Quarterly Updates: Evidence Based Practice For Public Health Nurses Session III

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Quarterly UpdatesEvidence Based Practice For
Public Health NursesSession III

• Public Health Nursing Section, Evidence Based
  Practice Committee

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EVIDENCE BASED PUBLIC HEALTH NURSING PRACTICE
CLIENT VALUES/ PREFERENCES
CLINICAL EXPERTISE/ JUDGMENT
KNOWLEDGE/ RESEARCH
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http//www.youtube.com/watch?v2BzCXDZ1NRk
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• One of the greatest discoveries a man makes, one
  of his great surprises, is to find he can do what
  he was afraid he couldnt do.
• Henry Ford

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Objectives

• Develop an understanding of the meaning of
  critical appraisal of evidence
• Describe how levels of evidence are used in
  appraisal of evidence
• Explore how other methods (e.g. statistics) can
  be used to appraise evidence
• Apply the process for appraising evidence to
  public health nursing

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Evidence Based Practice

• Uses highest quality of knowledge in providing
  care to produce the greatest impact on health
  status and health care

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Critical Appraisal of Evidence

• Key characteristic of evidence based practice
• Core skill needed to use evidence to support
  nursing practice decisions

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Critical Appraisal of Evidence

• Ensures relevance and transferability of evidence
  from the search to the specific population for
  whom the care will be provided

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Critical Appraisal of Evidence Defined

• 1) Assessing the strength of the scientific
  evidence
• 2) Evaluating the research for its quality and
  applicability to health care decision making

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1) Strength of Evidence

• Grading of strength of evidence should
  incorporate
• Quality
• The extent to which bias was minimized (internal
  validity)
• Quantity
• The extent of the magnitude of effect, numbers of
  studies, and sample size or power.
• Consistency
• The extent to which similar and different study
  designs report similar findings

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1) Strength of Evidence

• Evidence exists on a continuum of rigor
• Amount of research attention or maturity of
  science varies, therefore evidence varies
• Type of research design reflects the strength of
  the evidence known as levels of evidence

Stevens Ledbetter, 2000
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Levels of Evidence

• Ranking as to how well the evidence informs
  clinical interventions
• The stronger the level of evidence, the greater
  the confidence that the probability of applying
  the evidence in practice will be effective
• Levels of evidence are based on research design

Stevens Ledbetter, 2000
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Levels of Evidence

• Experts have developed a number of taxonomies to
  rate strength of evidence
• Most are organized around research designs

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Levels of Evidence

• National Guidelines Clearinghouse
• Ia Evidence obtained from meta-analysis or
  systematic review of randomized controlled trials
• Ib Evidence obtained from at least one randomized
  controlled trial
• IIa Evidence obtained from at least one
  well-designed controlled study without
  randomization
• IIb Evidence obtained from at least one other
  type of well-designed quasi-experimental study,
  without randomization
• III Evidence obtained from well-designed
  non-experimental descriptive studies, such as
  comparative studies, correlation studies, and
  case studies
• IV Evidence obtained from expert committee
  reports or opinions and/or clinical experiences
  of respected authorities

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Levels of Evidence

• Rating System for the Hierarchy of Evidence
• Level I Evidence from a systematic review or
  meta-analysis of all relevant randomized
  controlled trials (RCTs), or evidence based
  clinical practice guidelines based ons systematic
  reviews of RCTs
• Level II Evidence obtained from at least one
  well-designed RCT
• Level III Evidence obtained from well-designed
  controlled trials without randomization
  (quasi-experimental)
• Level IV Evidence from well-designed
  case-control and cohort studies (studies of
  prognosis)
• Level V Evidence from systematic reviews of
  descriptive and qualitative studies
• Level VI Evidence form a single descriptive or
  qualitative study
• Level VII Evidence from the opinion of
  authorities and/or reports of expert committees
• 
  

(Melnyk Fineout-Overholt, 2005)
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Levels of Evidence

• RATING SYSTEM FOR LEVELS OF EVIDENCE
• Type of evidence
• I. Meta analysis or comprehensive systematic
  review of multiple experimental research studies
  (Cochrane , National Guidelines Clearinghouse
  (AHRQ), The Joanna Briggs Institute, Other
  groups)
• II. Well designed experimental study
• III. Well designed quasi-experimental study
  (Non-randomized controlled, Single group pre-post
  design, Cohort, Time series (one group of
  subjects over time), Matched case-controlled
  studies (two or more groups are matched on
  certain variables)
• IV. Well designed non-experimental study
  (Correlational or comparative descriptive
  studies, Case study design, Qualitative studies)
• V. Clinical examples and expert opinion (Text
  books, Non-research journal articles, Verbal
  report, Non-research based professional
  standards/guidelines/
• group article) 
• Strength of evidence
• A. Type I evidence or consistent findings from
  multiple studies from levels II, III, or IV.
• B. Multiple studies with evidence types II, III,
  or IV that are generally consistent.
• C. Multiple studies with evidence types II, III,
  or IV that are inconsistent.
• D. Limited research evidence or one type II
  study only.
• E. Type IV or V evidence only
•  
•  
•  
•  

Adapted from Joanna Briggs Institute and
AHCPR Eilers Heerman, 2005
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The U.S. Preventive Services Task Force (2008)
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Level of Certainty Description
High The available evidence usually includes consistent results from well-designed, well conducted studies in representative primary care populations. Thee studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as The number, size, or quality of individual studies Inconsistency of findings across individual studies Limited generalizability of findings to routine primary care practice Lack of coherence in the chain of evidence As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.
Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because The limited number or size of studies Important flaws in study design or methods Inconsistency of findings across individual studies Gaps in the chain of evidence Findings not generalizable to routine primary care practices Lack of information on important health outcomes More information may allow estimation of effects on health outcomes
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Systematic Reviews

• Provides state of the science conclusions about
  evidence supporting benefits and risks of a given
  healthcare practice (Stevens, 2001)
• Most powerful and useful evidence available
• Refers to summary that uses a rigorous scientific
  approach to combine results from a body of
  original research studies into a clinically
  meaningful whole

Systematic Reviews Meta Analysis
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Meta-Analysis

• Statistical approach to synthesizing the results
  of a number of studies summarizes results of
  all studies included in the review
• Produces a larger sample size and thus greater
  power to determine the true magnitude of an
  effect, yields a summary statistic

Systematic Reviews Meta Analysis
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Randomized Controlled Trial

• Experimental studies are the gold standard of
  research design (randomization of participants to
  treatment and control, rigorous methods used to
  minimize bias)
• Provides most valid, dependable research
  conclusion about clinical effectiveness of an
  intervention and establishing cause and effect
• Allows us to say with a high degree of certainty
  that the intervention we used was the cause of
  the outcome

Randomized Controlled Trials
Systematic Reviews Meta Analysis
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Quasi-Experimental

• Differs from RCTs only in that participants are
  NOT randomized to treatment and control groups

Quasi-Experimental
Systematic Reviews Meta Analysis
Randomized Controlled Trials
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Non-Experimental

• Cohort participants are studied over time,
  study population shares common characteristics
• Case-Control studies that address questions
  about harm or causation, investigates why some
  people develop a disease or behave the way they
  do vs others who do not
• Descriptive main objective is to describe some
  phenomena
• Qualitative - "any kind of research that produces
  findings not arrived at by means of statistical
  procedures or other means of quantification"
  (Strauss and Corbin, 1990, p. 17).

Non-Experimental
Systematic Reviews Meta Analysis
Randomized Controlled Trials
Quasi-Experimental
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. Clinical Examples Expert Opinion

• Expert Opinion arriving at a value judgement
  which incorporates the main information available
  on the subject as well as previous experiences
• Clinical examples
• The 5 rights

Clinical Examples Expert Opinion
Systematic Reviews Meta Analysis
Randomized Controlled Trials
Quasi-Experimental
Non-Experimental
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2) Evaluating Quality Applicability

• What are the results?
• Are the results valid?
• Can the results be applied to the targeted
  population and/or public health practice and
  intervention?

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What are the results?

• Were the results similar from study to study (if
  systematic review or meta-analysis)?
• What are the overall results?
• How precise were the results?
• Can a causal relationship be inferred from the
  data?

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Are the Results Valid?

• Does this article explicitly address our public
  health question?
• Was the search for our article detailed and
  exhaustive? Is it likely that important, relevant
  studies were missed?
• Does the study selected appear to be of high
  methodological quality?
• Do you feel the study selected is reproducible?

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Is the Evidence Applicable?

• How can the results be interpreted and applied
  to public health practice and intervention?
• Are study subjects similar to clients to whom
  care is to be delivered?
• Were all important outcomes considered?
• Are the benefits worth the costs and potential
  risks?

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Other Methods Used to Appraise Evidence

• Fineout-Overholt, E., Melynk, B.M. (2004).
  Evaluation of studies of prognosis. Evidence
  Based Nursing, 7, 4-8.
• Melynk, B.M. (2003). Finding and appraising
  systematic reviews of clinical interventions
  Critical skills for evidence-based practice.
  Pediatric Nursing, 29(2), 147-149.
• Melynk, B.M., Fineout-Overholt, E. (2005).
  Rapid critical appraisal of randomized controlled
  trials An essential skill for evidence-based
  practice. Pediatric Nursing, 31(1), 50-52.
• Melynk, B.M., Fineout-Overholt, E. (2002). Key
  steps in implementing evidence-based practice
  Asking compelling, searchable questions and
  searching for the best evidence. Pediatric
  Nursing, 22(3), 262-266.

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Other Methods Used to Appraise Evidence

• Statistical Evaluation, for example calculating
  effect size
• Effect size measures the magnitude or strength
  of the treatment or intervention effect (how
  well the intervention worked in the group who
  received the intervention vs the group that did
  not receive the intervention)
• Small, medium and large effects are designated as
  .2, .5, and .8 respectively
• Several formulas to use depending on statistical
  analysis used (e.g. t-tests, etc)
• Thalheimer, W., Cook, S. (2002, August). How to
  calculate effect sizes from published research
  articles A simplified methodology. Retrieved
  April 29, 2009 from http//www.work-learning.com/w
  hite_papers/effect_sizes/Effect_Sizes_pdf5.pdf

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Other Methods Used to Appraise Evidence

• AGREE instrument (AGREE Collaboration, London)
• http//www.agreecollaboration.org/instrument/
• AGREE is an international collaboration of
  researchers and policy makers who seek to improve
  the quality and effectiveness of clinical
  practice guidelines by establishing a shared
  framework for their development, reporting and
  assessment shared framework is the AGREE
  instrument (Appraisal of Guidelines for Research
  Evaluation).
• CATmaker (Centre for Evidence Based Medicine,
  Oxford, U.K.)
• http//www.cebm.net/index.aspx?o1216
• Is a software tool which helps you create
  Critically Appraised Topics, or CATs, for
  articles found when searching for evidence (free
  download)
• Rapid (Joanna Briggs Institute, University of
  Adelaide, Australia)
• http//www.joannabriggs.edu.au/services/rapid.php
• On-line critical appraisal of evidence training
  program
• Rap Maker is a program to appraise a study, its
  methods, findings and applicability. RAP maker
  facilitates construction of a final report, which
  may then be submitted on-line to the RAPid
  library for independent critique, then uploading
  for world wide access.

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• Search evidence rich resources first

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EBP Rich Resources for P/CHN

• Cochrane review http//www.cochrane.org/reviews/
• DARE Database of Abstracts of Reviews of
• Effectiveness http//www.mrw.interscience.wiley.co
  m/cochrane/cochrane_cldare_articles_fs.html

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Agency for Healthcare Research and Quality (AHRQ)

• National Guidelines Clearinghouse
  www.guidelines.gov
• Guide to Clinical Preventive Services (2008)
  http//www.ahrq.gov/clinic/pocketgd.htm
• Evidence reports ahrq www.ahrq.gov/clinic/epcix.ht
  m

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EBP Rich Resources for P/CHN

• Guide to Community Preventive Services
• http//www.thecommunityguide.org/index.html

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Centers for Disease Control Prevention

• CDC for Public Health Professionals
• http//www.cdc.gov/CDCForYou/public_health_profess
  ionals.html

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Association of State and Territorial Health
Officials

• Evidence Based Practice
• http//www.astho.org/?templateevidence_based_ph_p
  ractice.html

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National Association of City and County Public
Health Officials

• The Model Practices Database
• http//www.naccho.org/topics/modelpractices/
• http//archive.naccho.org/modelPractices/
• Online searchable collection of
  practices across public health areas.
• Allows you to benefit from colleagues'
  experiences, to learn what works, and to ensure
  that resources are used wisely on effective
  programs that have been implemented with good
  results.
• The database features practices in the following
  areas
• Community Health
• Environmental Health
• Public Health Infrastructure
• Emergency Preparedness

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EBP Rich Resources for P/CHN

• Health Services/Technology Assessment Text
  (HSTAT)
• http//hstat.nlm.nih.gov
• Searchable collection of large, fulltext practice
  guidelines, technology assessments and health
  information

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EBP Rich Resources for P/CHN

• Health Policy Guide
• http//www.healthpolicyguide.org/
• evidence-based policies to improve the publics
  health
• 150 policy topics to support advocacy and
  decision making at the state and local levels

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EBP Rich Resources for P/CHN

• http//guides.nursinglibrary.yale.edu/content.php?
  pid14371sid96991
• National Institute for Health clinNICE is an
  independent organisation responsible for
  providing national guidance on promoting good
  health and preventing and treating ill health.

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Evidence Based Public Health Nursing

• http//www.uic.edu/depts/lib/projects/ebphn/
• http//www.uic.edu/depts/lib/projects/ebphn/module
  smain.html
• http//www.uic.edu/nursing/aphne/

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EBP Rich Resources for P/CHN
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Application Exercise

• PICO QUESTION
• For the 4 year old pre-K age group, are there
  fewer injection site complications with giving
  the immunizations in the thigh as compared to
  giving the immunizations in the arm?

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Cochrane Review

• Tinnion O, Hanlon M. Acellular vaccines for
  preventing whooping cough in children. Cochrane
  Database of Systematic Reviews 1999, Issue 2.
  Art. No. CD001478. DOI 10.1002/14651858.CD001478
  .pub2
• Differences in trial design precluded pooling
  of the efficacy data and results should be
  interpreted with caution. Most systemic and local
  adverse events were significantly less common
  with acellular than with whole cell pertussis
  vaccines.
• Emailed page to print off

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National Guidelines Clearinghouse

• 1) General recommendations on immunization
  recommendations of the Advisory Committee on
  Immunization Practices (ACIP). 2) Update
  recommendations from the Advisory Committee on
  Immunization Practices (ACIP) regarding
  administration of combination MMRV vaccine.

http//www.guidelines.gov/summary/summary.aspx?doc
_id12325nbr006390stringvaccineANDadministra
tionANDsiteANDroute
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National Guidelines Clearinghouse

• Injection Route and Injection Site
• With the exception of Bacillus Calmette-Guerin
  (BCG) vaccine, injectable vaccines are
  administered by the intramuscular and
  subcutaneous route. The method of administration
  of injectable vaccines is determined, in part, by
  the presence of adjuvants in some vaccines. The
  term adjuvant refers to a vaccine component
  distinct from the antigen that enhances the
  immune response to the antigen. The majority of
  vaccines containing an adjuvant (e.g., DTaP, DT,
  Td, Tdap, PCV, Hib, HepA , HepB, and HPV) should
  be injected into a muscle because administration
  subcutaneously or intradermally can cause local
  irritation, induration, skin discoloration,
  inflammation, and granuloma formation.

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National Guidelines Clearinghouse

• Routes of administration are recommended by the
  manufacturer for each immunobiologic. Deviation
  from the recommended route of administration
  might reduce vaccine efficacy or increase local
  adverse reactions.

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CDC Advisory Committee on Immunization Practices

• Route
• Administering a vaccine by the recommended route
  is imperative. Deviation from the recommended
  route of administration might reduce vaccine
  efficacy or increase the risk of local reactions.
  (p. D5)

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CDC Advisory Committee on Immunization Practices

• Site
• Although there are several IM injection sites on
  the body, the recommended IM sites for vaccine
  administration are the vastus lateralis muscle
  (anterolateral thigh) and the deltoid muscle
  (upper arm). The site depends on the age of the
  individual and the degree of muscle development.
• The usual sites for vaccine administration
  subcutaneously are the thigh (for infants lt12
  months of age) and the upper outer triceps of the
  arm (for persons gt12 months of age). If
  necessary, the upper outer triceps area can be
  used to administer subcutaneous injections to
  infants.

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CDC Advisory Committee on Immunization Practices

• Injectable Vaccine Administration for Children
  Birth to 6 years
• IM
• anterolateral thigh or deltoid Use of deltoid
  muscle in children 18 monts and older (if
  adequate muscle mass) is an option for IM
  injections (p. D22)
• SC
• anterolateral thigh or lateral upper arm (p. D22)

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• Schecter, Zempsky, Cohen, McGrath, McMurtry,
  Bright (2007). Pain reduction during pediatric
  immunizations evidence-based review and
  recommendations. Pediatrics, 119(5), e1184-98.
• Evidence is limited and somewhat controversial..
• The limited data available suggests that
  intramuscular administration of immunizations
  should occur in the anterolateral thigh or
  vastus lateralis for children lt 18 months of age
  and in the upper arm or deltoid for those gt 36
  months of age.
• Controversy exists in site selection for 18 to
  36 month old children.

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Schecter, Zempsky, Cohen, McGrath, McMurtry,
Bright (2007). Pain reduction during pediatric
immunizations evidence-based review and
recommendations. Pediatrics, 119(5), e1184-98.

• The shift from thigh to arm should occur when the
  upper arm has adequate muscle mass to allow
  injection. This shift is driven by research with
  18month old infants that suggests that injection
  in the thigh is more painful and causes more
  incapacitation (decreased movement of the
  extremity, limping) than injection in the arm.
  However, redness and swelling was found to occur
  more frequently when given in the arm.

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Application Exercise

• PICO QUESTION
• For the 4 year old pre-K age group, are there
  fewer injection site complications with giving
  the immunizations in the thigh as compared to
  giving the immunizations in the arm?

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Source Level of Evidence
Cochrane Review ?
National Guidelines Clearinghouse ?
CDC Advisory Committee on Immunization Practices ?
Evidence Based Review ?
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Cochrane Review
Did the Evidence Answer our PICO Question?
National Guidelines Clearinghouse
CDC ACIP
Evidence Based Review
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RECOMMENDATIONS?