Evidence-Based Practice

Infusing Quality into Practice

Goal – To Restructure Clinical Practice

• To prepare health professionals to lead in continual improvement of health care.

• To know how to use scientific evidence to identify good care.

• To know the actual measured performance gaps between good care and actual local care.

• To know what activities are necessary to close the gaps.

Why Change?

• Patient outcomes are better when evidence is used as a basis for practice.

• Nursing care is more efficient as ineffective processes are replaced.

• Errors in decision-making become less frequent

Social Trends for EBP

• Consumerism

• Magnet Hospital Status

• Cost Concerns

• Staffing

• Accreditation Requirements

• Population Health

Expectations for Magnet Hospital Status

• Transformational Leadership

• Structural Empowerment

• Exemplary Professional Practice

• New Knowledge, Innovation, and Improvement

• Empirical Outcomes

Impetus for Evidence-Based Practice

• Quality care lags behind knowledge – our best knowledge is not being implemented in patient care – Volume and complexity of literature– Form of knowledge – evidence alone is never

sufficient. There is a hierarchy of evidence – the best research evidence must be integrated with clinical expertise and patient values -EBP

The Star Model – U. of Texas - 2006

Discovery

Summary

TranslationIntegration

Evaluation

Discovery

• There is a multitude of evidence out there. MEDLINE has 4,600 journals and that’s only 30% of the world’s biomedical literature. There are over 560,000 new articles in MEDLINE every year. There are over 20,000 RCTs added annually to Cochrane Central every year. (It listed 446,156 in July 2005) There are 1500 articles and 55 new trials every day. We are overloaded with scientific evidence – quantitative studies - and can no longer keep up and assimilate all of the information.

Summary

• The EBP Solution is to provide evidence summaries – systematic reviews to reduce the volume and complexity of evidence by integrating all research results into a meaningful whole – meta-analysis

– Reduces information into a manageable form– Establishes generalizability – participants, settings, treatment

variations, study designs– Assesses consistencies across studies – Reduces biases and improves true reflection of reality– Increases power in cause and effect– Integrates information for decisions – reduces time until

implementation and offers basis for continuous updates

Rating System for Grading Levels of Evidence

• Level I – Multiple randomized controlled trials– Randomized trials with large sample sizes and

large effect sizes

• Level II– Evidence from at least one well-designed RCT– Single randomized trials with small samples

Rating System for Grading Levels of Evidence

• Level III– IIIA

• Evidence from well-designed trials without randomization

– IIIB• Evidence from studies of intact groups

• Ex-post facto and causal comparative studies

• Case/control or cohort studies

Rating System for Grading Levels of Evidence

– IIIC• Evidence obtained from time series with and without an

intervention

• Single experimental or quasi-experimental studies with dramatic effect sizes

• Level IV– Evidence from integrative reviews

– Systematic reviews of qualitative or descriptive studies

– Case series, uncontrolled studies, expert opinion

Translation

• The summary of the scientific evidence is translated into clinical recommendations (That is what AHCPR attempted with its 19 guidelines prior to 1996) AHRQ now just does meta-analysis – evidence summaries, but a National Guideline Clearinghouse and a National Quality Measures Clearinghouse are now organized to make recommendations and suggest guidelines.

Definition of an EBP Guideline

• A guide to nursing practice that is the outcome of an unbiased, exhaustive review of the research literature, combined with clinical expert opinion and evaluation of patient preferences. It is generally developed by a team of experts.

Howser (2007)

Integration

• This requires a change in professional practice at the individual, system (organizational) and environmental levels through formal and informal channels. This might be the most difficult step in the process because people’s preferences – both providers and consumers - come into play

People Needed for Integration

• Clinicians– Panels of experts

– Practice groups

– Consensus statements

• Patients– Satisfaction

– Quality of life

– Treatment burden

– Qualitative studies

Nursing Practice Use

• Nursing care processes – assessment, diagnosis, treatment, and evaluation

• Policies and procedures that guide practice in an organization

• Patient care management tools such as care maps, standard order sets, and critical paths

• Care decisions regarding individual patient needs

Howser (2007)

Evaluation

• Health outcomes, satisfaction, efficacy, efficiency, health status impact, economic analyses, etc., should be evaluated to determine endpoints and effectiveness of change.

Resources

• The Cochrane Collaboration – USA, UK, Canada, Brazil, China, Australia – quantitative, meta-analysis, randomized controlled trials (RCT) – http://www.cochrane.org/index0.htm http://www.cochrane.org/cochrane/revabstr/mainIndex.htm

• Joanna Briggs Institute – qualitative, meta-synthesis; attempt to combine themes, metaphors, categorizations into a single description of the theses that authentically represents all of the cases – cross case generalization – JBI-QARI – http://www.joannabriggs.edu.au/about/home.php

• National Guideline Clearinghouse http://www.guideline.gov• National Quality Measures Clearinghouse http://

www.qualitymeasures.ahrq.gov/• National Quality Forum http://www.qualityforum.org/

Clinical Effectiveness of EBP

– Feasibility – the extent to which an intervention or activity is practical

– Appropriateness – the extent to which an intervention or activity fits with or is appropriate in a situation

– Meaningfulness – how an intervention or activity relates to the context in which care is given and the personal experience, opinions, values, thoughts, beliefs, and interpretations of patients

– Effectiveness - evidence-based - best available evidence, not necessarily the best possible

Barriers to Translating Evidence into Practice

• Overwhelming information or contradictory findings in research or negative attitudes towards research

• Financial disincentives – no administrative support• Lack of skills, facilities, or equipment – demanding

workloads and conflicts in priorities• “Standard of Care” based on community consensus, not

evidence - peer emphasis on status quo• Lack of knowledge or skill (individual and expert)• Belief that guidelines are “cookbooks”• Misinformed lay public and patient expectations

(antibiotics)

Johns Hopkins Method of Using EBP

• Practice question– Identify an EBP question– Define the scope of the practice question– Assign responsibility for leadership– Recruit a multidisciplinary team– Schedule a team conference

Johns Hopkins Method of Using EBP cont.

• Evidence– Conduct an internal and external search for

evidence– Critique all types of evidence– Summarize evidence– Rate the strength of evidence– Develop recommendations for change in care or

systems based on the strength of the evidence

Johns Hopkins Method of Using EBP

• Translation– Determine the appropriateness and feasibility of translating

recommendations into the specific practice setting– Create an action plan– Implement the change– Evaluate the outcomes– Report the preliminary evaluation results to decision makers– Get support from decision makers to implement the change

internally– Communicate the findings

Catholic Health Initiatives (CHI)

• CHI, the organization of which Memorial Health Care System is a part, proposed that certain EBP guideline be implemented by all of its members. Members are required to implement three of the EPB guidelines in 2010 and to maintain 85% compliance with the guidelines.

• The aim is to improve safety and reduce risk.

Guidelines Selected by CHI

• Hand Hygiene– Implement the CDC guidelines and practices for hand

hygiene in the healthcare setting.

• Catheter-Associated Urinary Tract Infection– Implement standardized surveillance strategies

including identification of risk factors and recommendations for catheter use.

– Implement evidence-based catheter insertion techniques.

– Implement evidence-based care, maintenance, and removal guidelines for catheters.

Guidelines Selected by CHI

• Central Line-Associated Blood Stream Infection (Bundle)– Implement standardized surveillance strategies

including the assessment of risk factors.– Implement evidence-based techniques for the

insertion of a central venous catheter, including the use of a standardized catheter checklist.

– Implement evidence-based use, monitoring, and maintenance guideline.

Guidelines Selected by CHI

• Surgical Never Events– Implementation of the WHO Surgical Checklist.

• Pain Management– Assessment of pain as the fifth vital sign.

– Utilization of age-appropriate pain scales.

• DVT/Pulmonary Embolism– Implement surgical care improvement program

guidelines and care recommendations for DVT risk assessment and prophylaxis.

Guidelines Selected by CHI• Fall Prevention

– Assess and document all inpatients for intrinsic risk factors to fall using the Morse Fall Scale for adults and the Humpty Dumpty Scale for pediatrics.

– Assess and document the patient care environment routinely for extrinsic risk factors to fall and institute corrective care,

– Perform post-fall assessment following a patient fall to identify possible fall causes.

– Implement a multi-factorial approach to fall prevention, to include evaluation of the patient’s environment, medications, functional and cognitive status, mood, continence, and dizziness.

Guidelines Selected by CHI

• CHF Discharge Instructions– Standardized discharge instruction forms

• 2010 clinical EBP goals set by Memorial:– Central line-associated blood stream infection– Surgical never events– Pressure ulcer