Utilizing Evidence Based Practice in the Acute Care Clinical Setting

Brenda P. Johnson, PhD, RNDepartment of Nursing

Southeast Missouri State University

Objectives

• Identify key purposes and elements of evidence-based practice

• Discuss ways of asking questions in a relevant format

• Explore strengths of several databases for relevant evidence

• Identify strategies for utilizing EBP in everyday nursing practice

Why EBP and why EBP NOW???

• The Evidence-based Practice (EBP) approach in health care is a response to the need to improve care!

Only 1 in 2 patients receive the healthcare they should receive according to THE EVIDENCE!

The 100,000 lives campaign!!!IOM reports on quality

Utilizing current “best evidence” (vs. tradition) in delivering careEnsuring safe care and improving the quality of care across settings and geographic areasIOM reports on quality (To Err is Human, 2000; Crossing the Quality Chasm, 2001)Providing clinicians with an efficacious and efficient way to incorporate research and expertise into their everyday practice

EBP Models

• Iowa Model of Evidence-Based Practice to Improve Quality Care (Titler, Kleiber, Steelman, Rakel, et al., 2001) and current EBP projects in the Iowa system

• The Star Model of Knowledge Transformation© (ACE-Star Model) and current EBP projects at the University of Texas Health Sciences Center

Why is “best evidence” important?

• Exemplars of need for change• Prone vs. supine position for sleeping infant

(AAP, 2000)• Risks of long-term use of combined

estrogen/progestin hormone (Women’s Health Study Initiative, )

• Use of side rails, restraints, and bed alarms in preventing falls in elderly ( )

Systematic Reviews & Clinical Practice Guidelines

• The core elements of EBP are Systematic Reviews and Clinical Practice Guidelines. Centers of Research that subscribe to an evidence-based practice approach do systematic reviews of primary research that rate the strength of evidence according to a stringent set of criteria. A valid systematic review usually takes a staff of 12 to 15 over a year at a cost of nearly $250,000! (Stevens, 2006).

•

• Clinical Practice Guidelines from an EBP perspective are the clinical recommendations developed from systematic reviews. The purpose of these recommendations are to assist practitioners in delivering the most appropriate up-to-date, and sound interventions in specific clinical situations.

Getting Started…….

• PICO format• P Patient population• I Intervention• C Comparison

intervention• O Outcome

Ask the “burning” questions (generally deemed that due to the quantity or the severity of the problem) in a format that will yield the most relevant and the highest quality evidence

Framing the Question• A clinical issue is best defined by

the patient characteristics or population, nursing intervention or action, and the desired outcome. It may be helpful to use the following question as a template:

• What is the effect of ________________ (intervention/action) on _____________ (patient outcome/issue) for ______________ (patient characteristics/population)?

• Issue: Side rails and fall prevention

• PICO format:• Does the use of side

rails lower the risk of falls and the risk of serious injury from falls for the elderly delirious hospitalized patient?

Searching for Best Evidence

• Hierarchy of Evidence• “Gold standard” in EBP is the systematic

review • Range from Level 1: Meta-analysis of all

randomized controlled trials to Level VI or Level VII (depending upon system of categorization used) which is expert opinion of a group of authorities of expert committee

Levels of Evidence

• Level I: Systematic review or evidence-based clinical practice guideline based on systematic review of RCTs

• Level II: At least one well-designed RCT• Level III: Well-designed RCT without randomization• Level IV: Well-designed case-control or cohort studies• Level V: Systematic reviews of descriptive or Qualitative

studies• Level VI: Single descriptive or qualitative study• Level VII: Opinion of authorities and/or reports of expert

committees Melnyk & Fineout-Overholt (2005)

Searching for Best Evidence

• Should begin with search for systematic reviews or clinical practice guidelines

• Centers of EBP for systematic reviews– Cochrane Collaboration: established in 1992 in

U.K. and focuses on medical interventions– Joanna Briggs Institute; International and focuses

on interdisciplinary (including nursing) outcomes

Clinical Practice Guidelines

• Commonly referred to as “Best Practices” and are specific practice recommendations that are based on a rigorous review of the best evidence on a specific topic

• The National Guideline Clearinghouse (www.guideline.gov) disseminates a wide variety of guidelines.

Organizations

• Hartford Institute for Geriatric Nursing (http://www.consultgerirn.org)

• Nursing Best Practices Guidelines from the Registered Nurses Association of Ontario (RNAO)

• Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

In the final analysis…

• Nursing judgement is needed for determining relevance of the EBP findings to YOUR specific patient question and care setting

• Determining the best ways by which to integrate the evidence with YOUR specific patient or setting

• It is not done until you have evaluated the effectiveness of the EBP-based intervention!!!

????? Questions ?????

Identify two current patient issues in a PICO format and identify two databases you would search for evidence…..