1. Evidence Based Practice April 2013 version
Naomi Trostler, Hebrew Univeristy of Jerusalem, Israel
Elke Naumann, HAN University, The Netherlands
Julia Eisenblätter, Bern University of Applied Sciences, Switzerland

2. “This project has been funded with support from the European Commission.
This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein“.

3. Why do we need evidence based health care?

4. Evidence based practice (international perspective)
Evidence-based dietetics practice is informed by ethical principles of dietetics practice and codes of good practice.  This includes reflection on how a dietitian’s own perspectives or biases may influence the interpretation of evidence.
Evidence-based dietetics practice is about asking questions, systematically finding research evidence, and assessing the validity, applicability and importance of that evidence.  This evidence-based information is then combined with the dietitian's expertise and judgment and the client’s or community’s unique values and circumstances to guide decision-making in dietetics.
Vienna 2013

5. What is Evidence Based Practice?
Evidence based practice involves:
best available clinical evidence
patient’s values & expectations
individual clinical expertise

6. The doctor told me that I have a mild hypertension.
The clinical problem
What do you already know about diet counselling regarding hypertension?
The doctor told me that I have a mild hypertension.
I am not sure at the moment, but I will find out and discuss the results with you in the next consultation?
Certainly, I already heard that a low sodium diet helps to reduce blood pressure
But is the effect really so relevant, that it is worth changing my whole lifestyle?
Do you have some more ideas for this dialogue?

7.  Appraise the evidence Where should I start?
I have heard about the five steps of Evidence based. Perhaps they are useful in this case.
Do you think there are better/other questions to ask?
Is there a better picture than a pictogram? Should the pictogram be feminine, or is this more gender conform like this?

8. review on the materials presented just far
This is an excellent summary presentation by Pauline Douglas, on Practice Based Practice, that will provide a
review on the materials presented just far

9. Evidence based practice
The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

10. Evidence based practice
The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

11.  Appraise the evidence
There is this PICO principle, but what does it mean?
How can you formulate a structured question? 
Do you think there are better/other questions to ask?

12. Formulate the question
PICO Question: P I C O
Patient
or Problem
Intervention
Comparison
Outcome

13. Formulate a question Example: P I C O patients with mild hypertension
nutrition counseling regarding a low-sodium diet
no dietary advice
blood pressure

14. Formulate the question
Example:
‘in patients with mild hypertension, does nutrition counseling regarding a low-sodium diet, compared with no dietary advice, lead to a fall in blood pressure?’

15. Evidence based practice
The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

16. How can I transfer my PICO question into a search term?
Appraise the evidence
How can I transfer my PICO question into a search term? 
Do you think there are better/other questions to ask?
Is there a better picture than a pictogram? Should the pictogram be feminine, or is this more gender conform like this?

17. Boolean operator AND OR NOT
Boolean operators connect your seach words together to either narrow or broaden your set of results.
The three basic operators are:
AND
Using AND narrows the search to the results that include all search words. OR
OR connects two or more synonyms, thus it broadens the search by searching for any of these words.
NOT
NOT excludes words from the search.

18. Create a search term P I C O
Transfer your PICO question into a search term P I C O
mild Hypertension
nutrition counseling
low-sodium diet -
blood pressure
Finaly, connect words with AND when the search should include both of them .
Firstly, search for Synonyms of your keywords. For example:
Secondly, connect synonyms with OR. OR
AND
Thirdly, connect the parts of the PICO questions with AND .
High blood pressure
AND
AND

19. Create a search term
Resulting search term:
(mild hypertension OR high blood pressure) AND nutrition counseling AND low-sodium diet AND blood pressure.

20.  Appraise the evidence
Where can I search for an answer to my question?
Which database suits best for this topic? 
Do you think there are better/other questions to ask?
Is there a better picture than a pictogram? Should the pictogram be feminine, or is this more gender conform like this?

21. search for answers Examples of common Databases: PubMed Embase
The public version of medline. Contains predominantly American articles.
Embase
The Excerpta Medica database (Embase) is often referred to as the "European MEDLINE.“
Cochrane Library
The Cochrane Library is a collection of seven databases. One database contains a collection of systematic reviews of high quality.
Science direct
ScienceDirect is a full text database that covers titles from the core scientific literature, including high-impact factor titles such as THE LANCET, Cell and Tetrahedron.
Psycinfo
PsycINFO® is an abstracting and indexing database with more than 3 million records in the behavioral sciences and mental health.
Do you think we have do have more information about the search itself?

22. Appraise the evidence
The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

23.  Appraise the evidence Are the results of the study relevant ?
Is the literature I retrieved valid? 
How can I assess the literature?
Do you think there are better/other questions to ask?
Is there a better picture than a pictogram? Should the pictogram be feminine, or is this more gender conform like this?

24. What kind of study design was used in the literature I retrieved?
Appraise the evidence 
What kind of study design was used in the literature I retrieved?

25. Appraise the evidence
There are several questionairs available in the internet for assessing the validity and relevance of the literature. Which one to choose is dependent on the kind of literature you retrieved.
Qualitative Studies
Guidelines
Quantitative Studies
Guidelines
or alternatively deside first which study design was used:
Algorithm for classifying study design
Do you have an idea for that slide? I think it is confusing, but I do not have a better idea.
Systematic Revies/Metaanalyses
Practical Guidelines

26. Algorithm for classifying study design for questions of effectiveness
Comparison between Interventions/ exposures no
Non-comparative Study (case series,
case study)
yes
Did investigator assign interventions/ exposure?
yes
Observational study
Experimental study
More than one group studied? no
Before–After study/
interrupted time series
Interventions/exposures randomly allocated?
yes no
yes
Randomised Controlled Trial
Non-Randomised
Controlled Trial
Exposure and outcome measured at the same time no
Cross-sectional
Study
yes
Ccse-control
Study
yes
Groups defined by outcome? no
Cohort study
Adapted from NICE (

27. Evidence based practice
The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

28. Apply the results
Is my patient similar to the participants in the study?
What are the costs of the intervention? 
Do the benefits predominate the harms of the intervention?
If not, are the results transferable?
Will the outcomes in the literature be the best for this individual patient?
Do you think there are better/other questions to ask?
Is there a better picture than a pictogram?

29. Apply the results
The results of my investigations are... Does this meet your expectations?
.....
Do you think the implementation of the intervention fits with your lifestyle ?
Do you think there are better/other questions to ask?
Should the patient answer something? What could be the answer of the patient? I

30. Evidence based practice
The process of EBP consists of five steps: 1. Formulate the question 2. Search for answers 3. Appraise the evidence 4. Apply the results 5. Assess the outcomes

31.  Reflection Was my PICO question precise and did it meet the problem?
What did I do exactly?
Did I meet the values and expections of the patient? 
What were my values and expectations in this case?
Process
1. Formulate the question
2. Search for answers
3. Appraise the evidence
4. Apply the results
Was my search well structured?
Was the validity and relevance of the evidence well assessed?
What would I do different next time? t

32. REVIEW
The following overview presentation was prepared by students of the Department of Nutrition and Dietetics at HAN University, The Netherlands.
The link is:
Click in the picture and when open use these arrows to move the presentation

33. Keep in mind…
Albert Einstein: “not everything that can be counted counts and not everything that counts can be counted”2
EBP is real, complex and not always controlled, its documented, measured, occurs.
EBP is process of measurements, recording and tracking not controlling how practice is delivered. It answers the question "does practice/intervention “x” cause outcome “y” in the patient?"
Patients are not controlled as research subjects

34. Guidelines Developed from systematically collected real outcomes and
synthesized them into a proposed practice/guideline
Clinical practice GL provide the practitioner with a valuable
starting point when faced with a patient scenario
GL are not a binding/restricting "cookbook" for practice, but a base
for decisions regarding the appropriate counseling for the individual patient
Practitioners are responsible to measure and record what they do
and the outcomes to contribute to the growing data base of clinical scenarios
and resulting outcomes to improve guidelines

35. more information
Evidence-Based practice: an idea whose time has come. Roberts KL, Collegian 1998; 5(3):24-27.
Practice-Based evidence. Swisher AK. Cardiopulm PhysTher J. 2010; 21(20:4.)
Evidence-Based medicine: application in dietetic practice. Gray GE & Gray LK.
J Amer Dietet Asso 2002; 102 (9):
Evidence-Based practice: what are dietitians' perceptions, attitudes, and knowledge?
Byham-Gray LD, Gilbride JA, Dixon LB, King-Sage F. J Amer Dietet Assoc 2005; 105(10):
Evidence-Based nutrition guidelines for diabetes and scope and standard of practice.
Franz MJ, Boucher JL, Green-Pastors J, powers MA. J Amer Dietet Assoc 2008;108(4):S52-S58.
Making research relevant; if it is an evidence-based practice, where’s the practice-based evidence?
Green LW. Family Practice 2008; 25: i20-i24.
The clinical reasoning of novice and expert occupational therapists. Unsworth CA.
Scand. J Occup Ther 2001; 8:

36. questions about EBP
evidence based practice means that practice is mainly baised on scientifica evidence.
yes OR no
Do you have answers to these questions?
Answer: NO

37. questions about EBP
2. The process of EBP consists of five steps in the following order:
formulate the question
search for answers
appraise the evidence
apply the results
assess the outcomes
yes OR no
Do you have answers to these questions?
Answer: YES

38. questions about EBP
3. Let’s imagine: As a dietitian, you have seen a lot of children over the past years with obesity. Your treatment is mainly based on dietary advise. Last week one of the parents indicated that they do not need your advise anymore. They heard that increasing exercise is more helpful to reduce body weight compared to dietary advise.
Formulate the Patient, Intervention, Comparison and Outcome of this question.
Answer:
In children with obesity (P), does increasing exercise (I) reduces body
weight more (O) compared with dietary advice (C)?
Do you have answers to these questions?

39. Evaluation of this e-course
This e-course is developed by the DIETS network. Your comments and suggestions are very welcome!
Please let us know what you think about this e-course by completing an online questionnaire: …link to website
Your comments and suggestions will help us to improve this e-course.
Thank you very much!
Do you have answers to these questions?

40. EVIDENCE BASED PROFESSIONAL PRACTICE Seminar
Developing Clinical Questions & a Search Strategy

41. Objectives
To develop a clinical question as first step in EBP process.
To develop an appropriate search strategy.

42. Reasons for Developing a Focused Question
3 key reasons for focusing Qs:

43. Reasons for Developing a Focused Question
3 key reasons for focusing Qs:
To facilitate search for relevant evidence.
To sort best evidence from weaker, less valid evidence.
To decide whether evidence is applicable to your patients.
[Craig & Smyth (2002) The Evidence Based Practice Manual for Nurses, p27]
Recap with students the reasons for developing a focused Q.
Activity: Get students to think about reasons for developing a focused Q
EBP process flows from the research/clinical Q as it does with the research process. You will discover as we progress through the module and as you develop your own research Qs, that the question itself determines the design and methods of the study.

44. Identifying Clinical Questions
Types of questions:
diagnosis and prognosis
intervention
patient experiences
efficiency and effectiveness
Elements of questions:
situation (patient or problem) (P)
intervention (I)
comparison treatment (if appropriate) (C)
Outcome (O)
Show this slide just to recap what was covered in Keynote 2
Elements - will be practicing this later. Also will be considering how to match questions to research approaches to get different kinds of research evidence. Key is to be focused.

45. Profession Specific EBP Scenario
People in hospital (normally older people) who have had a stroke or other conditions which affects their swallow response will have to have special consideration to make sure that they receive all their nutrients and energy and also do not lose their enjoyment of eating.
It is possible to train assistants to support meal and other eating times to make sure that individuals receive their food.
In a time of increasing ‘value-for-money’ many hospitals and other institutions are concerned about effectiveness of training assistants or could they use food supplements more cheaply?
Using the above scenario get each student to think of a question about an aspect of the care process. Get the students to answer the following questions:
How would you go about finding the answer to this Q?
How would you assess the quality of the answers you found?

46. Profession Specific EBP Scenario
Dietitians are being asked for their professional opinion and any evidence to support their views. You are wondering what the answers may be; would training assistants or providing nutritional supplements improve the nutritional intake.
? patient or problem
? intervention
? comparison
? outcome
Using the above scenario get each student to think of a question about an aspect of the care process. Get the students to answer the following questions:
How would you go about finding the answer to this Q?
How would you assess the quality of the answers you found?

47. Questions What question can we answer?
Too many variables make a question difficult to answer
So simplify and focus; be clear; be SMART
(Specific, Measureable, Acheiveable,
Realistic and Time)