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Everything you always wanted to know about EBN
but were afraid to ask…
Carl Thompson and Nicky CullumCentre for Evidence Based
Nursing, University of York
Aims
•To introduce you to key principles and processes of evidence based nursing including strategies and resouces to promote evidence based care
Clinical ScenarioYou are a senior nurse on an
acute admissions ward where lumbar punctures are regularly undertaken for diagnostic purposes. Standard practice has long been to lie people flat to reduce the likelihood of headache but the Unit Manager asks if this period of bedrest can be reduced or abolished as this bed-blocking is giving her a headache…
Please write on the pink paper how long you think
someone should lie flat after lumbar puncture (please
make it clear whether your answer is in minutes or
hours)
Where do we go for help with decisions when we are not sure how to proceed?
Good Idea or Bad Idea?• A weekly exercise programme for
nursing staff in the workplace• Bicycle safety education
programmes for children• Driver education for teenagers• Pint glasses made of toughened
glass for use in pubs• Lying babies prone to prevent
choking
Good Idea or Bad Idea??
• Weekly exercise programme for nursing staff had no effect on fitness and health, merely interfered with ability to plan work
• Bicycle safety education programme for children increased risk of injury overall, doubling risk in boys
• Teenage driver education associated with a modest but potentially important increase in teenagers involved in traffic crashes
• Use of toughened pint glasses in bars increased injury rate by 60% because the glass shattered more easily
• Lying babies prone for sleep intuitively makes sense (reduction of risk of inhaling vomit or choking), but increases risk of sudden infant death syndrome
We may inadvertently widen health inequalities …
• Bike Ed cycle safety programme was more harmful in younger children, those from families with lower parental education levels, those in families without other cyclists
• Sesame Street benefited all children but gap between fast and slow learners increased
Evidence based
decision
Evidence from research
Patient Preferences
Available resources
Professional expertise
REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY
PHRASE ANSWERABLE QUESTIONS
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
IMPLEMENTATION WHERE APPROPRIATE
AUDIT
Nursing Uncertainty• Diagnosis• Selecting interventions
– targeting– timing
• Organising Care• Communication (including communication
of risks and benefits)• The patient experience• Prognosis• Health Needs Assessment
Question formation - PICO
• Population (who are the relevant people?)
• Interventions or exposures (diagnostic tests, foods, drugs, environmental hazards etc)
• Control or Alternative intervention/exposure
• Outcome (what are the person-level consequences we are interested in?)
Population
Who are the relevant people?
Intervention
What are they exposed to?
Alternative or control intervention
Outcome (what are the person-level consequences we are interested in?)
Focusing Answerable Questions
Population Intervention or Exposure
Alternative Intervention or Exposure
Outcomes
Scenarios• Focus these
uncertainties into answerable questions
Falls Prevention
• You are working in a PCT and a GP rings to say she is developing a practice protocol on preventing falls in older people. She asks you what should go into the protocol.
Focusing Answerable Questions
Population Intervention or Exposure
Alternative Intervention or Exposure
Outcomes
Exercise on Prescription
•You are working in a PCT and your Chief Executive decides that local practices should run an exercise on prescription scheme – how would you respond?
Focusing Answerable Questions
Population Intervention or Exposure
Alternative Intervention or Exposure
Outcomes
Mammography
A 40 year old friend with no symptoms or family history, has registered with a new GP who suggested that she have her first mammogram. Your friend asks you your opinion as to whether this is worthwhile?
Focusing Answerable Questions
Population Intervention or Exposure
Alternative Intervention or Exposure
Outcomes
REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY
PHRASE ANSWERABLE QUESTIONS
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
IMPLEMENTATION WHERE APPROPRIATE
AUDIT
Fundamental Principle of Evidence Based anything…• The weight given to research evidence for
any decision depends on internal validity and relevance (external validity) of research
• Match the type of question with the best research design– Certain research designs likely to yield
more valid (more likely true) results for particular types of questions (minimise bias)
Matching questions to designsType of Question
Best Design
Intervention incl. prevention
RCT
Screening RCT
Diagnostic test Independent comparison with gold standard
Harm RCT; cohort
Aetiology Prospective cohort
Describing phenomena
Qualitative
Why are randomised controlled trials the best design for answering questions of effectiveness?
• Only when the treatment under evaluation is the only systematic difference between the groups in a trial can we confidently attribute a difference in outcomes to the treatment
Randomised controlled trial
Eligible patients
Experimental intervention
Control intervention
OUTCOME
NO OUTCOME
OUTCOME
NO OUTCOME
Direction of data collection: exposure outcome
Poor quality and/or irrelevant research
The total body of research is distilled down to a conclusion based on the best available, reliable and relevant research
Systematic reviews
• Reviews that look, in a systematic way, at all the available research on a topic
• Systematic reviews have a clear method - like original research
• Critically appraise each piece of research they include
• Reliable information for practice
Examples of Systematic Reviews from the Cochrane Library• Beds, mattresses and cushions for
preventing pressure ulcers• Non-nutritive sucking for pre-term infants• Absorbent products for containing urinary
and/or faecal incontinence in adults
• Caregiver support for women during childbirth
• Communiciating with children and adolescents about their cancer
REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY
PHRASE ANSWERABLE QUESTIONS
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
IMPLEMENTATION WHERE APPROPRIATE
AUDIT
Take Home MessageWhere most research belongs
Only approximately 10% of articles in the most prestigious internal medicine journals can be regarded as “valid” and ready for application
Critical Appraisal
• Important for practitioners to be able to sort the good research from the bad quickly
• A number of checklists available; different ones for different research designs
• See Evidence Based Nursing Users’ Guides
• CASP website http://www.phru.org.uk/~casp/appraisa.htm
Features of Clinically Useful Information
•Trustworthy (pre-appraised)•Concise•Easy to understand•Easy to access•Clear implications for
practice
Sources of Pre-Appraised Research
• Clinical Evidence • Evidence Based journals
– Evidence Based Nursing, Medicine, Mental Health etc
• Systematic reviews– Cochrane Library (via NeLH)
•Cochrane Database of Systematic Reviews
•DARE - Database of Abstracts of Reviews of Effectiveness
Evidence Based journals
• Aim to select, from international literature, best quality research and reviews relevant to medicine, nursing etc
• Summarises each article in “value-added” abstracts
• Commentary from clinical expert
Sources of Clinically Useful Information
• SYSTEMS – decision support – brings research directly into clinical decision making
• SYNOPSES – eg. Clinical Evidence, evidence based journals, DARE database, précis and appraisal element
• SYNTHESES – systematic reviews of all relevant primary research (Cochrane Library) (primary research pre-appraised_
• STUDIES – MEDLINE, Cinahl, etc.
Haynes’s Typology of Research Information (4S)
syntheses
synopses
Systems
Synopses
Syntheses (reviews)
Studies
Search For A Relevant Synopsis Of (or Including) A Valid, Up to Date Systematic Review (eg, Evidence Based journals, Clinical Evidence)
Search The Cochrane Library For A Valid, Up to Date Systematic Review
Search for a Synopsis of Primary Research eg, RCTs (Evidence Based journals, Clinical Evidence)
Search MEDLINE, CINAHL, Cochrane Library (Cochrane Controlled Trials Register) for primary research
No?
No?
Whatever you find, remember to appraise for validity! Use of Checklist!
No?
Focusing Answerable Questions
Population Intervention or Exposure
Alternative Intervention or Exposure
Outcomes
Women over 40
Mammo-graphy screening
No Mammo-graphy
Mortality
Focusing Answerable Questions
Population Intervention or Exposure
Alternative Intervention or Exposure
Outcomes
People aged over 70 years
Fall prevention strategies eg. exercise
No fall prevention or alternative
Fracture rates
Focusing Answerable Questions
Population Intervention or Exposure
Alternative Intervention or Exposure
Outcomes
People with CHD
Exercise on prescrip-tion
No exercise on script
Coronary events
REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY
PHRASE ANSWERABLE QUESTIONS
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
IMPLEMENTATION WHERE APPROPRIATE
AUDIT
Where do you start?
• Work with nurse colleagues to identify common clinical uncertainties
• Frame these as answerable, searchable questions
• Search for answers following the synopsis, synthesis, study approach
Back to Lumbar Puncture
Question would be?
Question would be
In patients having cervical or lumbar puncture, is longer bed rest more effective than immediate mobilisation or short bed rest in preventing headache?
Search For A Synopsis Of A Valid, Up to Date Systematic Review (eg, Evidence Based journals, Clinical Evidence)
Search The Cochrane Library For A Valid, Up to Date Systematic Review
Search for a Synopsis of Primary Research eg, RCTs (Evidence Based journals, Clinical Evidence)
Search MEDLINE, CINAHL, Cochrane Library (Cochrane Controlled Trials Register) for primary research
No?
No?
Whatever you find, remember to appraise for validity! Use of Checklist!
No?
“However, there is really no good evidence that routine bed rest after dural puncture is beneficial, whatever the reason for the procedure, and the available data suggest that it may even increase the risk of postural headache…
…Hence, while there is clearly a role for bed rest for the relief of the symptoms of established post-dural puncture headache, the results of this review indicate that routine bed rest should be abandoned, and that patients should be encouraged to mobilise freely after dural puncture as soon as they are able.”
Sudlow and Warlow, Cochrane Review first published 2002.
Are You Convinced By This Evidence?
Please write on the orange paper what duration of bedrest you
would now advocate after lumbar puncture
Email survey of teaching staff in our department
“Royal Marsden Manual (2000) suggests 4 hours if there is no headache. If there is then they should continue to lie flat and be observed for signs of alteration in intracranial pressure. In this case they can presumably sit up in the absence of any signs and once headchae reolved”
“I think its around four to six hours but varies between hospitals up to 12 hours”.
“They should lie flat in a comfortable position for up to 90 minutes after the test, this will depend upon how traumatic the tap was, age, BP etc'. The aim is to allow the CSF circualtion to re-establish itself and prevent a low pressure headache.”