LuAnn Tandy 2009 1

UNPACKING THE PIECES FOR EVIDENCE BASED PRACTICEUNPACKING THE PIECES FOR EVIDENCE BASED PRACTICELuAnn Tandy, RN, PhD StudentLuAnn Tandy, RN, PhD Student

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Today’s Goal

EBP EBP

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We went to school to be…..

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But its more like….

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7 Days Worth of Stuff

It used to be that patients stayed in the hospital about 7 days.

So….we taught nurses how to do 7 days worth of stuff.

Now patients stay 2-3 days We continue to hold nurses to providing the

same standard of care we gave patients when their stays were 7 days.

Dr. Tim Porter-O’Grady 2007

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Evidence-based Medicine

The Institute of Medicine defines evidence-based practice (EBP) as “the integration of best research, clinical expertise, and patient values in making decisions about the care of individualized patients”

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Evidence-based Nursing Practice

Sigma Theta Tau definition:

“Integration of the best evidence available, nursing expertise, and the values and preferences of individuals, families and communities who are served”

Sigma Theta Tau International Evidence-Based Nursing Position Statement, 2005

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What is EBNP?

EBP is a problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences and a clinician’s expertise in making decisions about patient care.

Melnyk & Fineout-Overholt, 2005

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You might be practicing EBP if you…

question your practice go to the literature to determine best

practice rather than a peer Embrace change and let go of old

practices Quit saying “because that’s the way I

was taught” (30 years ago)

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Ways to Use EBP

Improve outcomes Increase efficiency Improve patient satisfaction Improve nurse satisfaction Improve physician satisfaction Lower costs

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List the Following…

Everything you have added to your practice in the last 5 years (i.e.. VAP protocol, two patient identifiers)

List things you have given up in the last five years (i.e.. Changing IV sites every other day)

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Interdisciplinary EBP ……different points of view

Patient

Physician

Therapist

Nurse

Administrators

Dietician

CaseManager

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Why EBP?

THE QUALITY OF CARE LAGS BEHIND KNOWLEDGE AND

EBP IS SEEN AS THE SOLUTION

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So Why are We Behind?

Knowledge Explosion

• Every 9 years the number of journals increases by……

Time it takes to move research into practice?..........

Research is not always able to be translated into practice

EBP is a way to bundle that knowledge and put it into usable interventions

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History of EBP

Evidence Based Practice was used by Florence Nightingale years ago.• Observation informed her on what worked and

what didn’t

1990’s EBP became a viable framework for positive clinical outcomes

Driven by cost-containment efforts that were initiated by health administrators and payers.

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History of EBP

Educated health care consumers expect their health care providers to be on the cutting edge and they demand high quality care and outcomes.

With the coming of the web health care consumers do their research and they may know the best treatment before the physician or the nurse.

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EBP: We’ve Come A Long Way Baby

In 1977 the standard of care for a patient post-op open heart surgery was to give pain medications as needed.

In 2008 our standard of care is to schedule pain medication with dosages based on the patient’s pain rating.

In 1977 family visits were restricted to 5 minutes every hour and only 2 people at a time.

In 2008 family members have unrestricted visiting privileges

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EBP: Then and Now

In 1977 only patients with diabetes had their blood glucose levels monitored and controlled

In 2008 all open-heart surgery patients glucose levels are maintained between 80 and 110 mg/dL.

Sendelbach, S.E. (2008) Evidence Based Practice:Then and Now, AJN, 108:10, 75-76.

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UNC-Chapel Hill EBP Process

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Evidence Based Process

ASK

• Define the question AQUIRE

• Find the evidence APPRAISE

• Evaluate the evidence APPLY

• Apply the evidence ASSESS

• Assess the outcome

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Evidence Based Process

ASK* AQUIRE APPRAISE APPLY ASSESS

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ASK :Questions arise out of our daily practice and daily life. These are a few real life examples….

Janey’s story• Sister in the hospital was febrile and

shivering

• Blankets or no blankets?

Jennifer’s story• Noticed several standards of practice in the

ICU regarding tube feedings

• When should tube feedings be held?

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ASK

Mary Ann’s story• Heard on CNN that you no longer need to

apply alcohol to a newborn’s umbilical cord

• Is this true?

You need to define the question in order to find the evidence• PICO is one strategy

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PICO

P is for patient for population I is for intervention C is for conventional treatment O is for outcome

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Patient or Population

How would you describe a group of patients that are similar to yours?• Primary problem, disease or co-existing

condition

• Sex, age or race

• Socio-economic situation• Country they live in

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Intervention

What main intervention are you considering

What do you want to do to the patient? What are the co-existing issues?

• Age

• Addictions

• Mobility

• Socio-economic concerns

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Comparison

What is the main alternative to compare with the intervention?

Is it better to instill normal saline into the trachea before you suction or not?

You do not always need a comparison

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Outcomes

What are you trying to measure? What are you trying to improve? What are you trying to do for the patient?

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Janey’s Story

Janey’s sister was in the hospital and had a fever and she was shivering. The nurse wanted to take away the blankets and Janey felt bad for her sister and fought to keep them. After that situation she wondered what really was the best thing to do in that situation. What is Janey’s PICO

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Janey’s PICO

P = In post-op patients who are febrile and shivering

I = is taking away the patient’s blankets C = or allowing them to keep the

blankets O = more effective in reducing the fever?

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Mary Ann’s Story

Mary Ann was driving to work one day to her job in the labor and delivery department. On the radio she heard that it was no longer necessary to apply alcohol to the newborn’s umbilical cord, you could just use soap and water.

What is Mary Ann’s PICO?

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Mary Ann’s PICO

P = In newborn’s I = is soap and water C = better than alcohol O = in preventing infection of the

umbilical cord?

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PICO

Think of your EBP question and write it down

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Evidence Based Process according to UNC-Chapel Hill

ASK

AQUIRE* APPRAISE APPLY ASSESS

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ACQUIRE: Selecting the Resources and Conducting the Search

Locating the highest quality and relevant information from the medical literature to answer your question

How do you find the literature? How do you know the literature is of the

highest quality?• By determining the levels of evidence.

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DETERMINING THE LEVELS OF EVIDENCE

Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence based clinical practice guidelines based on systematic reviews of RCTs.

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Systematic Reviews

A summary of evidence on a particular topic that uses a rigorous process for retrieving, critically appraising, and synthesizing studies in order to answer a question about a burning clinical question

Melnyk, 2004

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Meta-analysis

A systematic review that uses quantitative methods to summarize the results of multiple studies.

It produces a summary statistic

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Where to find Systematic Reviews

Cochrane Database Worldviews on Evidence-Based Nursing

by Sigma Theta Tau Peer reviewed journals

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Levels of Evidence

Level II: Evidence obtained from at least one well-designed RCT• Experimental study in which subjects are

randomly assigned to experimental and control groups.

• Randomized trial is an opportunity for anyone that fits the criteria for inclusion to have a chance to be in the study.• Pointing to names in the phone book

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Levels of Evidence

Level III: Evidence obtained from well-designed controlled trials without randomization• Without randomization you can’t assume that

subjects in the study are equal on demographic and clinical variables.

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Levels of Evidence

Level IV: Evidence from well-designed case-control and cohort studies• Case control study compares certain characteristics of an

individual such as a person with diabetes to the characteristics of another individual without the disease.

• This type of study is used to identify variables that might predict the condition.

• A cohort study gathers two groups on individuals, one with exposure to a disease and one without and follow them over time to measure outcomes of the disease.

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Levels of Evidence

Level V: Evidence from systematic review of descriptive and qualitative studies• This is similar to meta-analysis only using

qualitative studies

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Levels of Evidence

Level VI: Evidence from a single descriptive study

Level VII: Evidence from the opinion of authorities and/or reports of expert committees

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Issues with Evidence

Too much Too little Same author publishes all the studies Only vendor research

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Interpreting the Results: Statistics

Sample size Reliability Validity Significance Clinical significance

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Sample Size=n

Number of people in the study The larger the better Determining a good sample size

depends upon the size of the population that is being studied.

Sometimes it’s a small sample size but if the whole population is in the study, then that means you sampled 100%

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Significance = p

A good significance level is between <.01 and .05 in most cases

Significance is the risk of error we are willing to accept and still say our results are correct

.05 means that 95 times out of 100 “IT” works .01 means that 99 times our of 100 “IT”

works

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Reliability

Reliability means that the tool you used to measure results in your research study will measure the same way every time.

You wouldn’t want to use a tape measure that stretches.

You might stretch it more one time than you do the next.

Look for clues that they didn’t measure things the same way every time

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Validity

When research is valid it means that the tool used to measure the results measures what it is supposed to measure.

You don’t want to use a tape measure to weigh a baby. It measures inches not pounds.

Look for clues that they didn’t use the right tool to measure their results.

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Clinical Significance

Sometimes you don’t need a .01 to a .05 significance to be clinically significant.

Sometimes a study isn’t statistically significant, but it made something better

For example: extremely depressed people became less depressed but the depression scale didn’t show that it was statistically significant. They got better, but they didn’t get relieved of their depression to equal normal.

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Evidence Based Process according to UNC-Chapel Hill

ASK AQUIRE APPRAISE

APPLY* ASSESS

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APPLY

Application is the step where you integrate the evidence with your clinical expertise and the unique needs and values of your patient/situation• Once you have gathered your evidence and

you have determined that it is of the highest quality you can find, you must match it to the patient, situation, and organizational environment.

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APPLICATION….

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APPLY

Match the evidence to the patient or population• Patient’s religious beliefs

Match the evidence to the situation• USA versus a third world country

Match the evidence to the organizational culture• Physician culture, economic issues

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Evidence Based Process according to UNC-Chapel Hill

ASK AQUIRE APPRAISE APPLY

ASSESS*

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ASSESS

Determine outcomes Develop short and long term goals Gather feedback Monitor costs/cost savings Determine success Celebrate success Share your success

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Evidence Based Process in Summary

ASK AQUIRE APPRAISE APPLYASSESS

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Examples of Real Staff Nurse Projects….

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Stories: Janey’s Story

Janey wanted to know if it was better to let her sister have all the blankets she wanted or if she should take them away.

Results: vote• Issues with the literature review

• Surveyed current standard of practice

• Implemented into organizations post-op surgery protocol and fever protocol

• No cost

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Jennifer’s Story

Jennifer noticed there was a different standard of care between nurses in regards to when to hold a tube feeding in the ICU.• What is the PICO

• Issue with the literature search

• Survey of unit nurses

• Results

• Organizational climate concerns

• Interdisciplinary focus

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Mary Ann’s Story

Heard on CNN that she no longer needed to use alcohol on newborn umbilical cords and no longer need to teach mom’s to do it at home

Results? Vote• Issues in the literature

• Application of findings

• Expertise

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Sharon’s Story

Sharon noticed that her IV team members were using different amounts of t-PA to clear central line blockages.

What is the PICO? Results: Vote

• Working with peers

• Cost savings

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Donna’s Story

In Donna’s unit a physician wanted to start using rectal tubes and she didn’t know much about them• What is the PICO?

• Issues with the literature

• What being knowledgeable about the research can do for you

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Outcomes

Increased Patient Satisfaction Increased Nurse Satisfaction Improved Care Save nurses time Standardize care Improve nurse confidence Reduce cost Improved Quality Improved efficiency

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Point to Ponder

Traveling naked into the land of uncertainty allows for another kind of learning, a learning that helps us forget what we know and discover what we need. It is this journey that leads to the discovery of what is needed to help us create the future…Robert E. Quinn

P 123 in Quantum Leadership by Porter-O’Grady & Malloch 2003

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Levels of Evidence- Melnyk, 2004

Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence based clinical practice guidelines based on systematic reviews of RCTs.

Level II: Evidence obtained from at least one well-designed RCT Level III: Evidence obtained from well-designed controlled trials

without randomization Level IV: Evidence from well-designed case-control and cohort

studies Level V: Evidence from systematic review of descriptive and

qualitative studies Level VI: Evidence from a single descriptive study Level VII: Evidence from the opinion of authorities and/or reports

of expert committees

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Evidence Based Process-UNC-Chapel Hill

ASK• Define the question

AQUIRE• Find the evidence

APPRAISE• Evaluate the evidence

APPLY• Apply the evidence

ASSESS• Assess the outcome

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PICO- UNC-Chapel Hill P is for patient for population

• describe a patient or group of patients that are similar to yours I is for intervention

• What main intervention are you considering?

• What do you want to do to the patient? C is for conventional treatment

• What is the main alternative to compare with the intervention?

• You do not always need a comparison O is for outcome

• What are you trying to measure?

• What are you trying to improve?

• What are you trying to do for the patient?