1. Distinguishing Tradition-Based and Evidence-Based Care Eleanor S. McConnell, PhD, RN, GCNS-BC Duke University School of Nursing Durham Veterans Affairs Medical Center Geriatric Research, Education and Clinical Center November 2013 http://coegne.nursing.duke.edu

2. Think of a situation when…. You were afraid you were going to do more harm than good….. Examples… Should I give a 45 year old woman with abdominal pain morphine in the ED? Should I give Herpes Zoster vaccine to someone who has already had shingles? Should I use a falls alarm to prevent falls…. What is your example?

3. Evidence-based Practice Defined “..the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. “ Clinical expertise: the clinician's accumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. Best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett, 2002) Patient values Clinical Expertise Best Scientific Evidence

4. EBP – Begins and Ends with a Patient

5. Case 1 Mrs. A is a 45 y.o. woman recently admitted to your Emergency Department with acute abdominal pain. One member of the treatment team wishes to give her morphine to relieve her pain A second member of the treatment team believes that morphine is contraindicated, because it will mask the signs needed to make an accurate diagnosis What would you do?

6. Cycle of Evidence-based Practice To learn more, go to these 2 sites: http://www.hsl.unc.edu/services/tutorials/ebm/welcome.htm OR http://www.cebm.utoronto.ca/practise/ AskPertinent question in area of uncertainty @ practice AcquireBest available scientific evidence Computers make this possible in “real time” AppraiseNot all evidence is created equal ApplyBased on clinical experience, patient preference

7. Cycle of Evidence-based Practice AskIn a 45 y.o. woman with acute abdominal pain will MS04 compared to no Rx result in inaccurate dx ? AcquireMedline Search: Abdominal pain OR Acute abdomen AND adult AND diagnosis AND RCT search filter Appraise9 RCTs – latest, 2006 1 review paper (2003) Apply VAS improved 31 mm MSO4 v. placebo Difference in clinically important diagnostic outcome was 1% (95% confidence interval [CI] -11% to 12%).

8. Search comes up with good answer because of “well-built” question & EBM search filters

10. Notice that most articles have abstracts that are available for free – in real time

11. Case 2 Mrs. J is an 82 y.o. woman who comes to your clinic for her annual evaluation. She tells you she has seen recent advertisements on TV for medicines that can prevent dementia. Her mother died with dementia 20 years ago, and she does not want to be a burden on her family. What would you recommend?

12. Cycle of Evidence- based Practice AskAmong healthy 80 year old women what preventive approaches to dementia are effective? AcquirePub-Med Search: Dementia & Prevention – filter by systematic review  AppraiseSystematic Review examining prevention of vascular dementia Apply

13. Sample Review Paper

14. Risk factors for vascular dementia (VaD), Alzheimer disease (AD), unspecified dementia, and Cognitive Impairment. Copyright © American Heart Association Risk FactorVascularAlzheimer’sDementiaCognitive Impairment 1.Non-modifiable: age & genetics (APO-E) Yes Maybe Yes 2. Lifestyle factors: Education Smoking Diet Physical Activity Obesity No Yes 3. Physiological Risk Factors: Hypertension Hyperglycemia & Diabetes Lipids Yes Yes Maybe Maybe Yes Maybe Yes Maybe Yes Maybe 4. Vascular Disease: Stroke Coronary artery disease Atrial fibrillation Yes No Maybe Yes Maybe Yes Dichgans M, and Zietemann V Stroke 2012;43:3137-3146

15. Temporal relationship between the critical period for elevated blood pressure and randomized trials of blood pressure-lowering treatment. Dichgans M, and Zietemann V Stroke 2012;43:3137-3146 Copyright © American Heart Association

17. Now really..Who has time for this? Realistic concern given our busy lives One answer: Substitute for continuing education or haphazard journal article reading Just-in-time education Another answer: Consider using pre-appraised evidence

18. Pre-appraised Literature Sources TypeExampleSource GuidelinesAMDA Guideline for Pressure Ulcers www.guidelines.gov JournalsEvidence-based Nursing http://ebn.bmj.com/ Bibliographic Search Engines Pub-Med http://www.ncbi.nlm.nih.gov/ pubmed/ Workshops & Learning Networks Evidence-Based Practice in Geriatric Care Settings http://cgne.nursing.duke.edu/

19. Source 1: Guidelines

20. Search Results from www.Guidelines.gov

21. Source #2: Pre-appraised Evidence: Journals Source: Evid Based Nurs 2009;12:2 55 10.1136/ebn.12.2.55

22. Final Step: Apply Evidence Easier said than done! 1.Learning Collaborative: Institute for Health Care Improvement Carolinas Center for Medical Excellence – QAPI in LTC 2.Evidence Based Practice Committee Journal Clubs Other strategies….

23. Summary Tradition-based? Few experts, may be biased, out of date Evidence-based? Many experts, procedures to limit bias Begins and ends with patient Growing trend, accelerates access to scientific discoveries Helps free us from doing more harm than good

24. To learn more:

25. To learn more: http://www.hsl.unc.edu/services/tutorials/ebm/index.htm Very well-done self-instructional module You can start and Stop where you wish!

26. To learn more… www.mclibrary.duke.edu

27. So what about that zoster vaccine???? Go to PubMed and put “herpes zoster vaccine in search box…”

28. And you’re really thinking….. Who has time to look at 1116 citations????? And we would say…..no one! What about 32? Or 3?

29. Which one to pick? Sort by Relevance

30. What did we learn?

31. What else did we learn?