1. Everything you always wanted to know about EBN but were afraid to ask… Carl Thompson and Nicky Cullum Centre for Evidence Based Nursing, University of York

2. Aims To introduce you to key principles and processes of evidence based nursing including strategies and resouces to promote evidence based care

3. Clinical Scenario You 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…

4. 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)

5. Where do we go for help with decisions when we are not sure how to proceed?

6. 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

7. 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

8. 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

9. 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

10. Evidence based decision Evidence from research Patient Preferences Available resources Professional expertise

11. REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY PHRASE ANSWERABLE QUESTIONS SEARCH FOR RESEARCH EVIDENCE CRITICAL APPRAISAL OF THE RESEARCH IMPLEMENTATION WHERE APPROPRIATE AUDIT

12. Nursing Uncertainty Diagnosis Selecting interventions –targeting –timing Organising Care Communication (including communication of risks and benefits) The patient experience Prognosis Health Needs Assessment

13. 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?)

14. Population Who are the relevant people?

15. Intervention What are they exposed to?

16. Alternative or control intervention

17. Outcome (what are the person-level consequences we are interested in?)

18. Focusing Answerable Questions PopulationIntervention or Exposure Alternative Intervention or Exposure Outcomes

19. Scenarios Focus these uncertainties into answerable questions

20. 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.

21. Focusing Answerable Questions PopulationIntervention or Exposure Alternative Intervention or Exposure Outcomes

22. 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?

23. Focusing Answerable Questions PopulationIntervention or Exposure Alternative Intervention or Exposure Outcomes

24. 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?

25. Focusing Answerable Questions PopulationIntervention or Exposure Alternative Intervention or Exposure Outcomes

26. REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY PHRASE ANSWERABLE QUESTIONS SEARCH FOR RESEARCH EVIDENCE CRITICAL APPRAISAL OF THE RESEARCH IMPLEMENTATION WHERE APPROPRIATE AUDIT

27. 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)

28. Matching questions to designs Type of QuestionBest Design Intervention incl. prevention RCT ScreeningRCT Diagnostic testIndependent comparison with gold standard HarmRCT; cohort AetiologyProspective cohort Describing phenomena Qualitative

29. 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

30. Randomised controlled trial Eligible patients Experimental intervention Control intervention OUTCOME NO OUTCOME OUTCOME NO OUTCOME Direction of data collection: exposure  outcome

31. 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

32. 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

34. 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

35. REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY PHRASE ANSWERABLE QUESTIONS SEARCH FOR RESEARCH EVIDENCE CRITICAL APPRAISAL OF THE RESEARCH IMPLEMENTATION WHERE APPROPRIATE AUDIT

36. Take Home Message Where most research belongs

37. Only approximately 10% of articles in the most prestigious internal medicine journals can be regarded as “valid” and ready for application

38. 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

39. Features of Clinically Useful Information Trustworthy (pre-appraised) Concise Easy to understand Easy to access Clear implications for practice

40. 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

43. 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

44. 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.

45. Haynes’s Typology of Research Information (4S) syntheses synopses Systems Synopses Syntheses (reviews) Studies

47. Focusing Answerable Questions PopulationIntervention or Exposure Alternative Intervention or Exposure Outcomes Women over 40 Mammo- graphy screening No Mammo- graphy Mortality

51. Focusing Answerable Questions PopulationIntervention or Exposure Alternative Intervention or Exposure Outcomes People aged over 70 years Fall prevention strategies eg. exercise No fall prevention or alternative Fracture rates

54. Focusing Answerable Questions PopulationIntervention or Exposure Alternative Intervention or Exposure Outcomes People with CHD Exercise on prescrip- tion No exercise on script Coronary events

57. REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY PHRASE ANSWERABLE QUESTIONS SEARCH FOR RESEARCH EVIDENCE CRITICAL APPRAISAL OF THE RESEARCH IMPLEMENTATION WHERE APPROPRIATE AUDIT

58. 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

59. Back to Lumbar Puncture

60. Question would be?

61. 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?

68. “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.

69. Are You Convinced By This Evidence? Please write on the orange paper what duration of bedrest you would now advocate after lumbar puncture

70. 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”

71. “I think its around four to six hours but varies between hospitals up to 12 hours”.

72. “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.”