Steps of Evidence Based Practice

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• Steps of Evidence Based Practice
• By
• Dr. Hanan Said Ali

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Objectives

• Enumerate the steps of EBP.
• Identify how to
• Ask burning clinical question.
• Search for best evidence.
• Critical appraise the evidence.
• Integrate the evidence to the practice.
• Evaluate the evidence based intervention.
• Explain the Controversial surrounding EBP.

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What are the steps of EBP?

• 1. Ask the burning clinical question.
• 2. Collecting the most relevant and best evidence
  to answer the clinical question.
• 3. Critically appraise the evidence for its
  validity, relevance, and applicability.

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What are the steps of EBP? Cont.

• 4. Integrate the evidence with ones clinical
  expertise, assessment of the patient condition,
  and available healthcare resources along with the
  patient preferences and values to implement a
  clinical decision .
• 5. Evaluate the change resulting from
  implementing the evidence in practice .

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1. Asking burning clinical question

• Clinical question should be asked in PICO format
• P patient population
• I intervention of interest (area of
  interest)
• C comparison intervention or status
• O outcome

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1. Asking burning clinical question Cont.

• In teenagers, how effective is Depo Provera ( the
  intervention) versus oral contraceptives ( the
  comparison intervention) in the prevention of
  pregnancy ( the outcome).
• P teenagers
• I effective of Depo Provera
• C versus oral contraceptives
• O prevention of pregnancy

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1. Asking burning clinical question Cont.

• Example of non-intervention question
• What is the duration of the breast feeding in new
  mothers who have breast related complications in
  the first 3 months after the infant birth versus
  who those do not have breast related
  complications ?

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1. Asking burning clinical question Cont.

• P new breast feeding mothers
• I breast feeding complications
• C those mothers who do not have
• complication
• O breast feeding duration.

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1. Asking burning clinical question Cont.

• In multiple clinical question, the priority
  should be given (most important or that occur
  most frequently)
• For example
• In post operative patients, how effective is
  morphine versus hydromorphone in relieving pain?
• What is the most effective intervention for
  preventing pressure sores in postoperative,
  middle- aged patients?

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1. Asking burning clinical question Cont.

• The clinical priority would be answering the
  first question because pain is a daily
  occurrence, versus seeking an answer to the
  second question because pressure ulcers rarely
  occur in postoperative, middle- aged patients

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2. Search for Best Evidence

• First begin with systematic reviews or meta-
  analyses and evidence- based clinical practice
  guidelines.
• Conclusions are drawn about the data gathered
  through this process
• e.g., How effective is massage versus
  pharmacologic agents in reducing pain in adult
  women with arthritis?
• What are the major factors that predict heart
  disease in women?

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2. Search for Best Evidence Cont.

• Evidence- based clinical practice guidelines are
  specific recommendations that are based on a
  methodologically rigorous review of the best
  evidence on a specific topic.
• They have tremendous potential ( big effort) to
• improve the quality of care.
• Improve the process of care.
• patient outcome.

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2. Search for Best Evidence Cont.

• Example
• National Guidelines Clearinghouse
• Elderly suicide Secondary prevention by the
  University of Lowa Gerontological nursing
  intervention research center (June 2002)
• 2001 Consensus guidelines for the management of
  women with cervical cytological abnormalities by
  the American Medical Association

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2. Search for Best Evidence Cont.

• If systematic review or evidence- based
  guidelines are not available, the search process
  should proceed with an investigation for original
  randomized controlled trials in databases such as
  MEDLINE or CINAHL.
• If randomized trials are not available , the
  search should continue for other types of studies
  (descriptive studies)

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3. Critical Appraisal

• These can be efficiently accomplished by
  answering three key questions
• 1. What were the result of the study?
• e.g., In intervention trials, this includes how
  large are the treatment effects.
• 2. Are the result valid?
• e.g., In intervention trials, it would be
  important to determine whether the subjects were
  randomly assigned to treatment or control groups
  and whether they were equal on key
  characteristics prior to the treatment.

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3. Critical Appraisal Cont.

• 3. Will the results of the study facilitate the
  care of the practitioners patient ?
• It include asking
• Whether the subject in the study were similar to
  the patients for whom care is being delivered?
• Whether the benefits are greater than the risk of
  treatment?

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3. Critical Appraisal Cont.

• Example
• If systematic review provide evidence to support
  the positive effects of using distraction to
  alleviate pain in post surgical patients between
  the ages of 20 and 40 years , those the same
  results may not be relevant for post surgical
  patients who are 65 years or older.

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4. Integrate the Evidence

• Integrating the evidence found from search with
  health care providers expertise, clinical
  assessment of patient and available health care
  resources as well as patient preferences to
  implement a decision.

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4. Integrate the Evidence Cont.

• Example
• If the evidence strong support certain treatment
  is beneficial (e.g. hormone replacement therapy
  to prevent osteoporosis in a very high risk
  women), discussion with the patient may reveal
  her intense fear of developing breast cancer
  while tacking HRT. As part of history taking or
  physical examination or contraindication may be
  found that increase the risk of HRT ( e.g., prior
  history of stroke).

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4. Integrate the Evidence Cont.

• Therefore,
• despite compelling evidence to support the
  benefits of HRT in preventing osteoporosis in
  high- risk women, decision against its use may be
  made after a thorough assessment of the
  individual patient and a discussion of the risks
  and benefits of treatment.

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4. Integrate the Evidence Cont.

• A clinicians assessment of healthcare resources
  that are available to implement a treatment
  decision is a critical part of the EBP decision-
  making process.

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4. Integrate the Evidence Cont.

• For Example
• On follow- up evaluation, a clinician notes that
  the first- line treatment of acute otitis media
  in a 3- year- old patient was not effective. The
  latest evidence indicates that antibiotic A has
  slightly greater efficacy than antibiotic B in
  the second- line treatment of acute otitis media
  in young children . However, because antibiotic A
  is far more expensive than antibiotic B and the
  family of the child does not have prescription
  coverage, the practitioner and parents together
  may decide to use the less expensive antibiotic
  to treat the childs unresolved ear infection.

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5. Evaluate Effectiveness

• Evaluating the evidence based intervention in
  terms of how the treatment worked or how
  effective the clinical decision was with a
  particular patient or practice setting.
• This type of evaluation is essential in
  determining whether the change based on evidence
  resulted in expected outcomes.

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5. Evaluate Effectiveness Cont.

• If the treatment did not produce the expected
  effect, outcomes analysis should include the
  formulation of all possible alternative
  explanation for the finding ( e.g., nonadherence
  to the treatment regimen by the patient, lack of
  appropriate doses of medication, different
  demographic characteristics of the providers
  patients versus those used in the studies
  reviewed).

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Controversies Surrounding EBP

• First
• It is basically new term of research utilization
  which is the use of some portion of a single
  study in practice that is similar to the manner
  in which it was used in the original study.

EBP required amore complex knowledge and skill
set.
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Controversies Surrounding EBP Cont.

• Second
• Some individuals believe that EBP is cookbook
  care in which there is disregard for the
  individualization of client care.

The incorporation of research evidence into
practice should consistently include the
patients unique clinical circumstances , his or
her preferences and values and available health
care resources.
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Controversies Surrounding EBP Cont.

• Third
• EBP contain evidence only from RCTs. Although
  data from RCTs is strongest evidence because bias
  and confounding variables are controlled through
  the use of random assignment to experimental and
  control group, evidence from other types of
  studies is recognized as valuable.

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Controversies Surrounding EBP Cont.

• Fourth
• Various experts can appraise the same data from
  studies and come to different conclusions.
• Guidelines alone have little impact if they
  cannot be translated into tools that healthcare
  providers can use in every day practice.
• Whether EBP guideline can be produced and update
  frequently enough to consider new evidence from
  the most recently studies

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Controversies Surrounding EBP Cont.

• Finally

EBP does not consider theory as well as the
humanistic aspects of care.
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Thank You