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Evidence-Informed Practice Workshop Series

Level 1: Introduction to

Evidence – Informed Practice

Outline

• Session – Presentation – 90 mins.

• Break – 30 mins

• Question excercise – 30 mins

• Large group discussion – 60 mins.

Objectives

• Understand the definitions of “evidence” and how it can be used to inform practice decisions.

• Develop the cognitive and affective learning necessary to begin incorporating the principles of evidence-informed practice into individual practice.

Definition

• Integration of best research evidence with clinical expertise and patient values to facilitate clinical decision-making – “Evidence Informs Practice”

• Examples of research to inform practice: – Effectiveness and safety of interventions

– Accuracy and precision of assessment measures

– Power of prognostic markers

– Strength of causal relationships

– Cost-effectiveness of interventions

– Meaning of illness or patient experiences.

Health Care Resources

Clinical State & Circumstances

Patient Preferences & Actions

Research Evidence

Clinical Expertise

Evidence-Informed Practice Model

From: DiCenso A, Guyatt, G & Cilicska, D (2005) Evidence-Based Nursing

Where to Start

• Mandated tasks

• Observations from practice

• Patient/Family/Staff complaints

• High volume tasks

• Organization’s priorities

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Priorities!

• Examine practice

• Examine patient outcomes

• Ask “So What?” – What happens if the guideline was not

there?

– What happens if people don’t follow it?

– What are the risks? Benefits?

How to choose priorities?

Steps for moving from Inquiry to Action

Identify a problem precisely

Identify information required to solve the problem

Efficient and comprehensive search of the literature and other levels of available evidence

Select the best answer for your clinical situation

Plan, implement, evaluate, revise (Plan, Do, Study, Act)

Background and Foreground Questions

Background

• General questions about conditions, tests etc.

Foreground

• Specific questions about aspects of treatment, approaches, tests

Asking Questions

Foreground Questions

Background Questions

Novice Expert

From: Guyatt G & Rennie D (2002) Users’ Guides to the Medical Literature

For every intervention, think like a 2-year old

and ask:

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Elements of Searchable Questions

1. Population - Specific health care problem, group of patients or individual

2. Intervention or Exposure

3. Control or Comparison

4. Outcome – Patient relevant consequences (good or bad)

Framing Questions

Among x (population)…,

Does x (intervention / comparison)…,

Impact x (outcome)…

Research Evidence

6S Hierarchy

•Includes studies and synthesized evidence

•Incorporated into the model developed by DiCenso – they comprise the top 6 layers of the total hierarchy

•We will go through each layer individually

Health Care

Resources

Clinical State

& Circumstances

Patient Preferences

& Actions

Research EvidenceClinical

Expertise

Evidence-Informed Practice

From DiCenso A, Bayley L & Haynes B (2009)

Personal Experience

• Base of the hierarchy

• “pooled” experience strengthens it

• Dangers of looking through blinders

Expert Opinion & Consensus Statements

• Delphi methods

• “Review” articles

Example:

“Oral Rehydration Therapy and Early Refeeding in the Management of Childhood Gastroenteritis”

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• Observational studies

• Case-control

• Population studies

• Quasi-Randomized

• Qualitative research

Qualitative Research Evidence Hierarchy

Other Research Designs Elements of Searchable Qualitative Questions

1. Population

2. Situation

• Circumstances, conditions or experiences

Qualitative Research Designs

Ethnography

Examples:

• Field work

• Study of a culture

• Narrative discourse

Grounded Theory

• Develop a theory during the study

Phenomenology

• Nature or meaning of “lived experience”

Quantitative

• Informs

• Controls context

• One reality

• Direct application of research findings in procedures, clinical protocols,

practice guidelines,

standard care plans

Qualitative

• Enlightens

• Explores context

• Multiple realities

• Practitioners become aware of research findings, take them in, and

let them inform their practice in ways that are often indirect

Randomized

Controlled Trials

Original Single RCT’s Using a Study to Answer a

Clinical Question

• Critical appraisal worksheets tailored to the type of research:

– Intervention

– Systematic Review

– Qualitative

– Harm

– Prognosis

– Outcomes

– Quality of Life

Level 2

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Treatment versus Harm

Treatment

• Therapies or intervention that practitioners engage in independently or collaboratively to benefit patients, families or communities

Harm

• Unintended adverse consequences of – a treatment

– people’s lifestyle choices

– circumstances

• One page reports with a recommendation for practice

• Evidence-Based Journals are focused on specific professions and areas and employ critical filters for method and quality

Synopsis of Studies

U of M library has 27 “Evidence-Based xx ”

journals!

• Cochrane Library

• PubMed filtered only to provide systematic reviews

• Toolkits on UofM library website – find it through: www.umanitoba.ca

Systematic Reviews

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• Reviews of reviews

• Ensures that they don’t become outdated

• They measure the quality of the reviews

• More evidence-based journals are publishing them

• Screened for relevance and appraised for

quality

• DARE: healthevidence.ca

• EB Journals – one page commentaries

Synopsis of Reviews

• Large organizations who work through the literature and develop recommended practices

• Not all guidelines will be of the highest quality; evaluate them using the AGREE Tool http://www.agreecollaboration.org/instrument/

Summaries & Practice Guidelines

UofM library

toolkits:

Links to hundreds

of guidelines

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Decision Support Systems: Decision Coaching

• When the population is one patient/family

• Coaching vs giving advice

•Ottawa Health Research Institute •Computerized algorithms •Search: “health decision support aid” •http://decisionaid.ohri.ca

Decision Aids

Example No Decision Aid?

“Knowledge Brokers”

• Organizations that provide evidence-based information to individuals to help them make decisions

Clinical State, Setting & Circumstances

• Conditions that affect our ability to implement recommendations

Example:

• A specific drug may be best, but not all disciplines can write prescriptions, or it may not be on the formulary

•A particular unit may be implementing other “priority” changes – timing is everything

Health Care

Resources

Clinical State

& Circumstances

Patient Preferences

& Actions

Research EvidenceClinical

Expertise

Evidence-Informed Practice

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Health Care Resources

Are there limits on what we can offer?

On what we should offer?

Health Care

Resources

Clinical State

& Circumstances

Patient Preferences

& Actions

Research EvidenceClinical

Expertise

Evidence-Informed Practice

Elements of Clinical Decision Making:

Putting it all together

• Research evidence – is the literature strong enough or does it leave options open?

• Clinical state, setting and clinical circumstances

• Health care resources – can we do it, or what do we need to do it?

• Patient preferences and actions

• Clinical Expertise is what ties it all together

System Strategies

• Library and electronic supports for literature searches – develop the skills yourself, or utilize the resources of those who have them

• Systems that integrate evidence-based info. – guidelines, pathways, policies etc.

• Dedicated space for evidence-based activities

• Resources to assist with EB practice

• Dissemination of findings – ie workshops and courses

• Initiatives to stimulate critical thinking

Barriers to Using Evidence to Inform Practice

Individual

• Evaluating the quality of research

• Lack of time

Organizational

• Insufficient time and resources

• Lack of vision / leadership / support

• Decreased autonomy to implement changes based on evidence

WRHA Evidence-Informed Practice Workshops

Level 1: Introduction: Learn to formulate questions.

Level 2: Learn how to critically appraise research using worksheets:

• Health care intervention

• Systematic review

WRHA Evidence-Informed Practice Workshops

Level 3: Making Practice Recommendations

• Strategies to determine what to do

• Basic introduction to the GRADE Process

Level 4: Implementation of Practice Change

• How to plan and implement a specific change

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Searchable Questions

1. Population - Specific health care problem, group of patients or individual

2. Intervention or Exposure

3. Control or Comparison

4. Outcome – Patient relevant consequences (good or bad)

Example: Routine Practices

Question 1

P – health care workers

I – traditional handwashing

C – alcohol based antiseptic

O – infection transmission

Question 2

P – health care worker

I – procedure mask

C- N95 mask

O – contract infection from patient

Question 3

P – health care worker / various patients

I – gloving during procedure

C – no gloves during procedure

O – VAP, nurse acquiring patient infection

Question 4

P- health care worker / various patients

I – protective eye wear

C – no protective eye wear

O – contract infection from patient

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Question 5

P- health care workers

I- having WRHA policy on intranet

C- reminders of content of policy - various

O- compliance with routine practices

Questioning Exercise Part 1

• Take a policy / guideline etc

• Scrutinize it and break it down into all the “answerable” questions you can

• Work in groups or individually

• Present your questions to the whole group

Question Exercise Part 2

• Individually or in small groups develop focused clinical “answerable” questions using the PICO format:

Patient

Intervention

Comparison

Outcomes

Conclusion of Level 1

• Don’t feel overwhelmed

• Take a break, be refreshed for level 2!