Translating Evidence into practice: using a critical eye

1. Susan Fowler, PhD, RN, CNRN, FAHA Director of Magnet, Education, Quality, & Research Translating Evidence into practice: using a critical eye

2. At the end of this presentation, attendees will: • Define evidence-based practice. • Describe critical parts of a critique of evidence. • Apply critical analysis to infection control practices. objectives

3. Evidence-Based Practice • Who does it pertain to? • What is it? • When do I use it? • Why is it important? • How do I go about evidence-based practice?

4. Mandate for ebp • Focus on outcomes and cost • Unnecessary variations in practice persist • Gap between evidence and practice • Unmanageable amounts of information

5. EBP originated in medicine. • Dr. Archie Cochrane, Epidemiologist • Crossing the Quality Chasm (IOM, 2001) • Studies in medicine and nursing indicated that interventions based on evidence have better outcomes.

7. Definition • Evidence Based Practice of nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences. • Nurse, Clinical Expertise, Patient, Evidence • Reality • We use evidence everyday without thinking about it • Sources of evidence can be too few or too many • It’s easier to base practice on myths and the way we have always done things than attempt to understand the evidence and change practice Evidence-Based Practice

8. Essentials of practice • Art • Our ability to connect to those around us • We just ‘know’ what to do to meet a patient’s emotional needs: when to hold a patient’s hand, stroke their brow, crack a joke or even just sit and listen • Calls you to the profession • Science • Body of knowledge • Uses scientific methods • Generate and test theory, discover meaning, and grow knowledge • A scholarly adventure EBP combines the art and science of nursing

9. Ask the burning clinical question (PICO). Collect the best evidence. Critically appraise the evidence. Integrate the evidence, clinical expertise, and patient factors/preferences to implement a decision. Evaluate the outcome. The Process of EBP

10. The Link Between EBP and Research • Research • Conducted a systematic & scientific manner • Follows a series of steps with a rigorous standard protocol • Purpose is to generate new knowledge • Evidence-based Practice • The process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences • Where are the similarities and differences? • Both use a process/specific approach • Both are trying to gain something – knowledge, a new way of doing something • Research more ‘rigorous’ with more steps • Research tries to gain new knowledge whereas EBP might try to confirm knowledge

11. EBP RESEARCH • Ask the burning clinical question (PICO) • Collect the best evidence • Critically appraise the evidence • Integrate the evidence, clinical expertise, and patient factors/preferences to implement a decision • Evaluate the outcome • Statement of the Problem; Purpose of the Study • Significance (WHY is this important to nursing – SO WHAT??) • Review of the Literature; Research ? • Conceptual Framework • Methods/Design/Data Collection • Data Analysis • Findings • Discussion/implications Comparing ebp & research

12. EBP Process Practice Question, Evidence, Translation (PET) Practice Question Evidence Translation (Newhouse, R.P., Dearholt, S., Poe, S., Pugh, L.C., White, K. 2005)

13. P – patient population I – intervention of interest C – comparison intervention or status O – Outcome In caring for disabled adults, does the use of level-access showers improve patient hygiene more than bed bathing??? How Do I Ask an EBP Question?

14. PICO Question • In adult surgical patients, does getting the patient out of bed ambulating help with bowel elimination more than just sitting in the chair?

15. PICO Question • In hospitalized elderly, does brushing their teeth before every meal improve the amount of food eaten compared to no oral care?

16. Levels of Evidence Level l – experimental/RCT/meta-analysis of RCTs Level II – quasi-experimental Level III – non-experimental or qualitative Level IV – opinion of experts and/or reports of nationally recognized expert committees, evidence from case reports Level V – opinion of nationally recognized experts based on experience

18. Levels of Chocoloate • Top to Bottom • Truffles • Donnelly Chocolates • Ghiradelli Chocolate bars • Hershey kisses • Fannie Farmer sample • Nestle’s Quik

19. Stevens (2005) Essential Competencies (20)From:Stevens, K. (2005). Essential competencies for evidence-based practice in nursing. (1st ed.). San Antonio, TX: ACE, UTHSCSA. • Define EBP in terms of evidence, expertise, and patient values. • Critically appraise original research reports for practice implications. • Classify clinical knowledge as primary research, evidence summary, or practice guideline. • Recognize ratings of strength of evidence when reading literature.

20. Essentialcompetencies (cont.) • Use evidence summary databases to locate systematic reviews and evidence summaries on clinical topics. • Participate on a team to develop agency-specific evidence-based clinical guidelines. • Deliver care using evidence-based clinical practice guidelines. • Choose evidence-based approaches over routine as basis for own clinical decision-making.

21. AACN Essential Competencies (1998) Related to Critical Thinking • Apply research-based knowledge from nursing and sciences as the basis for practice. • Evaluate nursing care outcomes through the acquisition of data and questioning of inconsistencies.

22. AACN essentials (cont.) Related to Provider of Care • Integrate theory and research-based knowledge from the arts, humanities and sciences to develop a foundation for practice. • Participate in research that focuses on the effectiveness of nursing interventions. • Utilize outcome measures to evaluate effectiveness of care.

23. Models • Why pick a model for EBP? • Provides an organized approach • Prevents incomplete implementation • Maximizes nursing time and resources (Gawlinski & Rutledge, 2008)

24. Depicts 3 essential cornerstones that form the foundation for professional nursing Nursing practice is the means by which a patient receives nursing care; education reflects the acquisition of the nursing knowledge and skills necessary to become a proficient clinician and to maintain competency; and research provides new knowledge to the profession and enables the development of practices based on scientific evidence. John Hopkins EBP Model & Guidelines

25. JHN Evidence-based Practice Conceptual Model Practice External Factors Internal Factors Culture Environment Equipment/Supplies Staffing Effectiveness Standards Accreditation Core Measures Legislation Licensing Standards • Research • Experimental • Quasi-experimental • Non-experimental • Qualitative • Non-Research • Organizational experience • Quality improvement • Financial data • Clinical expertise • Patient preference Education Research  The Johns Hopkins Hospital/ The Johns Hopkins University

26. Steps Step 1: Identify an EBP question Step 2: Define scope of practice question Step 3: Assign responsibility for leadership Step 4: Recruit multidisciplinary team Step 5: Schedule team conference

27. More steps Step 6: Conduct internal and external search for evidence Step 7: Critique all types of evidence Step 8: Summarize evidence Step 9: Rate strength of evidence Step 10: Develop recommendations for change in processes of care or systems based on the strength of evidence

28. Guides clinical decision-making; details implementation of EBP; considers practice & organizational perspectives • Examples (at the Univ. of Iowa Hospitals & Clinics) • Pain in acute care and outpatient settings • Assessment and intervention to decrease patients’ risk for falling while hospitalized • Facilitating visitation by family pets in acute care • Nurse retention Iowa Model of EBP

29. Iowa Model • Successfully implemented since 1994 internationally • Infuses research into practice to improve quality of care • Planned change principles integrate research and practice • Utilizes a multidisciplinary team approach • Utilizes feed-back loops

30. The Iowa Model of Evidence-Based Practice to Promote Quality Care Problem Focused Triggers Knowledge Focused Triggers Priority for Organization Consider other triggers NO YES Form a team

31. Assemble Relevant Research & Related Literature Critique and Synthesize Research for Use in Practice Sufficient Research? Pilot Change in Practice Base Practice on other Types of Evidence Conduct Research

32. Should we Adopt this change into practice? Continue to Evaluate quality Care and New Knowledge Yes No Institute Change Monitor and Analyze Structure, Process, and Outcome Data Disseminate Results

33. Selecting a Topic“The Burning Question” • Problem Focused Triggers • Risk management data • Identification of a clinical problem • QI or Financial Data • Knowledge Focused Triggers • New research or other literature • Philosophies of Care • Agencies or Organizational Standards and guidelines

34. Priority for Likelihood to Topic Idea Nursing 1=low; 5=high Organization 1=low; 5=high Improve Quality of care 1=low; 5=high Decrease LOS/ Contain Costs 1=low; 5=high Improve Patient Satisfaction 1=low; 5=high Improve Employee Satisfaction 1=low; 5=high Body of Science 1=little 5=multiple studies Setting priorities • 3 step process • EBP expert and clinician • Nursing Research Committee • Endorsement by executive leadership

35. ACE star model - The university of Texas health science center at san antonio

36. -the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes by way of EB care • Knowledge transformation is necessary before research results are useable in clinical decision making. • Knowledge derives from a variety of sources. In healthcare, sources of knowledge include research evidence, experience, authority, trial and error, and theoretical principles. • The most stable and generalizable knowledge is discovered through systematic processes that control bias, namely, the research process. • Evidence can be classified into a hierarchy of strength of evidence. Relative strength of evidence is largely dependent on the rigor of the scientific design that produced the evidence. The value of rigor is that it strengthens cause-and-effect relationships. Knowledge Transformation

37. Knowledge exists in a variety of forms. As research evidence is converted through systematic steps, knowledge from other sources (expertise, patient preference) is added, creating yet another form of knowledge. • The form ('package') in which knowledge exists can be referenced to its use; in the case of EBP, the ultimate use is application in healthcare. • The form of knowledge determines its usability in clinical decision making. For example, research results from a primary investigation are less useful to decision making than an evidence-based clinical practice guideline. • Knowledge is transformed through the following processes: • summarization into a single statement about the state of the science • translation of the state of the science into clinical recommendations, with addition of clinical expertise, application of theoretical principles, and client preferences • integration of recommendations through organizational and individual actions • evaluation of impact of actions on targeted outcomes Knowledge transformation

38. Why measure ebp outcomes? • Outcomes reflect IMPACT!!! • EBP’s effect on patients: • Physiologic, pyschosocial, function • EBP’s effect on the health system: • Decreased cost, length of stay • Nursing retention/job satisfaction • Interdisciplinary collaboration

39. A Model for ebp(Rosswurm & larrabee, 1999) • 1. Assess need for change in practice • Include stakeholders • Collect internal data about current practice • Compare internal data with external data • Identify problem • 2. Link problem, intervention, and outcome • Use standardized • Classification systems and language • Identify potential interventions and activities • Select outcomes indicators

40. Model continued • 3. Synthesize best evidence • Search research literature related to major variables • Critique and weigh evidence • Synthesize best evidence • Assess feasibility, benefits, and risk • 4. Design practice change • Define proposed change • Identify needed resources • Plan implementation process • Define outcomes

41. Model continued • 5. Implement and evaluate change in practice • Pilot study demonstration • Evaluate process and outcome • Decide to adapt, adopt, or reject practice change • 6. Integrate and maintain practice change • Communicate recommended change to stakeholders • Present staff inservice education on change in practice • Integrate into standards of practice • Monitor process and outcomes

42. A dog bit my mother-in-law three weeks ago. She has known the dog for many years, but the immunization status of the dog was unconfirmed. Her wound was small, so she did not seek treatment at that time. The biggest fear after a dog bite is contracting rabies. Rabies is a zoonotic disease (one transmitted to humans from animals) caused by a virus. Last week she went to her primary care provider (PCP) for treatment, two weeks after the initial bite. Her PCP recommended rabies post-exposure immunization. My husband, a resident physician, and I were shocked as neither of us has ever recommended the rabies immunization for post-exposure treatment in a case like hers. We both quickly consulted our databases of choice for a quick look at what we thought were the recommendations for rabies treatment. I consulted www.emedicine.com and found “Human rabies immune globulin and vaccine are recommended for bites and exposures regardless of the period between exposure and treatment unless the individual is previously vaccinated and rabies antibodies can be detected.” (2007, 11). EBP Case Story from ASU College of Nursing & Health Innovation

43. Of note, the average delay in the United States between exposure and treatment is 5 days, which does not appear to compromise successful prophylaxis. My husband consulted the Up to Date database and found “for persons who have never been vaccinated against rabies, post-exposure antirabies vaccination should always include administration of both passive antibody (HRIG) and vaccine (human diploid cell vaccine [HDCV] or purified chick embryo cell vaccine [PCECV])”. Finally we looked at the Centers for Disease Control (CDC) website and found their recommendation to be “for persons who have never been vaccinated against rabies previously, post-exposure anti-rabies vaccination should always include administration of both passive antibody and vaccine”. Post-exposure prophylaxis is a series of multiple injections around the already painful wound and follow-up is generally poor for patients (Moran, G.J. Talan, D.A. Mower, W. Newdow, M., Ong, S., Nakase, J., et al., 2000). Case continues…

44. We were frustrated and confused. It seemed that all three databases recommended that the post-exposure vaccine be given. Yet in all of the nine facilities that we have worked in across three different states, this has never been standard of care. Since I have been learning the process of evidence-based practice (EBP) and how to search the literature for the best evidence, I thought that I would apply it to this situation. A PICO question was developed to drive the search of the literature. In (p) patients with animal bites does the (i) administration of post-exposure prophylaxis (PEP) compared to (c) observation or testing of the animal only (o) provide the most appropriate treatment? Case continues…

45. I performed a quick search of the CINAHL, PubMed, and Google Scholar databases. After rapidly critically appraising the articles I found and synthesizing my findings, I know that I now have a validated response to my mother in law when I say that the post-exposure treatment of rabies is not warranted in her case. I can show her the evidence. There is even an easy algorithm to follow called the "Algorithm for Determining Appropriateness of Animal Exposure Treatments" (Moran, G.J. Talan, D.A. Mower, W. Newdow, M., Ong, S., Nakase, J., et al., 2000). My “EBP Story” shows how I have taken what I have learned in the last five months and not only applied it to my practice, but also my personal life. This week my mother-in-law’s dog drank antifreeze. Perhaps next week I will do a mini-synthesis of evidence for a recommendation on the treatment for that issue. Case…The End

46. Barriers/Challenges to EBP in Clinical Settings from Pravikoff et al., (2005). Readiness of US Nurses for Evidence-Based Practice. AJN, 105. • Lack of knowledge about EBP. • Lack of knowledge about library and online resources. • Inconvenient/inaccessible library/internet. • Misperceptions or negative views of research. • Devotion to traditional care.

47. Barriers (continued) • Overwhelming patient care load. • Voluminous amounts of literature. • Difficult patient care situations. • Organizational constraints. • Inadequate information in prelicensure nursing program. • Laziness/lack of motivation/ burnout.

48. EBP Facilitators – Adds to success • Educational emphasis in nursing schools and hospitals. • Administrative support and encouragement. • Time to think through patient care situations. • Time to critically appraise studies and implement findings. • Clearly written, well-done research reports. • Library and internet access in the clinical area.

49. Strategies to advance ebp • Enhance critical appraisal skills • Discuss of findings • Journal Clubs • Systematically examine the stage of adoption of practice guidelines • Facilitate systematic reviews • Facilitate primary research • EBP Grand Rounds • Scholar in Residence • Web Support/Toolbox • Research corner in newsletter

50. APIC (2000, 2011) • Behavioral management science • Surveillance standards • Infection prevention resource optimization • Standardization in infection prevention practices and program resource allocation Directions for EBP and Research