1. Evidence-Based Practice & Outcomes: Transforming Practice at the Point of Care
Christine M. Pacini, PhD, RN
Dean & Professor
College of Health Professions
McAuley School of Nursing
University of Detroit Mercy

2. Objectives
Upon completion of this presentation, the participants will be able to:
Recognize the power of evidence to change practice
Define key “how-to” principles required for utilization of evidence in practice
Identify examples of clinicians using evidence to transform practice in a variety of settings

3. OMG! What WERE we thinking?
Examples of craziness….

4. OMG! So, NOW what do we do? We change! And why do we change?
So that we cease and desist from doing stupid things.
Take up a stance of professional accountability on behalf of patients and in light of exercising intellect in practice.
Exercise social responsibility – for that’s what professions do. We are caretakers of society – licensure is a social mandate. Our patients expect this.
Demonstrate leadership via change/improvement.

5. It’s Obvious!
When asked about the care that they personally want to deliver or receive, clinicians choose EBP over care that is steeped in legacy and tradition.
If you were diagnosed with cancer…?
If your mother was diagnosed with Alzheimer’s disease…?
If you are caring for a child who was in a MVA…?

6. An Overview of Evidence-Based Practice

7. What is EBP?
An early definition of EBP proposed by physician David Sackett (1996)
The conscientious, explicit and judicious use of current best evidence in making decisions about the care of patients.

8. What is EBP? Nursing Definition
A problem-solving approach to clinical practice that integrates:
A systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question
One’s own clinical expertise and patients’ preferences and values
Melnyk & Fineout-Overholt (2005, p. 6)

9. What is EBP? Both definitions emphasize the essentials of EBP:
Using current best evidence for the purpose of providing the highest quality patient care

10. What EBP is NOT Misconceptions and controversies about EBP:
EBP means doing research
EBP is a new “buzzword” for research utilization
EBP is a “cookbook” approach to health care

11. EBP is NOT the same as “doing research”
EBP means using the BEST AVAILABLE evidence (typically research evidence) to solve patient care problems – the emphasis is patient care
Often EBP involves using research findings that have already been generated and published
But if no evidence is available to answer one’s clinical problem, EBP may involve conducting research

12. EBP is NOT a new “buzzword” for Research Utilization
Research utilization means using the results of a research study to address a nursing practice problem
Research utilization involves taking existing research findings and making them part of one’s practice
Research utilization may be less systematic and formal than EBP – RU could involve one nurse using the results of one study

13. EBP is NOT a “cookbook” approach to health care
The definition of EBP includes incorporating patients’ values and preferences AND clinicians’ expertise into clinical decisions
Modifications in care might be made for individual patient’s needs
Clinicians’ judgment is always primary – evidence may not always apply to every patient

14. History of EBP
Dr. Archie Cochrane in the UK is attributed as the founder of the EBP movement in 1972
Dr. Cochrane’s focus was on developing high quality synthesis of clinical trials
The Cochrane Center was established in 1992 in the UK

15. Why the emphasis on EBP? Crossing the Quality Chasm IOM report in 2001
U.S. health care practices were fragmented and based on tradition and previous training rather than scientific evidence
Recommendation – health care professionals need to employ evidence-based practice as a standard of practice

16. The Basics of EBP: What is evidence?
Dictionary definition:
“Something that furnishes proof”

17. What is EVIDENCE in EBP?
Traditionally, evidence in EBP = research studies, specifically:
Scientific evidence from randomized clinical trials or experiments

18. But what if no clinical trials will answer your clinical problem?
Sometimes your problem can’t be answered by a clinical trial
Sometimes there is nor clear answer or available research
If no research is available, EBP means using the best available evidence

19. Evidence in EBP for Nursing Practice
In nursing, best available evidence may include:
Results of qualitative studies
Benchmarking data
Case studies
Clinical reports
Expert opinion
Epidemiologic studies and statistics

20. EBP Models in Nursing EBP Models provide roadmaps for the EBP process
There are several models of EBP that have been used in nursing:
Rosswurm & Larrabee Model
Stetler Model
Iowa Model
AceStar Model
Most have the same fundamental steps

21. Rosswurm & Larrabee (1999)
Focuses on use of change theory, principles of research utilization and standardized nursing nomenclature.
Six steps include:
Assess the need for change in practice
Link the problem with interventions and outcomes (using standard nursing nomenclature)
Synthesize the best evidence
Design a change in practice
Implement and evaluate the practice
Integrate and maintain the practice change

22. Stetler Model (1994)
Applies research findings at the individual practitioner level. Critical thinking and decision making are emphasized.
The model has six phases:
Preparation
Validation
Comparative evaluation
Decision making
Translation and application
Evaluation

23. Iowa Model (1994)
Combines a Quality Assurance model with research utilization
Focuses on change for and entire organization
Includes 10 steps with 3 key decision points:
Is the topic a priority?
Is a research base sufficient?
Is the change appropriate for adoption in practice?

24. Iowa Model – 10 Steps “Trigger” to change practice
Is this a priority for the institution?* [yes/no]
Form a team
Assemble research & other evidence
Critique & synthesize research
Is there sufficient research?* [yes/no]
Develop plan/pilot change OR conduct research
Is change appropriate for adoption?* [yes/no]
Change practice
Monitor results

25. Ace Star Model (2004)
Focuses on the process of transforming new knowledge (research) into practice
Five phases of knowledge transformation are illustrated as 5 points on a star:
Discover (generation of new knowledge)
Summary (synthesis of research knowledge on a topic)
Translation (or research knowledge into practice recommendations)
Implementation (integrating knowledge into practice)
Evaluation (of outcomes from EBP)

26. Six Steps of EBP Most nursing EBP models have common steps:
State the problem
Search the literature
Appraise and synthesize the literature
Identify and plan practice changes
Implement practice changes
Evaluate practice changes
Sounds an awful lot like the nursing process or the research process – don’t you agree?
This is truly not rocket science – it is accountability “science.”

27. 1. State the Problem
Problems = clinical issues that suggest a need to change practice
The issues could be clinical concerns that emerge from daily practice
OR, they could be the need to address new standards of care in current practice
Like why in the world am I painting Maalox ion this wound? Who said that this was OK?

28. State the Problem This is a very important part of EBP
The PICO format helps to state the problem clearly:
Patient population
Intervention
Comparison intervention (optional)
Outcome
This is no different than when I taught research.
Folks struggled mightily with the work of stating the research question.
What IS the focus?

29. PICO Format -- Example
One has heard about promoting “family presence” in the ICU and one wonders how well it works for families.
The PICO format helps one to create a problem statement that can guide an evidence-based practice change.
Here is a problem statement, restated in PICO format:
For families of critically ill patients [P], does family presence during invasive procedures [I] reduce family stress and increase satisfaction [O]?

30. 2. Search the Literature (Research & other evidence)
The goal is to locate all of the high quality evidence for one’s clinical question
The PICO statement guides the literature search and helps one to find the right type of evidence
Reference librarians are your best friends!!

31. Types of Evidence What’s out there? There are many types of evidence:
Data-based evidence
Research studies
Statistical data, etc.
Expert opinion evidence
Experts on a topic write about their experience or opinions

32. Types of Evidence For research evidence, one may find: Primary or
Secondary research literature

33. Primary Research Evidence
Original research articles reported by the investigator
e.g., reports of clinical trials in MEDLINE or research articles in CINAHL
Reader must determine the quality of the study, including its methods and conclusions

34. Secondary Research Evidence
Summary or evaluation of original research
e.g., Cochrane Database of Systematic Reviews
Very useful for EBP – experts review multiple studies on a particular topic for design, methods and conclusions, and then synthesize findings and conclusions – saving one from doing own search & synthesis
Examples:
Systematic Review
Meta-analysis

35. Secondary Research Evidence
The Cochrane Databases of Systematic Reviews is the premier source of reliable secondary research evidence
The Cochrane organization uses a rigorous, standard process to search for and synthesize all of the research on hundreds of health topics such as pressure ulcers and falls prevention

36. Types of Evidence Levels of Evidence:
Higher level evidence is considered more reliable – if it answers your clinical question
“Hierarchies of evidence” organize different types of research according to reliability

37. Evidence Hierarchy: Example #1
Systematic reviews of randomized controlled trials
Randomized controlled trials
Non-randomized clinical trials
Systematic reviews of non-experimental studies
Cohort studies
Case control studies
Surveys
Case reports
(Craig & Smith, 2007, p. 103)
Top = strongest
Bottom = weakest

38. Evidence Hierarchy: Example #2
Level 1: Systematic review & meta-analysis of RCTs; evidence-based Clinical Practice Guidelines
Level 2: One or more RCTs
Level 3: Controlled trial (no randomization)
Level 4: Case-control or cohort study
Level 5: Systematic review of descriptive & qualitative studies
Level 6: Single descriptive or qualitative study
Level 7: Expert opinion

39. Where can you find evidence?
A good starting point is publication databases such as Medline or PubMed
Another good starting place is the Agency for Healthcare Quality and Research (AHRQ) – a U.S. government resource for EBP
AHRQ maintains the National Guideline Clearinghouse (NGC) – a high quality, searchable database of evidence-based practice guidelines

40. Where can you find evidence?
Peer-reviewed health care journals:
Nursing Research
Journal of Advanced Nursing
Research in Nursing and Health
Specialty nursing journals
AORN
AJCCN

41. Where can you find evidence?
Government organizations
CDC evidence summary related to hand hygiene
National organizations
Policy Statements
Practice Guidelines
e.g., Sleep Position and SIDS: Update from the American Academy of Pediatrics
This statement provides an update to the June 1992 AAP policy, “Infant Positioning and SIDS,” which recommended that healthy term infants be placed on their sides or backs to sleep. Recent data show that the original policy appears to have had a positive effect in decreasing the prevalence of prone sleeping significantly. (

42. 3. Appraise & Synthesize Evidence
Upon completion of the ROL, one will have a variety of evidence:
Secondary, primary, data-based, expert opinion, high quality, conflicting, not exactly congruent with patient population of interest
One will need to critique the evidence for:
Quality
Applicability
Meaning

43. Critique the Evidence: Quality
How reliable is the evidence?
Where does it fall on the evidence hierarchy “pyramid?”
What is the methodological quality?
If research, is the method sound?
If expert opinion, what is the source?
How much evidence is available and does it agree?

44. Critique the Evidence: Applicability
Is this evidence relevant to my setting and patients?

45. Critique the Evidence: Meaning
What are the risks/benefits of the evidence for may patients?
What are my patients’ preferences?
Does the evidence demonstrate clinically meaningful findings?

46. Synthesize the Evidence
Summarize the overall recommendations from the evidence
Weigh the overall risks, benefits and strength of evidence to answer the question: Does most evidence agree?
Note: EBP recommendations from reliable professional organizations do this step.

47. Decision Point: Is there sufficient evidence?
In the end, one will need to decide whether there is enough evidence to support a nursing practice recommendation
The decision balances the risks, benefits and strengths of evidence
Risks/weak evidence = don’t use
Benefits/strong evidence = do use

48. 4. Identify and Plan Practice Change
Translate evidence into a plan for nursing practice
Identifying outcomes
The results that one wants
A plan for data collection
Developing written practice guidelines
Outline the practice changes, including the details of the practice and the roles of staff

49. Identify & Plan Practice Change
A pilot trial is recommended
Trial practice change on a small scale
Collect data on outcomes, process and user concerns
Engage the skeptics
Refine the change based on results of the pilot trial

50. 5. Implement evidence-based practice change
The next step is “whole scale” implementation of the practice change
Consider how to inform and educate staff
Consider how to sustain the change

51. 6. Evaluate Results of Practice Change
Consider the following types of outcomes:
Patient outcomes/satisfaction
Nurse satisfaction
Cost

52. Overcoming Barriers: How to Make EBP Happen
Necessary processes and needs:
EBP education
EBP mentors/champions
CNSs, NPs, Unit Educators
Computers & internet access
Librarian assistance
Supportive culture
Communication of latest evidence directly to nurses at the point of care

53. Evidence-based practice tries to bridge the gap between research and clinical practice. The aim is to incorporate patient care practices that are as accurate, safe and effective as possible, based on the best available current evidence. Our patients deserve evidence-based care!

54. Exemplars Non-invasive BP monitoring
Family presence during CPR and invasive procedures
Management of the child with fever
Installation of normal saline before endotracheal suctioning
Management of adult depression

55. ?? Questions ??