

always done things than attempt to understand the evidence and change practice

Essentials of practice Art

Our ability to connect to those around us We just ‘know’ what to do to meet a patient’s emotional needs:

when to hold a patient’s hand, stroke their brow, crack a joke or even just sit and listen

Calls you to the profession

Science Body of knowledge Uses scientific methods Generate and test theory, discover meaning, and grow knowledge A scholarly adventure

Ask the burning clinical question (PICO). Collect the best evidence. Critically appraise the evidence. Integrate the evidence, clinical expertise,

and patient factors/preferences to implement a decision.

Evaluate the outcome.

Research Conducted a systematic &

scientific manner Follows a series of steps with a

rigorous standard protocol Purpose is to generate new

knowledge Evidence-based

Practice The process by which nurses

make clinical decisions using the best available research evidence, their clinical expertise and patient preferences

Where are the similarities and differences? Both use a process/specific

approach Both are trying to gain

something – knowledge, a new way of doing something

Research more ‘rigorous’ with more steps

Research tries to gain new knowledge whereas EBP might try to confirm knowledge

EBP RESEARCH

Ask the burning clinical question (PICO)

Collect the best evidence Critically appraise the

evidence Integrate the evidence,

clinical expertise, and patient factors/preferences to implement a decision

Evaluate the outcome

Statement of the Problem; Purpose of the Study

Significance (WHY is this important to nursing – SO WHAT??)

Review of the Literature; Research ?

Conceptual Framework Methods/Design/Data Collection Data Analysis Findings Discussion/implications

Practice Question

Evidence Translation

Practice Question, Evidence, Translation (PET)

(Newhouse, R.P., Dearholt, S., Poe, S., Pugh, L.C., White, K. 2005)

P – patient population I – intervention of interest C – comparison intervention or status O – Outcome In caring for disabled adults, does the

use of level-access showers improve patient hygiene more than bed bathing???

In adult surgical patients, does getting the patient out of bed ambulating help with bowel elimination more than just sitting in the chair?

In hospitalized elderly, does brushing their teeth before every meal improve the amount of food eaten compared to no oral care?

Level l – experimental/RCT/meta-analysis of RCTs

Level II – quasi-experimental Level III – non-experimental or qualitative Level IV – opinion of experts and/or reports

of nationally recognized expert committees, evidence from case reports

Level V – opinion of nationally recognized experts based on experience

Top to Bottom Truffles Donnelly

Chocolates Ghiradelli

Chocolate bars Hershey kisses Fannie Farmer

sample Nestle’s Quik

Define EBP in terms of evidence, expertise, and patient values.

Critically appraise original research reports for practice implications.

Classify clinical knowledge as primary research, evidence summary, or practice guideline.

Recognize ratings of strength of evidence when reading literature.

Use evidence summary databases to locate systematic reviews and evidence summaries on clinical topics.

Participate on a team to develop agency-specific evidence-based clinical guidelines.

Deliver care using evidence-based clinical practice guidelines.

Choose evidence-based approaches over routine as basis for own clinical decision-making.

Related to Critical Thinking

o Apply research-based knowledge from nursing and sciences as the basis for practice.

o Evaluate nursing care outcomes through the acquisition of data and questioning of inconsistencies.

Related to Provider of Careo Integrate theory and research-based

knowledge from the arts, humanities and sciences to develop a foundation for practice.

o Participate in research that focuses on the effectiveness of nursing interventions.

o Utilize outcome measures to evaluate effectiveness of care.

Why pick a model for EBP? Provides an

organized approach Prevents incomplete

implementation Maximizes nursing

time and resources (Gawlinski & Rutledge, 2008)

Depicts 3 essential cornerstones that form the foundation for professional nursing

Nursing practice is the means by which a patient receives nursing care; education reflects the acquisition of the nursing knowledge and skills necessary to become a proficient clinician and to maintain competency; and research provides new knowledge to the profession and enables the development of practices based on scientific evidence.

ResearchResearchEducationEducation

InternalFactors

ExternalFactors

CultureEnvironment Equipment/Supplies Staffing EffectivenessStandards

AccreditationCore MeasuresLegislationLicensingStandards

The Johns Hopkins Hospital/ The Johns Hopkins University

ResearchResearch Experimental Quasi-experimental Non-experimental Qualitative Non-ResearchNon-Research

Organizational experience-Quality improvement-Financial data

Clinical expertise Patient preference

JHN Evidence-based Practice Conceptual Model

PracticePractice

Step 1: Identify an EBP questionStep 2: Define scope of practice

questionStep 3: Assign responsibility for

leadershipStep 4: Recruit multidisciplinary teamStep 5: Schedule team conference

Step 6: Conduct internal and external search for evidence Step 7: Critique all types of evidenceStep 8: Summarize evidence Step 9: Rate strength of evidenceStep 10: Develop recommendations for change in processes of care or systems based on the strength of evidence

Guides clinical decision-making; details implementation of EBP; considers practice & organizational perspectives

Examples (at the Univ. of Iowa Hospitals & Clinics) Pain in acute care and outpatient settings Assessment and intervention to decrease patients’ risk for

falling while hospitalized Facilitating visitation by family pets in acute care Nurse retention

Successfully implemented since 1994 internationally

Infuses research into practice to improve quality of care

Planned change principles integrate research and practice

Utilizes a multidisciplinary team approach

Utilizes feed-back loops

Problem Focused Triggers Knowledge Focused Triggers

Priority forOrganization

Consider other triggers

NO

Form a team

YES

Assemble Relevant Research & Related Literature

Critique and Synthesize Research for Use in Practice

SufficientResearch?

Pilot Change inPractice Base Practice on other

Types of Evidence

ConductResearch

Should weAdopt this change

into practice?No Yes InstituteChange

Continue toEvaluate qualityCare and New

Knowledge

Monitor and AnalyzeStructure, Process, and

Outcome Data

DisseminateResults

Problem Focused Triggers Risk management data Identification of a clinical problem QI or Financial Data

Knowledge Focused Triggers New research or other literature Philosophies of Care Agencies or Organizational Standards and

guidelines

3 step process EBP expert and clinician Nursing Research Committee Endorsement by executive leadership

  Priority for Likelihood to  

Topic Idea

Nursing1=low;5=high

Organization1=low;5=high

Improve Quality of care1=low;5=high

Decrease LOS/ Contain Costs1=low; 5=high

Improve Patient Satisfaction 1=low;5=high

ImproveEmployee Satisfaction1=low;5=high

Body of Science1=little5=multiple studies

               

-the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes by way of EB care Knowledge transformation is necessary before research results are

useable in clinical decision making. Knowledge derives from a variety of sources. In healthcare, sources of

knowledge include research evidence, experience, authority, trial and error, and theoretical principles.

The most stable and generalizable knowledge is discovered through systematic processes that control bias, namely, the research process.

Evidence can be classified into a hierarchy of strength of evidence. Relative strength of evidence is largely dependent on the rigor of the scientific design that produced the evidence. The value of rigor is that it strengthens cause-and-effect relationships.

Knowledge exists in a variety of forms. As research evidence is converted through systematic steps, knowledge from other sources (expertise, patient preference) is added, creating yet another form of knowledge.

The form ('package') in which knowledge exists can be referenced to its use; in the case of EBP, the ultimate use is application in healthcare.

The form of knowledge determines its usability in clinical decision making. For example, research results from a primary investigation are less useful to decision making than an evidence-based clinical practice guideline.

Knowledge is transformed through the following processes: summarization into a single statement about the state of the science translation of the state of the science into clinical recommendations, with addition of

clinical expertise, application of theoretical principles, and client preferences integration of recommendations through organizational and individual actions evaluation of impact of actions on targeted outcomes

Outcomes reflect IMPACT!!!

EBP’s effect on patients:

Physiologic, pyschosocial, function

EBP’s effect on the health system: Decreased cost, length of

stay Nursing retention/job

satisfaction Interdisciplinary

collaboration

1. Assess need for change in practice Include stakeholders Collect internal data

about current practice

Compare internal data with external data

Identify problem

2. Link problem, intervention, and outcome Use standardized Classification systems

and language Identify potential

interventions and activities

Select outcomes indicators

3. Synthesize best evidence Search research

literature related to major variables

Critique and weigh evidence

Synthesize best evidence

Assess feasibility, benefits, and risk

4. Design practice change Define proposed

change Identify needed

resources Plan implementation

process Define outcomes

5. Implement and evaluate change in practice Pilot study

demonstration Evaluate process

and outcome Decide to adapt,

adopt, or reject practice change

6. Integrate and maintain practice change Communicate

recommended change to stakeholders

Present staff inservice education on change in practice

Integrate into standards of practice

Monitor process and outcomes

A dog bit my mother-in-law three weeks ago. She has known the dog for many years, but the immunization status of the dog was unconfirmed. Her wound was small, so she did not seek treatment at that time. The biggest fear after a dog bite is contracting rabies. Rabies is a zoonotic disease (one transmitted to humans from animals) caused by a virus.

Last week she went to her primary care provider (PCP) for treatment, two weeks after the initial bite. Her PCP recommended rabies post-exposure immunization. My husband, a resident physician, and I were shocked as neither of us has ever recommended the rabies immunization for post-exposure treatment in a case like hers. We both quickly consulted our databases of choice for a quick look at what we thought were the recommendations for rabies treatment. I consulted www.emedicine.com and found “Human rabies immune globulin and vaccine are recommended for bites and exposures regardless of the period between exposure and treatment unless the individual is previously vaccinated and rabies antibodies can be detected.” (2007, 11).

Of note, the average delay in the United States between exposure and treatment is 5 days, which does not appear to compromise successful prophylaxis. My husband consulted the Up to Date database and found “for persons who have never been vaccinated against rabies, post-exposure antirabies vaccination should always include administration of both passive antibody (HRIG) and vaccine (human diploid cell vaccine [HDCV] or purified chick embryo cell vaccine [PCECV])”. Finally we looked at the Centers for Disease Control (CDC) website and found their recommendation to be “for persons who have never been vaccinated against rabies previously, post-exposure anti-rabies vaccination should always include administration of both passive antibody and vaccine”. Post-exposure prophylaxis is a series of multiple injections around the already painful wound and follow-up is generally poor for patients (Moran, G.J. Talan, D.A. Mower, W. Newdow, M., Ong, S., Nakase, J., et al., 2000).

We were frustrated and confused. It seemed that all three databases recommended that the post-exposure vaccine be given. Yet in all of the nine facilities that we have worked in across three different states, this has never been standard of care.

Since I have been learning the process of evidence-based practice (EBP) and how to search the literature for the best evidence, I thought that I would apply it to this situation. A PICO question was developed to drive the search of the literature. In (p) patients with animal bites does the (i) administration of post-exposure prophylaxis (PEP) compared to (c) observation or testing of the animal only (o) provide the most appropriate treatment?

I performed a quick search of the CINAHL, PubMed, and Google Scholar databases. After rapidly critically appraising the articles I found and synthesizing my findings, I know that I now have a validated response to my mother in law when I say that the post-exposure treatment of rabies is not warranted in her case. I can show her the evidence. There is even an easy algorithm to follow called the "Algorithm for Determining Appropriateness of Animal Exposure Treatments" (Moran, G.J. Talan, D.A. Mower, W. Newdow, M., Ong, S., Nakase, J., et al., 2000).

My “EBP Story” shows how I have taken what I have learned in the last five months and not only applied it to my practice, but also my personal life.

This week my mother-in-law’s dog drank antifreeze. Perhaps next week I will do a mini-synthesis of evidence for a recommendation on the treatment for that issue.

Lack of knowledge about EBP. Lack of knowledge about library

and online resources. Inconvenient/inaccessible

library/internet. Misperceptions or negative views

of research. Devotion to traditional care.

Overwhelming patient care load. Voluminous amounts of

literature. Difficult patient care situations. Organizational constraints. Inadequate information in

prelicensure nursing program. Laziness/lack of motivation/

burnout.

Educational emphasis in nursing schools and hospitals.

Administrative support and encouragement. Time to think through patient care

situations. Time to critically appraise studies and

implement findings. Clearly written, well-done research reports. Library and internet access in the clinical

area.

Enhance critical appraisal skills

Discuss of findings Journal Clubs Systematically

examine the stage of adoption of practice guidelines

Facilitate systematic reviews

Facilitate primary research

EBP Grand Rounds Scholar in Residence Web

Support/Toolbox Research corner in

newsletter

APIC (2000, 2011) Behavioral management science Surveillance standards Infection prevention resource optimization

Standardization in infection prevention practices and program resource allocation

Strategic Plan Enhance health promotion and disease

prevention Improve quality of life by managing

symptoms of acute and chronic illness Improve palliative and end-of-life care Enhance innovation in science and practice Develop the next generation of nurse

scientists

Hand hygiene Environmental cleaning PPE C-diff Catheter related blood

stream infections CAUTI MRSA Orthopedic site

infections VAP