LuAnn Tandy UNPACKING THE PIECES FOR EVIDENCE BASED PRACTICE LuAnn Tandy, RN, PhD Student

LuAnn Tandy Today’s Goal EBP

LuAnn Tandy We went to school to be…..

LuAnn Tandy But its more like….

LuAnn Tandy 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

LuAnn Tandy 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”

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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)

LuAnn Tandy Ways to Use EBP Improve outcomes Increase efficiency Improve patient satisfaction Improve nurse satisfaction Improve physician satisfaction Lower costs

LuAnn Tandy 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)

LuAnn Tandy Interdisciplinary EBP …… different points of view Patient Physician Therapist Nurse Administrators Dietician Case Manager

LuAnn Tandy Why EBP? THE QUALITY OF CARE LAGS BEHIND KNOWLEDGE AND EBP IS SEEN AS THE SOLUTION

LuAnn Tandy 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

LuAnn Tandy 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.

LuAnn Tandy 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.

LuAnn Tandy 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

LuAnn Tandy 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,

LuAnn Tandy UNC-Chapel Hill EBP Process

LuAnn Tandy Evidence Based Process ASK Define the question AQUIRE Find the evidence APPRAISE Evaluate the evidence APPLY Apply the evidence ASSESS Assess the outcome

LuAnn Tandy Evidence Based Process ASK* AQUIRE APPRAISE APPLY ASSESS

LuAnn Tandy 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?

LuAnn Tandy 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

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

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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

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

LuAnn Tandy 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

LuAnn Tandy 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?

LuAnn Tandy 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?

LuAnn Tandy 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?

LuAnn Tandy PICO Think of your EBP question and write it down

LuAnn Tandy Evidence Based Process according to UNC-Chapel Hill ASK AQUIRE* APPRAISE APPLY ASSESS

LuAnn Tandy 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.

LuAnn Tandy 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.

LuAnn Tandy 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

LuAnn Tandy Meta-analysis A systematic review that uses quantitative methods to summarize the results of multiple studies. It produces a summary statistic

LuAnn Tandy Where to find Systematic Reviews Cochrane Database Worldviews on Evidence-Based Nursing by Sigma Theta Tau Peer reviewed journals

LuAnn Tandy 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

LuAnn Tandy 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.

LuAnn Tandy 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.

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

LuAnn Tandy 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

LuAnn Tandy Issues with Evidence Too much Too little Same author publishes all the studies Only vendor research

LuAnn Tandy Interpreting the Results: Statistics Sample size Reliability Validity Significance Clinical significance

LuAnn Tandy 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%

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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.

LuAnn Tandy 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.

LuAnn Tandy Evidence Based Process according to UNC-Chapel Hill ASK AQUIRE APPRAISE APPLY* ASSESS

LuAnn Tandy 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.

LuAnn Tandy APPLICATION….

LuAnn Tandy 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

LuAnn Tandy Evidence Based Process according to UNC-Chapel Hill ASK AQUIRE APPRAISE APPLY ASSESS*

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

LuAnn Tandy Evidence Based Process in Summary ASK AQUIRE APPRAISE APPLY ASSESS

LuAnn Tandy Examples of Real Staff Nurse Projects….

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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

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

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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

LuAnn Tandy 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?