Transcript Evidence - Based Practice

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
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Consumerism
Magnet Hospital Status
Cost Concerns
Staffing
Accreditation Requirements
Population Health
Expectations for Magnet Hospital
Status
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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
Evaluation
Summary
Integration
Translation
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
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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
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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