1. EVIDENCE-BASED PRACTICE
Author:
Debra S. Hall, MSN, RN,C, CCRN
Clinical Nurse Researcher
Learning Objectives:
To understand the concept of Evidence-based practice
To understand the importance of evidence-based practice in the clinical setting
Performance Objectives:
Differentiate between the concepts of quality improvement, performance improvement, research utilization, and evidence-based practice.
Describe how Evidence-based practice can be used to improve clinical practice.
Identify process for implementation of evidence-based practice within a clinical setting.
1/17/2019
University of Kentucky Hospital

2. University of Kentucky Hospital
AUTHOR
I am currently the Clinical Nursing Researcher for the University of Kentucky Hospital in Lexington, Kentucky, USA. I became interested in Evidence-based practice while in a student in the PhD program at the University of Kentucky College of Nursing, as I tried to evaluate the effects of nursing interventions. I have chaired several clinical evidence-based practice groups, educated nursing staff about the process, and used the process to improve clinical practice and direct further research efforts.
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University of Kentucky Hospital

3. University of Kentucky Hospital
CONTENT
Definition of Evidence-based practice (EBP)
Effect of Evidence-based practice
Implementation of Evidence-based practice within a clinical setting
This lecture reviews the definition of evidence-based practice, its implementation in a clinical setting, and the various projects for which it can be used.
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University of Kentucky Hospital

4. EVIDENCE-BASED MEDICINE
A shift in the culture of providing healthcare away from basing decisions on opinion, past practice, and precedent toward making more use of science, research, and
evidence to guide
clinical decision-making
Evidence-based practice began its life in healthcare as evidence-based medicine. Evidence-based medicine is based on the concept of shifting healthcare away from basing decisions on opinion and past practices. Research has shown that physicians failed to recommend medications up to ten years after they have been shown to be efficacious and continue to recommend treatments up to ten years after they have been shown to be useless.
Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC: A comparison of results of meta-analyses of randomised control trials and recommendations of clinical experts. JAMA 1992;268:240-8.
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University of Kentucky Hospital

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“…Evidence-based practice is a state of mind…a constant process of inquiry. …Why am I doing it this way? Is there evidence that can guide me to a better outcome?…” (Foster, 1999)
Evidence-based practice originates with the clinician and focuses on clinical decision-making leading to improved patient outcomes.
Foster, R. L. (1999). Evidence-based practice. Journal of the Society of Pediatric Nurses, 4 (1), 4-5.
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University of Kentucky Hospital

6. EVIDENCE-BASED PRACTICE (EBP)
“The conscientious and judicious use of current best evidence to guide health care decisions for improving patient outcomes.”
Marita Titler, PhD, RN, FAAN
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University of Kentucky Hospital

7. University of Kentucky Hospital
RESEARCH
A systematic scientific process that generates new knowledge or validates existing knowledge
Research differs from EBP in that research is a specific scientific process of investigating a phenomena. Research includes a research question(s), a review of the literature on the area of interest, a study design to answer the question, interventions with resultant data collection, data analysis, and dissemination of the research results.
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University of Kentucky Hospital

8. University of Kentucky Hospital
RESEARCH UTILIZATION
Research Utilization (RU) differs from evidence-based practice (EBP) in that, although RU also serves to improve the quality of patient care,
it utilizes solely research
findings as a basis of practice
to improve patient care
Includes critique of research studies, synthesis of research findings, application/implementation of scientific findings into practice, and evaluating the practice change in relation to resource utilization. It is NOT the same as conducting research.
Should grade or evaluate the research or evidence you have available. (A-E) Discuss examples.
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University of Kentucky Hospital

9. University of Kentucky Hospital
QUALITY IMPROVEMENT
The betterment or enhancement of a product or service
This can be achieved by EBP, but is not limited to it
Quality improvement is a continuous process that builds upon traditional quality assurance methods by emphasizing the organization and focuses on “processes” rather than on the individual; recognizes both internal and external “customers;” promotes the need for objective data to analyze and improve processes; carried out by both employees and managers. Although this may be achieved by EBP, it is often achieved by the collection of raw data on patient outcomes, sentinel events, negative clinical outcomes or errors from an institution or organization. This data is often specific to the institution or organization.
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University of Kentucky Hospital

10. PERFORMANCE IMPROVEMENT
Focuses on the achievement of human performance goals
Focuses on the performance of the individual and person-specific goals
Performance improvement is similar to quality improvement, but its focus is on the performance of the individual and achieving person-specific goals, instead of reaching organizational or departmental goals.
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University of Kentucky Hospital

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Evidence-based practice in the clinical setting requires the integration of
individual clinical expertise
with the
best available external clinical evidence from systematic research
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University of Kentucky Hospital

12. INDIVIDUAL CLINICAL EXPERTISE
The proficiency and judgment that clinicians acquire through clinical experience and clinical practice leading to more effective and efficient patient assessment and diagnoses
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University of Kentucky Hospital

13. BEST AVAILABLE CLINICAL EVIDENCE
Clinically relevant patient-centered research, scientific evidence, empirical evidence, institutional data, and external data that indicate how to achieve patient outcomes that you wish to achieve
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EBP assists in -
practicing based on the evidence (rather than opinion)
Accepting clinical guidelines developed by other disciplines
Developing indicator conditions in which the management and performance of patient care create a difference in patient outcomes
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University of Kentucky Hospital

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The aim of evidence-based practice (EBP) is to reduce wide variations in individual clinician’s practices, eliminating worst practices, and enhancing best practices, thereby reducing costs and improving
quality.
Although the other processes, such as research, research utilization, quality improvement, and performance improvement are important and can easily be associated with EBP, their aims are somewhat different. The overall aim of EBP is to standardize practice by maximizing good practice, reduce costs, and improve quality of care.
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University of Kentucky Hospital

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OUTCOMES MANAGEMENT
Efficacy – the results of an intervention applied under ideal conditions (RCT)
Effectiveness – the results of an intervention applied in the real world; fewer controls; lack of random assignment
For clinicians, effectiveness is more important than efficacy. Due to its nature, EBP lends itself to outcomes management more so than research.
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University of Kentucky Hospital

17. EBP CHANGES THE FOCUS FROM PROCESS TO RESULTS
What systems or problems are not allowing growth?
What barriers are present that prevent you from delivering the quality of care you, and your staff, think is needed?
Quality Improvement also identifies issues or problems; however, EBP focuses on finding existing ways of overcoming problems or altering the manner in which outcomes are achieved based on evidence and positive results. What protocols, guidelines, practices do you need that you do not have?
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University of Kentucky Hospital

18. USE OF EBP IN ANALYSIS OF CARE ISSUES
Use of specialty beds in patients for skin care
Evidence supports use of some specialty beds only for pulmonary problems
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University of Kentucky Hospital

19. USING EBP TO EVALUATE THE QUALITY OF CARE
Obstructive sleep apnea (Sonnad, et al., 2003)
Cardiac Rehabilitation (Bitzer EM, Klosterhuis H, Dorning H, Rose S., 2003)
Oncology oral care (Stricker & Sullivan, 2003)
These studies used EBP to determine treatment modalities and develop guidelines.
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University of Kentucky Hospital

20. University of Kentucky Hospital
THE EBP PROCESS
Link your use of evidence-based practice to a process
May choose an existing process
May choose another process commonly used in your organization/institution
Clinicians can use the scientific process, Nursing process, or other process found in the literature. Rosswurm & Larrabee (1999) developed a systematic process for the change to evidence-based practice.
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University of Kentucky Hospital

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Assess the need for change in current practice by
including the stakeholders
collecting internal data about current practice
comparing internal/external data (benchmark)
identifying your problem statement/desired state
(Rosswurm & Larrabee, 1999)
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University of Kentucky Hospital

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Link problems, interventions & outcomes by
using standardized classification systems & language
identifying potential interventions & activities
selecting outcome indicators
(Rosswurm & Larrabee, 1999)
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23. University of Kentucky Hospital
PROBLEM STATEMENT
There is an increase in requests for nursing staff to administer unfamiliar anesthetic and sedative agents in the ICU area for procedures which affect patient care and staffing.
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University of Kentucky Hospital

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DESIRED STATE
Nursing staff will have guidelines for administration of sedatives during procedures and extended patient treatment and for care of such patients in the critical care area
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Synthesize the best evidence by
searching literature related to major issues
critiquing & weighing the evidence
assessing the feasibility, benefits, and risks
(Rosswurm & Larrabee, 1999)
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University of Kentucky Hospital

26. University of Kentucky Hospital
Design practice change by:
defining the proposed change
identifying needed resources
planning an implementation process
defining outcomes
(Rosswurm & Larrabee, 1999)
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27. University of Kentucky Hospital
OUTCOME INDICATORS
Data collected on administration of approved IVP drugs by ICU RNs (e.g., frequency)
Anecdotal reports from staff on administration of approved drugs
No negative patient outcomes with non-approved drugs
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University of Kentucky Hospital

28. University of Kentucky Hospital
Implement & evaluate the change in practice by:
pilot study demonstration
evaluate process & outcome
decide to adapt, adopt, or reject practice change
(Rosswurm & Larrabee, 1999)
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Integrate & maintain change in practice by
communicating recommendations to stakeholders
staff education on changes in practice
integrating changes into standards of practice
monitoring the process & outcomes
(Rosswurm & Larrabee, 1999)
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University of Kentucky Hospital

30. WHAT INFORMATION IS AVAILABLE ON THE WEB ON EBP?
McMaster University
Canadian Centres for Health Evidence
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University of Kentucky Hospital