What is Evidence Based Practice

1. What is Evidence Based Practice Barbara Ann M. Messina, PhD, RN, ANPClinical Associate ProfessorSchool of Nursing – Department of Adult HealthAdjunct Clinical Associate ProfessorSchool of Medicine – Department Pharmacology

2. Objectives • Define what is evidence based practice (EBP). • Discuss the history of EBP. • Implementing Evidence-Based Practice: The Iowa Model. • Discuss the Determination of Clinical Relevance in EPB. • Discuss how to Framing a Clinical Question using the PICO model. • Discuss the Literature Review and Search Techniques. • Define the AHRQ.

3. What is EBP? The use of evidence-based practice (EBP) and national guidelines to improve the quality of patient care. EBP closes the gap between research outcomes and practice (Newhouse, Dearbolt, Poe, Pugh, & White, 2005)

4. What is EBP? EBP uses current research evidence combined with clinical expertise and patient values to formulate sound interventions (DiCenso, Guyatt, & Clinska, 2005).

5. History of EBP FFCM (1909-1988) in 1972. Dr. Cochran, a British epidemiologist, identified a gap between current practices and evidence-based guidelines.

6. Implementing EBP:The Iowa Model The Iowa Model of EBP was developed by Marita G. Titler, PhD, RN, FAAN, Director Nursing Research, Quality and Outcomes Management, Department of Nursing Services and Patient Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa Iowa Model: Considers the entire health care system: • Provider • Patient • Infrastructure

7. Iowa Model • Identify a trigger – problem focused or knowledge focused • Determine clinical relevance – is it important to the organization or culture

8. Framing the Clinical Question What to include what to exclude?

9. PICO Model P = Who is the Patient Population? I = What is the potential Intervention or area of Interest? C = Is there a Comparison intervention or Control group? O= What is the desired Outcome? Your question drives your research!

10. The Literature Review • Cochrane Library • Clinical Practice Guidelines • Cumulative Index to Nursing and Allied Health Literature (CINAHL); and • PubMed. http://www.hsclib.sunysb.edu/

11. Types of Literature Reviews Systematic Review: Looks for similar Studies (Critiquing an Article) Meta Analysis: Statistical technique for averaging an effect of treatment across studies (Cochrane Data Base)

12. Levels of Evidence

13. Hierarchy of Evidence

14. Hierarchy of Evidence Levels of Evidence Category I:  Evidence from at least one properly randomized controlled trial. Category II-1: Evidence from well-designed controlled trials without randomization. Category II-2: Evidence from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. Category II-3: Evidence from multiple times series with or without intervention or dramatic results in uncontrolled experiments such as the results of the introduction of penicillin treatment in the 1940s. Category III: Opinions of respected authorities, based on clinical experience, descriptive studies and case reports

15. Hierarchy of Evidence

16. Hierarchy of Evidence

17. Evaluating Evidence

18. EBP(Medicine) United States: Agency for Health Care Policy and Research (AHCPR) • Department of Health & Human Services http://www.ahcpr.gov/ • Developed many clinical guidelines to direct the EBM movement.

19. GUIDELINE TITLEEvidence-based practice guideline. Exercise promotion: walking in elders. • BIBLIOGRAPHIC SOURCE(S) Jitramontree N. Evidence-based practice guideline. Exercise promotion: walking in elders. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2007 Jun. 57 p. [95 references] GUIDELINE STATUS This is the current release of the guideline. This guideline updates a previous version: Jitramontree N. Evidence-based protocol. Exercise promotion: walking in elders. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2001 Feb. 53 p. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10948&nbr=5728

20. References Ackermann, R.T. & Williams, J.W. (2002). Rational treatment choices for non-major depressions in primary care: an evidence-based review. Journal of General Internal Medicine, 17, 293-301. American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (Rev. ed.) (4th ed.). (DSM-IVTR). Washington, DC: American Psychiatric Association. Balas, E. & Boren, S. (2000). Managing clinical knowledge for health care improvement. In J. Bemmel & A.T. McCray (ed.). In Yearbook of Medical Informatics: Patient Centered Systems (pp. 65-70). Stuttgart, Germany: Schattauer Verlagsgesellschaft. Cliliska, D., Ciliska, D. , Pinelli, J., DiCenso, A., Cullum, N. (2001). Resources to enhance evidence-based nursing practice. American Association of Critical Care Nurses: Advanced Practice in Acute and Critical Care, 12(4), 520-528.

21. References Collins, S., Vothe, T., DiCenso, A., Guyatt, G. (2005). Finding the evidence. In DiCenso, A., Guyatt, G., Clinska, D. (Eds). Evidence-Based Nursing: A Guide to Clinical Practice. PA: Elsevier; 2005 DiCenso, A., Guyatt,G., & Clinska, D. (Eds.). (2005). Evidence-Based Nursing: A Guide to Clinical Practice. PA: Elsevier. Fineout-Overholt E., Melynk, B. , Schultz, A. (2005). Transforming health care from the inside out: Advancing evidence-based practice in the 21st century. Journal of Professional Nursing, 21, 335-344. Glass, G.V. (Ed.) (1976). Evaluation Studies Review Annual, Vol. 1. Beverly Hills: SAGE Publications.

22. References Gordis L. (2008). Epidemiology (4th ed.). PA: Elsevier-Saunders. Lang, N.M., Hook, M.L., Akre, M.E., et al., (2006). Translating knowledge-based nursing into referential and executable application in an intelligent clinical information system. In Weaver, C., Delaney, C., Webber, P., Carr, R. (Eds.). Nursing and Informatics for the 21st Century: An International Look at the Trends, Cases, and the Future (pp. 291-304). Chicago: Healthcare Information and Management Systems Society. Malloch, K., Porter-O'Grady T. (2006). Introduction to Evidence-Based Practice in Nursing and Health Care. Boston: Jones and Bartlett. Melnyk, B. & Fineout-Overhold, E. (2005). Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. PA: Lippincott, Williams, & Wilkins.

23. References Newhouse, R., Dearbolt, S., Poe, S., Pugh, L., & White , K. (2005). Evidence-based practice: A practical approach to implementation. Journal of Nursing Administration. 35, 35-40. Pignone, M.P., Gaynes, B.N., Rushton, J.L., et al., (2002). Screening for depression in adults: a summary of the evidence for the US Preventive Services Task Force. Annals of Internal Medicine,136, 765-776 Simon, G.E. (2000). Long-term prognosis of depression in primary care. Bull World Health Organization, 78:439-445. Titler, M.G., Kleiber, C., Steelman, V.J., et al. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nurse Clinical North America. 13, 497-509.

24. References Theroux, R. (2006). How to bring evidence into your practice. Association of Women's Health, Obstetric and Neonatal Nurses Lifelines. 10, 244-249 US Preventive Services Task Force (May, 2002). Screening for Depression: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved August 13, 2008, from http://www.ahrq.gov/clinic/pocketgd/gcps2c.htm