SEARCHING FOR EVIDENCE BASED PRACTICE

1. SEARCHING FOR EVIDENCE BASED PRACTICE Health Sciences Library

2. Objectives Upon completion of this module, the participant will: • Understand what Evidence Based Practice (EBP) is and why it is important. • Understand the steps involved in the EBP process. • Understand importance of critically appraising the evidence.

3. Introduction What is Evidence Based Practice (EBP)? Evidence-based practice is a framework for clinical practice that incorporates the best available scientific evidence with the expertise of the clinical staff and the patient’s preferences and values to make decisions about health care. [Levin, R. Teaching Evidence-based practice in nursing. NY: Springer, 2006. Pg. 6.]

4. In the critical appraisal of evidence, it is important to evaluate study design and the level of evidence. Levels of Evidence

5. Systematic Reviews The top level of evidence is the systematic review. A systematic review summarizes two or more Randomized Controlled Clinical Trials (RCCT). It can help clinicians get a broader view of a particular topic. A high quality systematic review starts with a clear clinical question and involves a comprehensive search of primary studies (RCCTs) and a thorough assessment of the methodological quality of the primary studies and reproducible decisions.

6. Systematic Reviews Here are three of the most authoritative publishers of systematic reviews: Cochrane database of Systematic Reviews ACP Journal Club Database of Abstracts of Reviews of Effectiveness (DARE)

7. Systematic Reviews Cochrane Database of Systematic Reviews: • Produced by the Cochrane Collaboration, an international network of doctors committed to preparing full text systematic reviews of the effects of healthcare. • Included are two types of systematic reviews: • Complete reviews – prepared and maintained by the Collaborative Review Groups. • Protocols – protocols for reviews containing background information, objectives, and methods.

8. Systematic Reviews ACP Journal Club Produces two EBM journals that identify studies that are both methodologically sound and clinically relevant. Editors write enhanced abstracts for articles and provide a commentary on the value of each article. • ACP Journal Club – a publication of the American College of Physicians. • Evidence-Based Medicine – a joint publication with the British Medical Group.

9. Systematic Reviews Database of Abstracts of Reviews of Effectiveness (DARE) • Full text database containing critical assessments of systematic reviews from medical journals. • DARE is produced by expert reviewers and information staff of the National Health Services’ Center for Reviews & Dissemination, University of York, England.

10. Randomized Controlled Clinical Trials Randomized Controlled Clinical Trials (RCCT), or the “Gold Standard” are clinical trials with at least one test treatment and one control treatment, concurrent enrollment and follow-up and in which the treatments to be administered are selected by a random process such as a random-numbers table. They are less susceptible to bias than nonrandomized trials, although individual RCCT are often limited by inadequate sample size. Cook, D. Clinical recommendations using levels of evidence for antithrombotic agents. Chest. 108 (Suppl 4): 227S-230S. 1995

11. EBP Process Five steps in the EBP Process: 1. Create focused questions 2. Find evidence that answers the question 3. Critically appraise the evidence for validity and usefulness 4. Apply the results in clinical practice 5. Evaluate the clinical application of the evidence

12. Step 1: Create Focused Questions • Construct a well-built question derived from a case. Do you need information on nursing intervention, treatment, diagnosis, prognosis or etiology? • The clinical question should consider: • Patient population – age, sex, disease symptoms • Is the concern treating, preventing, or diagnosing disease, defining prognosis or determining disease etiology? • Comparison of treatment, prevention or diagnostic method • Expected outcome

13. 2: Find the Evidence Answering the Question Places to search for the top two levels of EBP: Systematic ReviewsRandomized Controlled Clinical Trials CinahlCinahl Nursing@OvidNursing@Ovid Medline Medline Clinical Evidence Cochrane DARE ACP Journal Club

14. Case Study Case Study: Managing patients’ pain effectively can be difficult for nurses, especially if the patient cannot communicate verbally. In your nursing unit there has been some discussion of creating a pain assessment tool which could be useful in evaluating a patient’s level of pain. You need to search for evidence based practice literature to help guide the development of such a tool and the policy for its use.

15. Case Study • Before beginning a search, identify the key concepts in the case study: • Nonverbal communication • Pain assessment • Evidence based practice • Search each concept separately before combining together.

16. Searching Cinahl • Cinahl • Cinahl is the Cumulative Index to Nursing and Allied Health Literature • Covers 1982-present • Searches can be restricted to Research Articles • A tag assigned to articles in Cinahl that indicates a research study containing data collection, methodology, discussion of results, etc. • Has a subject heading Professional Practice, Evidence Based • Cinahl subject heading which is used to in articles about clinical practice that bases clinical decisions on research, clinical expertise, patient choices, and critical evaluation of the literature.

17. Searching Cinahl Access Cinahl from the library webpage by placing your cursor over the Quick Links tab and choosing Cinahl from the drop down menu.

18. Searching Cinahl Enter in search term or phrase and click on Browse; Cinahl will map your term to the appropriate subject headings.

19. Searching Cinahl Select the appropriate term(s). Click Explode to include narrower aspects of the concept. Leave this at “include all subheadings.” Click to search.

20. Searching Cinahl The term is posted to the Search History page. We still need to search for the other aspects of our query. Search for pain assessment.

21. Searching Cinahl Go through the same process: Select. We can’t explode this time because there are no narrower terms in the hierarchy of subhead headings. Leave this alone. Search.

22. Searching Cinahl Combine the two terms with AND on the search page.

23. Searching Cinahl To limit your results to specific levels of EBP, either click on the edit link next to the top search result, or on the Additional Limits link on the left side bar.

24. Searching Cinahl You can limit your search to EBP formats like Ranomized Clinical Trials and Systematic Reviews. There are also other limits such English and Evidence-Based Practice. Note that some limits will cancel each other out, such as clinical trials and review articles.

25. EBP Databases Nursing@Ovid • A Comprehensive, Integrated Nursing & Allied Health Portal • Supplemented by Ovid with over 1,000 new records added each week • Focuses on core specialties for the nurse in practice, education, research, and administration Note: for tips on searching Nursing @ Ovid, please refer to the module Searching Nursing@Ovid.

26. Searching Nursing@Ovid Access Nursing@Ovid from the Quick Links section of the Health Sciences Library’s homepage.

27. Searching Nursing@Ovid After going through your search, you can limit to EBP by using the Systematic review options above the search history box or by clicking on Additional Limits for more options.

28. Searching Nursing@Ovid After clicking on the Additional Limits button, these are a few of the options available within the Publication Type selection box: Clinical trial: Pre-planned clinical study of the safety, efficacy or optimum dosage schedule of one or more drugs, devices, or techniques in humans according to predetermined criteria of eligibility and observed for evidence of favorable or unfavorable effects. Meta-analysis: A quantitative method of combining the results of independent studies (usually drawn from the published literature) and synthesizing summaries and conclusions which may be used to evaluate clinical effectiveness. It is often an overview of clinical trials. Double-Blind method: A method of studying a drug or procedure in which both the subjects and investigators are kept unaware of who is actually getting which specific treatment.

29. Searching Ovid Medline Ovid Medline’s interface is similar to that of Nursing@Ovid, but differs by searching all of MEDLINE, the premier source for bibliographic and abstract coverage of biomedical literature. To access Ovid Medline choose it from the Quick Links tab.

30. Searching Ovid Medline Once you have finished combining your terms you have a couple options for limiting your results to high levels of EBP. One option is to tick the box next to Evidence Based Medicine Reviews and click Search. This will limit the results to ACP Journal Club, DARE, AIM, and Cochrane Topic Reviews. Note that you can’t click each of these boxes at once or they will cancel each other out. Another option is to click on the Additional Limits button and choose clinical trials, meta-analysis, or randomized clinical controlled trials from the publication type.

31. Searching PubMed for EBP articles • PubMed is the National Library of Medicine’s search engine for searching Medline. It is freely available worldwide on the Internet. • PubMedshould be accessed through the Library’s homepage (QuickLinks) to benefit from the library’s direct links to electronic full text articles and the library catalog.

32. Searching PubMed for EBP articles • Clinical Queries can be used to restrict results to sound clinical studies. This option is found on the welcome screen under PubMed Tools.

33. Searching PubMed for EBP articles • To search Clinical Queries, enter a search strategy that reflects your clinical question. The system uses built-in filters to find relevant articles.

34. Searching PubMed for EBP articles • There are Five Clinical Queries Filters: Therapy, Diagnosis, Etiology, Prognosis, & Clinical Prediction Guides. • Each category can be searched with the following focus • Sensitivity – includes most relevant articles & some less relevant ones. • Specificity – includes mostly relevant articles.

35. Additional Resources For more information about Evidence Based Practicego to the library home page, click on Nurses under the Resources For drop down menu; then click on Evidence Based Nursing Practice under Additional Resources, such as guides from other libraries and sources.

36. Step 3: Critically appraise the evidence for validity and usefulness • Determine validity of your results: • Primary Guides: • ● Was the assignment of patients to treatment randomized? • ● Were all patients who entered the trial accounted for and • attributed at its conclusion? • ● Was follow-up complete? • ● Were patients analyzed in the groups to which they were • randomized? • Secondary Guides • ● Were patients, their clinicians and study personnel kept 'blind' to treatment received? • ● Were the groups similar at the start of the trial? • ● Aside from the experimental intervention, were the groups treated • equally?

37. Step 3: Critically appraise the evidence for validity and usefulness • What are the results? • How large is the treatment effect? • How precise is the estimate of the treatment effect? • Will the results help me in my patient care? • ● Can the results be applied to my patients? • Were all clinically relevant outcomes considered? • Are the benefits worth the harms and costs? • From Guyatt GH. Users’ guides to the medical literature II. How to use an article about therapy or prevention. JAMA 270(21): 2598-601, 1993.

38. Ask a Librarian! If you need any further help finding EBP, don’t hesitate to contact a librarian. We’re here to help you! (708) 216-9192 researchservices@lumc.edu We will also do a search for you and email you a list of citations if you like. To do this, fill out the form here: