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EvidenceBased Practice and Quality Care

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Title: EvidenceBased Practice and Quality Care


1
Evidence-Based Practice and Quality Care
  • Sheila Cox Sullivan, RN PhD CNE
  • Associate Chief Nurse, Research
  • CAVHS

2
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

3
  • The fact that an opinion has been widely held is
    no evidence whatever that it is not utterly
    absurd.
  • -Bertrand Russell

4
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
5
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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10
Well done!
  • Now what?
  • The last step in the Iowa Model is ….
  • DISSEMINATION!

11
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.

12
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

13
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

14
It all starts with a good question!
15
Creating a Clear Clinical Question
  • Use PICO format
  • P patient population
  • I intervention in question
  • C compared to?
  • O outcome of action

16
For Example
  • P For clients with dementia in nursing homes
  • I does animal therapy
  • C vs. no animal therapy
  • O improve quality of life?

17
You write one!
  • P
  • I
  • C
  • O

18
Sources of Literature
  • CINAHL
  • Medline/PubMed
  • AHRQ (www.ahrq.gov )
  • National Guideline Clearinghouse
    (www.guidelines.gov )
  • The Cochrane Collaboration
  • (www.cochrane.org )

19
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

20
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.

21
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
22
A bit simpler…
23
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

24
  • Plan for Implementation The 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. Vlasses Keywords Organizational
culture, Patient safety, Reliability
November/December 2008
http//www.nahq.org/journal/ce/article.html?articl
e_id298
25
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).

26
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

27
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

28
Distributing the Guideline
  • Carefully choose the unit(s) for piloting
    protocol
  • Identify champions on each unit
  • Teach the teacher sessions

29
I cant believe Im saying this…
  • I want to PUBLISH!

30
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!

31
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

32
  • 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

33
FEAR IS LIKE A FOG….
WHEN YOU WALK THROUGH IT…
NOTHING IS THERE.
-Michael Jordan
34
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.
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