EvidenceBased Practice and Quality Care

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Evidence-Based PracticeandQuality Care

• Sheila Cox Sullivan, RN PhD CNE
• Associate Chief Nurse, Research
• CAVHS

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Objectives

• Define evidence-based nursing practice
• Discuss the Iowa Model for implementing EBP
• Evaluate the essential components of an
  evidence-based practice protocol
• Apply strategies for dissemination of results

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• The fact that an opinion has been widely held is
  no evidence whatever that it is not utterly
  absurd.
• -Bertrand Russell

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Here is one way to look at EBP

• The stark reality is that we invest
  billions in research to find appropriate
  treatments, we spend more than 1 trillion on
  healthcare annually, we have extraordinary
  capacity to deliver the best care in the world,
  but we repeatedly fail to translate that
  knowledge and capacity into clinical practice.

IOM, 2003 Priority Areas for National Action
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EBP Definition

• Merging personal clinical expertise with the
  best available research results according to
  patient preferences and values.
• -Sackett, et al, 1996

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Well done!

• Now what?
• The last step in the Iowa Model is .
• DISSEMINATION!

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A word of caution

• Please check and follow your institutions
  guidelines on Quality Improvement/EBP
  Projects/Research using human subjects.
• The current trend is zealous protection of human
  subjects, and studies/projects not approved by an
  IRB are not eligible for dissemination out of
  your institution/system.
• More importantly, there is the ethical issue of
  using humans as test subjects without their
  knowledge or consent.

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Methods of Dissemination

• Policy changes within facility via guidelines
• Education within facility
• Poster, Podium, or Panel Presentations
• Publication in Nursing Journals
• Journal Clubs
• Media/Testimony to Influence Health Policy

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Purpose of EBP Guidelines

• Promote delivery of high quality care
• Reduce inappropriate variations
• Assist practitioners in decision making
• Advance evidence-based practice
• Hold practitioners accountable
• Rationalize change in practice

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It all starts with a good question!
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Creating a Clear Clinical Question

• Use PICO format
• P patient population
• I intervention in question
• C compared to?
• O outcome of action

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For Example

• P For clients with dementia in nursing homes
• I does animal therapy
• C vs. no animal therapy
• O improve quality of life?

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You write one!

• P
• I
• C
• O

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Sources of Literature

• CINAHL
• Medline/PubMed
• AHRQ (www.ahrq.gov )
• National Guideline Clearinghouse
  (www.guidelines.gov )
• The Cochrane Collaboration
• (www.cochrane.org )

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Strength of Recommendations

• The U.S. Preventive Services Task Force
  (USPSTF) grades its recommendations according to
  one of five classifications (A, B, C, D, I)
  reflecting the strength of evidence and magnitude
  of net benefit (benefits minus harms).
• A. The USPSTF strongly recommends that
  clinicians provide the service to eligible
  patients good evidence that the service
  improves important health outcomes and concludes
  that benefits substantially outweigh harms.
• B. The USPSTF recommends that clinicians provide
  this service to eligible patients at least
  fair evidence that the service improves
  important health outcomes and concludes that
  benefits outweigh harms.

• U.S. Preventive Services Task Force Ratings
  Strength of Recommendations and Quality of
  Evidence. Guide to Clinical Preventive Services,
  Third Edition Periodic Updates, 2000-2003.
• Agency for Healthcare Research and Quality,
  Rockville, MD. http//www.ahrq.gov/clinic/3rduspst
  f/ratings.htm

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Strength of Recommendations (cont)

• C. The USPSTF makes no recommendation for or
  against routine provision of the service. at
  least fair evidence that the service can
  improve health outcomes but concludes that the
  balance of benefits and harms is too close to
  justify a general recommendation.
• D. The USPSTF recommends against routinely
  providing the service to asymptomatic patients.
  at least fair evidence that the service is
  ineffective or that harms outweigh benefits.
• I. The USPSTF concludes that the evidence is
  insufficient to recommend for or against
  routinely providing the service. Evidence that
  the service is effective is lacking, of poor
  quality, or conflicting and the balance of
  benefits and harms cannot be determined.

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Quality of Evidence

• The USPSTF grades the quality of the overall
  evidence for a service on a 3-point scale (good,
  fair, poor)
• Good Evidence includes consistent results from
  well-designed, well-conducted studies in
  representative populations that directly assess
  effects on health outcomes.
• Fair Evidence is sufficient to determine effects
  on health outcomes, but the strength of the
  evidence is limited by the number, quality, or
  consistency of the individual studies,
  generalizability to routine practice, or indirect
  nature of the evidence on health outcomes.
• Poor Evidence is insufficient to assess the
  effects on health outcomes because of limited
  number or power of studies, important flaws in
  their design or conduct, gaps in the chain of
  evidence, or lack of information on important
  health outcomes.

U.S. Preventive Services Task Force Ratings
Strength of Recommendations and Quality of
Evidence. Guide to Clinical Preventive Services,
Third Edition Periodic Updates, 2000-2003.
Agency for Healthcare Research and Quality,
Rockville, MD. http//www.ahrq.gov/clinic/3rduspst
f/ratings.htm
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A bit simpler
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Guideline Content

• Introduction outlining the need
• Evidence statement
• Levels of evidence
• Critical Appraisal
• Key references
• Recommendations (graded)
• Implementation discussion points
• Patient education
• Evaluation process
• Algorithms

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• Plan for ImplementationThe following outline is
  recommended for use by nurse managers who want to
  apply the principles of reliability science to
  create a culture of safety on their unit.
• 1. Educate yourself. Become an expert in the
  principles of reliability science and understand
  the link between the principles and how they can
  assist in creating a culture of safety.
• 2. Create a committee of your staff members that
  will be responsible for assisting you in
  implementing your plan. You can ask for
  volunteers, or you can select staff that you feel
  will be proactive and open to change. It is
  essential to have direct staff involvement in the
  implementation of your plan, because the plan
  will directly affect the manner in which they
  think about and deliver patient care.
• 3. Perform a needs assessment to evaluate the
  current culture of safety on your unit. It is
  difficult to implement change to a patient safety
  culture without knowing what the current culture
  of the unit is. Direct-care nurses can offer you
  the best information about the current culture.
  Also, AHRQ has a patient safety culture survey
  tool available on its Web site (www.ahrq.gov/qual/
  hospcul/).
• 4. Using the results of the needs assessment,
  prepare a plan for integrating the principles of
  reliability science into the daily operations of
  your unit.
• 5. Present the results of the needs assessment
  and your plan for implementation to your direct
  supervisor. Be sure to include the reasons that
  using the principles of reliability science is
  important in creating a patient safety culture
  and the reasons you believe that this change is
  necessary. It will be easier for you to implement
  the plan with the support of your direct
  supervisor.
• 6. Educate and train your staff regarding the
  principles of reliability science. Take time out
  to discuss the plan during staff meetings or
  create separate educational sessions. Be as
  creative as you like. Use any method that you
  feel works well with your staff.
• 7. Implement and evaluate your plan. After
  implementation, you must constantly evaluate the
  results. Keep what works and change what does
  not. Do not get discouraged if the initial
  results are not what you expected. You are
  attempting to change a way of thinking and an
  organizational culture that has existed for many
  years. This type of change can be painstaking and
  slow, and you may not see immediate results.
• 8. Present your results to your direct
  supervisor. He or she will want to know about
  your progress and may ask you to present your
  results to executive-level leadership. Be
  prepared to ask for assistance and support when
  necessary.

JHQ CE 210 Creating a Safety Culture Through the
Application of Reliability Science Kerri Fei,
Frances R. VlassesKeywords Organizational
culture, Patient safety, Reliability
November/December 2008
http//www.nahq.org/journal/ce/article.html?articl
e_id298
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Evaluating an EBP Protocol

• IOM
• Validity
• Reliability and Reproducibility
• Clinical Applicability
• Clinical flexibility
• Clarity
• Documentation
• Development by a multidisciplinary process
• Plans for Review
• (Craig Smyth, 2002).

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AGREE document

• http//www.agreecollaboration.org
• 6 domains, 23 items
• Scope and Purpose
• Stakeholder involvement
• Rigor of Development
• Clarity and Presentation
• Applicability
• Editorial independency
• For use by policy makers, guideline developers,
  providers, and educators

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Know how to critique guidelines

• Makes it easier to write one!
• Use the guides as a template and ensure that all
  the concerns are addressed
• Use the guidelines during the planning phase to
  ensure multidisciplinary participation and
  increase compliance after release

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Distributing the Guideline

• Carefully choose the unit(s) for piloting
  protocol
• Identify champions on each unit
• Teach the teacher sessions

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I cant believe Im saying this

• I want to PUBLISH!

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Where do I begin?

• Writing a manuscript is telling your story to
  other scientists in a concise way
• Generally, technical writing is the preferred
  style
• Avoid first person
• Avoid passive voice
• Be thorough but concise
• This is not creative writing!

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General Structure of a Paper

• EBP
• Introduction Provide rationale, including
  significance, and context for the study
• Study question PICO
• Literature Search Describe
• Search Methods
• Databases
• Keywords
• Results
• Rationale for inclusion/exclusion
• Summarize the literature
• Discuss how studies were critiqued and grading of
  the evidence

• Research
• Introduction Provide the rationale and the
  context for the study
• Background Summarize the literature
• The Study
• Aims
• Design/Methodology
• Sample/Participants
• Data Collection
• Validity and Reliability/Rigor
• Ethical Considerations
• Data Analysis

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• Research
• Results/Findings
• Discussion
• Conclusions
• Acknowledgements/ Conflict of Interest Disclosures

• EBP
• Results share your protocol
• Distinguish between DOE and POEM
• Discuss outcomes that you measured
• Patient results
• Process information
• Cost efficacy

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FEAR IS LIKE A FOG.
WHEN YOU WALK THROUGH IT
NOTHING IS THERE.
-Michael Jordan
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Resources

• Beyea, S. C., Slattery, M. J. (2006)
  Evidence-based practice in nursing A guide to
  successful implementation. Marblehead, MA HCPro,
  Inc.
• Ingersoll, G.L. (2000). Evidence-based nursing
  What it is and what it isnt. Nursing Outlook.
  48(4), pp. 151-152.
• Melnyk, B. M. Fineout-Overholt, E. (2005).
  Evidence-based practice in nursing and
  healthcare. Philadelphia Lippincott, Williams
  Wilkins.
• Sackett, D. L., Rosenberg, G., Gray, J. M.,
  Haynes, R. B., and Richardson, W. S. (1996).
  Evidenced-based medicine How to practice and
  teach EBM. New York Churchill Livingstone
• Siwek, J., Gourley, M.L., Slawson, D. C.,
  Shaughnessy, A. F. (2002). How to write an
  evidence-based clinical review article. American
  Family Physician, 65, 251-258.
• Sullivan, S. C. (2007). Evidence-based practice.
  In Concepts of the nursing profession. Pofliko,
  K. ed. Clifton Park, NY Thomson.
• Titler MG, Kleiber C, Rakel B, Budreau G, Everett
  LQ, Steelman V, Buckwalter KC, Tripp Reimer T,
  Goode C (2001). The Iowa Model of Evidence-Based
  Practice to Promote Quality Care. Critical Care
  Nursing Clinics of North America, 13(4)497-509.
• University of North Carolina Health Sciences
  Library. (2003). Evidence-based Nursing.
  Retrieved 8 Feb, 2008 at http//www.hsl.unc.edu/Se
  rvices/Tutorials/EBN/intro.htm
• Webb, C. (2005). Writing for publication. Oxford
  Blackwell Publishing, LTD.