Evidence Based Practice

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Evidence Based Practice

• Stephanie Burgess, PhD, APRN, BC
• 6th Annual SC Magnet Conference
• April 2008

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EBP

• WHAT
• WHY
• HOW

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What is EBP?

• An approach to clinical practice based on
• Asking questions
• Seeking evidence to answer questions
• Basing clinical decisions on the best evidence
  available
• Evaluating the outcomes of care

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Common myths of EBP

• If I have done one citation, then I have done EBP
• The search for evidence needs to be extensive
• Evidence must be critiqued and evaluated
• Just because They say it is so, it is soNOT

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What are some NOT acceptable sources for EBP?

• Readers digest
• I am Wandas Gallbladder
• WWW.babesareus.com
• The Psychic Network
• www.Ketamineotherpsychoactivedrugs.org
• Consumer magazines
• Running
• NASCAR
• National Inquirer

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EBP.WHAT IS IT???

• Research
• Kinds of research
• Qualititative
• Quantitative
• Reviews of Literature/research
• Clinical practice guidelines based on reviews of
  research
• Respectable Journals
• Peer reviewed

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EBP

• Can have some Opinion Based
• Clinical practice guidelines based on expert
  opinions from the research/evidence
• Who are experts
• In the healthcare system Licensed health care
  professionals
• RNs, Pharmacists, Md, SW, etc

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What is the Best Evidence?

• In general, look for quantity and quality of
  evidence
• In the situation, look for quality and quantity
  plus applicability and acceptability
• Dr. Herman went over critiquing evidence

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What is the Best Evidence?

• In general. Evidence should be Valid, reliable,
  replicated, clinically relevant research findings
  that are generalizable to the general population,
  setting, and clinical situation
• If not available
• Look for expert opinions

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What is our focus in the hospital setting?

• Ask important clinical questions
• Risk, quality assurance, cost, patient care
  healthcare problem
• Finding the relevant evidence
• Evaluation evidence for quality and applicability
• Synthesize evidence to make practice
  recommendations

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Where to start?

• The first question is
• What is the question???

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After you develop your question..

• Go to the evidence to solve your mystery.
• Try to find out what others do to solve the
  question at hand

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Use the PICO method

• P
• Population
• I
• Intervention
• C
• Compare groups
• O
• Outcome

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?

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The Question

• Make sure it is relevant
• Make sure it is well focused
• Make sure it is empirical. This means we can
  measure it with data

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How do we solve the question?

• PICO Format
• Problem of interest, Population
• Intervention
• Comparison
• Outcome of Interest

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Types of PICO Questions

• Examples of types of PICO questions.
• Risk Management
• Quality Assurance
• Cost
• Healthcare issue
• Therapy/Intervention
• Etiology
• Diagnoses
• Prevention
• Meaning

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PICO Format

• Population
• Patients
• Population of interest
• Intervention
• Treatment
• Exposure (fluids, MRSA)
• Prognosis
• Diagnostic
• Comparison
• Outcome

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PICO Risk Management

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Risk management issue
• How many Surgery patients did not have drug
  allergies documented on their pre-op chart?
• How many surgical patients received AB that they
  were allergic to because drug allergies were not
  properly documented.
• How many suffered an adverse outcome because of
  poor documentation of drug allergies? What were
  the adverse outcomes?

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PICO RISK

• What is the cost of adverse outcomes related to
  other treatments, length of stay, specialty care
  as it relates to medication administration of med
  allergies?
• PIC Among pre-operative patients, what was the
  effect of administering a med in holding area
  that the patient was allergic to (because of poor
  documentation) on their length of hospital stay
  as opposed to patients who had correct and
  complete med allergies documentation.

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PICO Risk

• Among members of a POPULATION, what is the risk
  on the OUTCOME compared with the COMPARISON
  GROUP?
• Among adult patients who have fallen off the
  stretcher in the hospital, is there a greater
  risk of falling off stretchers in the orthopedic
  units than those who have who fallen off
  stretchers in other units in the hospital.

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PICO QI

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• QI improvement areas
• Among day surgical patients, what is the effect
  of AB administration in the holding area on
  reducing post infection as opposed to surgical
  patients who first received the AB in the RR
  PACU?

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PICO COST

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Financial Cost improvement/efficacy
• Among surgery patients, what is the effect of
  pre-op patient teaching on reducing
  post-operative stays (as measured by 15 minutes
  increments) in the PACU as compared to patients
  who received no pre-op patient teaching? If so,
  what is the cost savings for each 15 minute
  increments?
• 15 minutes 375.00
• Patients average stay reduced by 10.9 minutes
  (250) for 31 patients per week 7750 per week
  or 387,500 per year for 50 weeks.

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PICO Cost

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Among day surgical patients, what is the effect
  of AB administration in the holding area on
  length of stay (15 minute increments) as opposed
  to surgical patients who first received the AB in
  the RR PACU?
• 15 minutes 375.00
• Patients average stay reduced by 5 minutes (125)
  for 50 patients per week 6250 per week or
  312,500 per year for 50 weeks.

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PICO Cost

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Among ER and Trauma units, does the use of
  electronic charting save money in paper and
  reduce patient stays (measured in 15 minute
  increments) as compared to the use of standard
  paper records.

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PICO Healthcare outcome

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Patient Clinical Care Problem
• What can we do to prevent an exacerbation of HTN
  II in patients with a history of HTN II who are
  in the II Surg Unit?

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PICO Therapy/Intervention

• Among patients with a history of HTN 2 admitted
  to ICU, what is the effect of administering daily
  Inderal on maintenance BP as opposed to patients
  with a history of HTN 2 who do not receive daily
  Inderal.

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PICO Therapy/Intervention

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Why do so many patients on Vents acquire MRSA and
  what can we do about it?
• Among adults admitted to ICU on a VENT, what is
  the effect of daily Vancomycin on reducing MRSA
  as opposed to those on the VENT without daily
  Vancomycin.

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PICO Therapy/Intervention

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Among patients admitted with CVA, what is the
  effect of administering daily NOSORE on reducing
  bed sores as opposed to patients who do not
  receive daily NOSORE.

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PICO Therapy/Intervention

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• Among adults with a history of HTN II who are
  admitted to Peri-operative area, what is the
  effect of a pre-hospital education program to
  reduce/prevent HTN II as compared to adults with
  a history of HTN II who dont receive
  pre-hospital education.

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PICO Therapy/Intervention

• Among members of a POPULATION, what is the effect
  of an INTERVENTION on the OUTCOME compared with
  the COMPARISON GROUP?
• In kids who are scheduled for elective surgery,
  what is the effect of receiving a pre-hospital
  tour on the Post-operative stay in minutes as
  compared to kids who have not received any
  pre-hospital education?

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PICO Diagnosis

• Among members of the POPULATION, is the
  INTERVENTION more accurate in diagnosing the
  OUTCOME and the COMPARISON?
• Among Trauma ICU adult patients, is the Glasgow
  Coma Scale more accurate in diagnosing levels of
  coma than the Burgess Coma Scale?

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PICO Meaning

• How do members of a POPULATION perceive/describe
  the OUTCOME?
• How do Women with Breast CA perceive going to the
  Oncology area for their first chemo treatment?

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PICO Meaning

• How do Adults with DM and foot gangrene perceive
  going to their diabetic nurse for support?

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Inadequate PICO

• Does education reduce barriers to analgesic usage
  help patients?
• P Population too broad (kids, adults,
  addictions, chronic pain, etc)
• I Education to reduce barriers to analgesic
  usage What kind of education program (patients,
  nurse, docs)?
• C No comparison is stated
• O No outcome is statedhelp patients do what?
• How to best state this In adults with chronic
  pain, does CE/higher level of education improve
  the nurses assessment and intervention to the
  patients request for pain meds as opposed to
  nurses who have no CE or have lower levels of
  education in pain management?

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Some excellent Resources for Literature
Reviews/Clinical Guidelines

• The Agency for Healthcare Research and Quality
  (AHRQ) research web-site http//www.ahrq.gov/.
• provides evidence-based information on health
  care outcomes quality and cost, use, and
  access.
• Information from AHRQs research helps people
  make more informed decisions and improve the
  quality of health care services.
• AHRQ was formerly known as the Agency for Health
  Care Policy and Research.

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Some excellent Resources for Literature
Reviews/Clinical Guidelines

• The Department of Health and Human Services
  National Guideline Clearing house has over 900
  clinical practice guidelines. Website
  www.guideline.gov or call 1-800-358-9265.
• Alberta Clinical Practice Guidelines Health
  conditions for screening, prevention, diagnosis,
  and management care. www.amda.ab.ca/cpg
• Bandolier Evidenced-based medicine guidelines.
  www.jr2ox.ac.uk/bandolier/bandlink.html
• Medscape Multi-specialty Practice Guidelines
  (free registration). Clinical practice
  guidelines for multispecialty practice.
  www.medscape.com
• Primary care clinical practice guidelines
  http//medicine.ucsf.edu/resources/guidelines/guid
  e.html

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Some excellent Resources for Literature
Reviews/Clinical Guidelines

• PubMed (web-site) http//www.ncbi.nlm.nih.gov/entr
  ez/
• was developed by the National Center for
  Biotechnology Information (NCBI) at the
  National Library of Medicine (NLM), located at
  the National Institutes of Health (NIH).
• It was developed in conjunction with publishers
  of biomedical literature as a search tool for
  accessing literature citations and linking to
  full-text journals at Web sites of participating
  publishers.

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Why do EBP?

• Scientific basis for your practice.
• JUST BECAUSE THEY SAY SODOES NOT MEAN IT IS.
• SHOW ME THE RULE BOOK

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What is end product of EBP?

• Develop Nursing Policies and Procedures
• Strengthen Nursing
• Develop Critical Pathways
• Develop Protocols
• Develop Algorithms
• Improved patient care outcomes
• Saves Money
• Reduces Risk

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How do we do EBP?Let us do some PICOs

• Break up in groups
• Develop your PICO question that is meaningful.
• Select someone to record your groups work.
• Where will you go for the answer?

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PICO

• PICO your burning question