An Introduction to Evidence Based Practice

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An Introduction to Evidence Based Practice

• N111 T.Shea, RN

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Evidence Based Practice

• Learning Objectives
• 1. Define evidence based practice
• 2. Describe why we use evidence based practice
• 3. Identify the four elements of a well-
  formulated clinical question

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Crossing the Quality Chasm

• IOMs 6 aims to improve the health care system
• Health care must be
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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How Can Nursing Meet Those Aims?

• By
• Increasing the body of nursing knowledge by
  conducting research
• Utilizing that research in a clinically relevant
  manner through evidence based practice

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What Is Knowledge?

• Knowledge is essential information acquired in a
  variety of ways, expected to be an accurate
  reflection of reality, and incorporated and used
  to direct a persons actions
• (Burns Grove, 2007, p.13)

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How Knowledge is Acquired in Nursing

• Traditional Methods

• New Methods

• Tradition
• Authority
• Borrowing
• Trial and Error
• Personal Experience
• Intuition
• Reasoning

• Nursing research
• A diligent and systematic inquiry to validate
  and refine existing knowledge ,and generate new
  knowledge that influences nursing
  practice,(Burns Grove, 2007, p.20).
• The application of scientific process to result
  in evidence based nursing practice

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Evidence Based Practice

• What is
• Evidence-Based practice (EBP)?
• It is the integration of best research evidence
  with the clinical problem, clinical expertise,
  and patient values

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Why do we care about EBP?
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Why Use EBP?

• Optimal patient outcomes
• Information accessibility for clinicians
• Evidence-based resources allow clinicians to make
  research-based decisions in a time-efficient,
  patient-focused manner
• No unaided human being can read, recall, and act
  effectively on the volume of clinically relevant
  scientific literature. (Institute of Medicine,
  2001, p.25)
• Image retrieved October 5, 2009 from
  www.enagri.info/images/clipart/6.jpg

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Nursing Role in Evidence Based Practice

• Individual RNs

• Must know and accept responsibility for
• Asking questions
• Reading literature
• Understanding
• Critical thinking
• Synthesizing info
• Applying science
• Image retrieved September 21, 2009 from
  atchealthcare.com/government.html

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Evidence Pyramid
EBP journals Cochrane DB Systemic reviews
Clinical Practice Guidelines
primary research articles CINAHL, Medline
Assoc. websites, textbooks Google
Adapted from http//www.pubmedcentral.nih.gov/arti
clerender.fcgi?toolpubmedpubmedid12113514
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Primary Evidence

• Primary evidence includes the original reports
  of research studies and are included in journal
  citation databases
• MEDLINE
• CINAHL

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Secondary Evidence

• Secondary evidence
• is the analysis
• of research studies
• Includes practice guidelines and systematic
  literature reviews
• Systematic reviews are known as the highest level
  of evidence in clinical research
• Examples
• Cochrane Database of Systematic Reviews (CDSR)
• Database of Abstracts of Reviews of Effects
  (DARE)
• National Guidelines Clearinghouse

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The National Guidelines Clearinghouse

• Includes evidence-based practice guidelines from
  various health centers and organizations.
• It can be searched by disease, treatment or
  organization.

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Steps to Evidence Based Practice

• An orderly series of steps that allows a
  researcher to find the answer to a question
• Consists of five steps
• Identify problem.
• Gather data.
• Analyze data.
• Use the findings.
• Evaluate outcomes.

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Steps to Evidence Based Practice

• 1. Identify the problem/question
• What do you want to do . . .
• Improve practice?
• Update knowledge?
• Validate a policy or procedure?
• Plan a new program/therapy/goal?

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Steps to Evidence Based Practice

• PICO the Anatomy of the Clinical Question
• Patient characteristics (Who)Intervention being
  considered (What)Comparison intervention (What
  else)Outcome of clinical interest (How)

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Steps to Evidence Based Practice

• Four elements of a clinical question
• Who is the focus of the question?
• What is the intervention being done to the
  patient/population?
• How does the intervention affect the
  patient/populations?
• What could be done instead?

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Steps to Evidence Based Practice

• An example question
• In a 55-year-old man with a 35-year-old history
  of chronic smoking, would the administration of
  bupropion as compared to a nicotine replacement
  therapy (NRT) be a better therapy in causing
  long-term abstinence from smoking?
• Can you identify each PICO component?

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Steps to Evidence Based Practice

• 2. Gather evidence
• Run your subject search
• Medline, CINAHL
• Locate other sources of information
• Consideration of hospital policy procedures
• Clinical expertise
• Cost effectiveness
• Chart reviews
• Patient preferences

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Steps to Evidence Based Practice

• 3. Examine the evidence and critically evaluate
  the literature
• Which research applies best ?
• How strong or weak is the research?
• Is this research relevant to the clinical
  scenario?
• Image retrieved September 21, 2009 from
  www.thoughtcrimez.com/.../gallery_photos.html

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Steps to answering Clinical Questions using the
Medical Literature

• 4. Apply the evidence clinical experience the
  patient's preferences
• 5. Evaluate patient outcomes

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What is Evidence Based Practice (EBP)

• A step-by-step, dynamic process used to solve
  clinical problems
• EBP solves problems by applying
• Best research data
• Best clinical judgment and expertise
• Clinical history and physical assessment
• Patient preferences and values

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Review with an example Systematic
Meta-analysis for Betadine vs. Chlorhexidine
gluconate(Miller, Rajender, Umscheid,
Williams, 2008).
Result The use of chlorhexidine for skin
antisepsis, instead of povidone-iodine, would
result in significant reductions in
hospital-acquired infections

• Data 9 randomized controlled clinical trial
  studies used for meta-analysis
• PARTICIPANTS Adults receiving topical antisepsis
  prior to surgery, blood cultures, and vascular
  catheter insertion
• INTERVENTIONS Chlorhexidine gluconate
• COMPARISONS Povidone-iodine
• OUTCOMES Positive surface cultures after skin
  preparation, surgical site infections, catheter
  site colonization, catheter-related sepsis

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Research Tutorials

• CINAHL
• EBSCOhost
• http//support.epnet.com/training/tutorials.php
• CINAHL.com
• Online training
• http//www.cinahl.com/library/library.htm

• Medline
• EBSCOhost
• PubMed
• Online training
• http//www.nlm.nih.gov/bsd/disted/pubmed.html

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References

• Burns Grove (2007) Understanding nursing
  research Building an evidence based practice.
  St.Louis, MO Saunders.
• Institute of Medicine (2001) Crossing the quality
  chasm A new healthcare for the 21st century.
  Washington, DC National Academies Press.
• Miller, J., Rajender, A., R., Umscheid, C.A.
  Williams, K. (2008). Chlorhexidine versus
  povidone-iodine in skin antisepsis A systematic
  review and cost analysis to inform initiatives to
  reduce hospital acquired infections. Retrieved
  October 5, 2009 from www.uphs.upenn.edu/.../2008.0
  4.0320SHEA20chlorhexedine20vs20betadine20post
  er.pdf
• Sackett D.L., Rosenberg W.M.C., Gray J.A.M.,
  Haynes R.B., Richardson W.S. (1996). Evidence
  based medicine What it is and what it isnt .
  British Medical Journal. Jan 13 312 (7023).
  71-2.