1. Evidence-Based Practice: Evidence-Based Practice: NUR 126 Denise Filiatrault Adopted from Curry College Division of Nursing Elizabeth Kudzma

2. Evidence-Based Practice (EBP) Process by which health care providers know how to find, critically appraise, and use the best evidence Process by which health care providers know how to find, critically appraise, and use the best evidence

3. Why Evidence-Based Practice (EBP) ?? Health care delivery is filled with uncertainty and many questions arise in every day practice… What kind of guidance would be most helpful to my patients? What kind of guidance would be most helpful to my patients? What clinical assessments and interventions are of the most benefit? What clinical assessments and interventions are of the most benefit?

4. Common questions that arise in everyday practice: Which combination and sequence of treatments is most effective? Which combination and sequence of treatments is most effective? Which patient symptoms predict better or worse outcomes? Which patient symptoms predict better or worse outcomes? What is the experience of illness for a patient with this diagnosis? What is the experience of illness for a patient with this diagnosis? Which treatment is most effective and will produce the best patient outcome? Which treatment is most effective and will produce the best patient outcome? If a diagnosis is left untreated, what might be the outcome? If a diagnosis is left untreated, what might be the outcome?

5. Evidence to Support Best Practices is Constantly Changing

6. Formulating the Clinical Question The “PICO” format is used to construct the clinical question specifically The “PICO” format is used to construct the clinical question specifically Using PICO format helps you find a needle in a hay stack of research information Using PICO format helps you find a needle in a hay stack of research information

7. PICO Format Patient Population Patient Population Intervention of Interest Intervention of Interest Comparison intervention or status Comparison intervention or status Outcome Outcome

8. Patient Population Consideration of the patient and population of interest Consideration of the patient and population of interest Limit to age group or subgroup if possible Limit to age group or subgroup if possible

9. Intervention Exposure Exposure Treatment Treatment Patient perception Patient perception Diagnostic test Diagnostic test

10. Comparison Could be true control, such as placebo or doing nothing Could be true control, such as placebo or doing nothing Could be another treatment Could be another treatment Sometimes it is the usual standard of care Sometimes it is the usual standard of care

11. Outcome Outcome may be very specific, e.g. death Outcome may be very specific, e.g. death Outcome may be something that has a variety of measures, e.g. dehydration could be a measure, also tachycardia, dry mouth, fever, restlessness and irritability Outcome may be something that has a variety of measures, e.g. dehydration could be a measure, also tachycardia, dry mouth, fever, restlessness and irritability

12. PICO format example Are 35 to 55 year-old women (p) who have high blood pressure (I) at increased risk for acute myocardial infarction (O) compared with women without hypertension (C) Are 35 to 55 year-old women (p) who have high blood pressure (I) at increased risk for acute myocardial infarction (O) compared with women without hypertension (C)

13. Rating System for Evidence Level I: evidence from systematic review, randomized control trials (RCTs), or evidence-based reviews Level I: evidence from systematic review, randomized control trials (RCTs), or evidence-based reviews Level II: evidence from one well-designed RCT Level II: evidence from one well-designed RCT Level III: evidence from well-designed studies without randomization Level III: evidence from well-designed studies without randomization Level IV: evidence from other types of studies including case- control and cohort studies Level IV: evidence from other types of studies including case- control and cohort studies Level V: evidence from systematic reviews of descriptive and qualitative studies Level V: evidence from systematic reviews of descriptive and qualitative studies Level VI: evidence from one descriptive or qualitative study Level VI: evidence from one descriptive or qualitative study Level VII: evidence from the opinion of authorities and/ or reports of expert committees Level VII: evidence from the opinion of authorities and/ or reports of expert committees Meynyk, B. & Fine-Overholt, E.. (2005). Evidence-Based Practice in Nursing and Healthcare. Lippincott, Wiliams & Wilkins. Meynyk, B. & Fine-Overholt, E.. (2005). Evidence-Based Practice in Nursing and Healthcare. Lippincott, Wiliams & Wilkins.

14. Siwek, J. et al. (2002). Am Fam Physician 65, 251-258. A Rating System for Looking at Evidence in Individual Studies Level A: Randomized control trial (RCT) Level A: Randomized control trial (RCT) Level B: (other evidence) Level B: (other evidence) Well-designed, nonrandomized trial Well-designed, nonrandomized trial Non-quantitative systematic review Non-quantitative systematic review Lower quality RCT’s, clinical cohort studies, case- control studies Lower quality RCT’s, clinical cohort studies, case- control studies High-quality historical, less controlled studies, well- designed epidemiological studies High-quality historical, less controlled studies, well- designed epidemiological studies Level C: consensus/expert opinion Level C: consensus/expert opinion

15. Searching for the Best Evidence: Searchable Databases CINAHL CINAHL MEDLINE: (PubMed) MEDLINE: (PubMed) National Guidelines Clearinghouse: http://www.guideline.gov National Guidelines Clearinghouse: http://www.guideline.gov http://www.guideline.gov Agency for Healthcare Research and Quality: www.ahrq.gov/clinic/cpgsix.htm Agency for Healthcare Research and Quality: www.ahrq.gov/clinic/cpgsix.htm National Institute of Nursing: http://ninr.nih.gov/ninr National Institute of Nursing: http://ninr.nih.gov/ninr http://ninr.nih.gov/ninr