Evidence Based Practice and the Development of AORNs Recommended Practices Lisa Spruce, DNP, RN, CNOR, ACNS, ACNP Director, Evidence-Based Perioperative Practice

It starts with research 2

It takes an average of 17 years to move research to practice EBP provides point of care clinicians tools needed to improve care EBP transforms health care based on one clinician, one encounter at a time Why EBP? 3

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EBP 5

By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patient’s predicaments, rights, and preferences in making clinical decisions about their care.³ EBP 6

“Rather than dictating a one-size-fits-all approach to patient care, clinical practice guidelines offer an evaluation of the quality of the relevant scientific literature and an assessment of the likely benefits and harms of a particular treatment¹.” ~Institute of Medicine Why Clinical Practice Guidelines? 7

Formulate the clinical question Where do we start? 8

IM Injections: Aspirate or not? Question: Among adult patients, does aspirating while giving an IM injection cause injury compared to no aspiration?

Search the literature 10

Conducting a Search Databases ~ Cochrane~ Google Scholar ~ AHRQ - NGC~ Joanna Briggs ~ Pubmed~ Virginia Henderson ~ CINAHL® International Nursing ~ ANA - Medline Library ~ AORN Journal~ Embase ~ Medical Library

Types of evidence 12

Appraise the evidence AORN’s tools Research Non-Research

Evidence appraisal 14 The strength of the research evidence is indicated by I, II, or III for research and IV or V for non-research The quality of the research evidence is indicated by A, B, or C

Appraisal Score

Quality is subjective 16

Quality is the challenge 17 Was there a clear explanation of the purpose of the study and, if so, what was it? Were there enough people in the study to establish that the findings did not occur by chance? How were variables defined? Were the instruments designed to measure a concept valid (did they measure what the researchers said they measured)? Were they reliable (did they measure a concept the same way every time they were used)?

What statistics were used to determine if the purpose of the study was achieved? Did people leave the study and, if so, was there something special about them? Did the researchers base their work on a thorough literature review? Is the study purpose an important clinical issue?² Quality 18

AORN Evidence Rating Model Appraisal Score Evidence RatingEvidence Requirements ResearchNon-Research IA IVA Regulatory 1: Strong Evidence 1: Regulatory requirement Interventions or activities for which effectiveness has been demonstrated by strong evidence from rigorously-designed studies, meta-analyses, or systematic reviews, rigorously-developed clinical practice guidelines, or regulatory requirements.  Evidence from a meta-analysis or systematic review of research studies that incorporated evidence appraisal and synthesis of the evidence in the analysis.  Supportive evidence from a single well-conducted randomized controlled trial.  Guidelines that are developed by a panel of experts, that derive from an explicit literature search methodology, and include evidence appraisal and synthesis of the evidence. IB IIA, IIB IIIA, IIIB IVB VA, VB 2: Moderate Evidence Interventions or activities for which the evidence is less well established than for those listed under “1: Strong Evidence.”  Supportive evidence from a well-conducted research study.  Guidelines developed by a panel of experts which are primarily based on the evidence but not supported by evidence appraisal and synthesis of the evidence.  Non-research evidence with consistent results and fairly definitive conclusions. IC IIC IIIC IVC VC 3: Limited Evidence Interventions or activities for which there are currently insufficient evidence or evidence of inadequate quality.  Supportive evidence from a poorly conducted research study.  Evidence from non-experimental studies with high potential for bias.  Guidelines developed largely by consensus or expert opinion.  Non-research evidence with insufficient evidence or inconsistent results.  Conflicting evidence, but where the preponderance of the evidence supports the recommendation. No requirement 4: Benefits Balanced With Harms Selected interventions or activities for which the AORN Recommended Practices Advisory Board (RPAB) is of the opinion that the desirable effects of following this recommendation outweigh the harms. No requirement 5: No Evidence Interventions or activities for which no supportive evidence was found during the literature search completed for the recommendation.  Consensus opinion.

AORN Evidence Rating Model 1:Strong Evidence 1:Regulatory requirement IA IVA Regulatory 1: Strong Evidence 1: Regulatory requirement Interventions or activities for which effectiveness has been demonstrated by strong evidence from rigorously-designed studies, meta-analyses, or systematic reviews, rigorously-developed clinical practice guidelines, or regulatory requirements.  Evidence from a meta-analysis or systematic review of research studies that incorporated evidence appraisal and synthesis of the evidence in the analysis.  Supportive evidence from a single well-conducted randomized controlled trial.  Guidelines that are developed by a panel of experts, that derive from an explicit literature search methodology, and include evidence appraisal and synthesis of the evidence.

AORN Evidence Rating Model 2:Moderate Evidence 3:Limited Evidence IB IIA, IIB IIIA, IIIB IVB VA, VB 2: Moderate Evidence Interventions or activities for which the evidence is less well established than for those listed under “1: Strong Evidence.”  Supportive evidence from a well-conducted research study.  Guidelines developed by a panel of experts which are primarily based on the evidence but not supported by evidence appraisal and synthesis of the evidence.  Non-research evidence with consistent results and fairly definitive conclusions. IC IIC IIIC IVC VC 3: Limited Evidence Interventions or activities for which there are currently insufficient evidence or evidence of inadequate quality.  Supportive evidence from a poorly conducted research study.  Evidence from non-experimental studies with high potential for bias.  Guidelines developed largely by consensus or expert opinion.  Non-research evidence with insufficient evidence or inconsistent results.  Conflicting evidence, but where the preponderance of the evidence supports the recommendation.

AORN Evidence Rating Model 4:Benefits Balanced with Harms 5:No Evidence No requirement 4: Benefits Balanced With Harms Selected interventions or activities for which the AORN Recommended Practices Advisory Board (RPAB) is of the opinion that the desirable effects of following this recommendation outweigh the harms. No requirement 5: No Evidence Interventions or activities for which no supportive evidence was found during the literature search completed for the recommendation.  Consensus opinion.

Evidence synthesis 23

Evidence Rating [3: Limited Evidence]

Public comment 25

AORN Evidence Rated RP

National Guideline Clearinghouse 29 National Guideline Clearinghouse™ The National Guideline Clearinghouse™ (NGC), an AHRQ initiative, is a publicly available database of evidence- based clinical practice guidelines and related documents. Updated weekly with new content, the NGC provides physicians and other health professionals, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.

Meeting NGC Criteria Documentation will need to be provided showing that the guideline is based upon a systematic review of the evidence. Documentation must contain an assessment of the benefits and harms of the recommended care and alternative care options.

Compassion 31

Questions 32

References Institute of Medicine. National Academy of Sciences, (2011). Clinical practice guidelines we can trust. Retrieved from IOM website: APAGovernmentReport&srcCode=9&more=yes&nameCnt=1 2.Fineout-Overholt, E., Melnyk, B., Stillwell, S., & Williamson, K. (2010). Evidence-based practice, step by step: Critical appraisal of the evidence part i. American Journal of Nursing, 110(7), Drisko, J. (2012, 0924). Social work resources: Evidence-based practice. Retrieved from