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Steps 0, 1 and 2 of EBP:From Igniting a Spirit of

Inquiry to Searchingfor Best Evidence

Ellen FineoutEllen Fineout--Overholt Overholt PhD, RN, FNAP, FAANPhD, RN, FNAP, FAANDean & Professor Groner School of Dean & Professor Groner School of

Professional StudiesProfessional StudiesChair, Department of NursingChair, Department of NursingEast Texas Baptist UniversityEast Texas Baptist University

EBP ProcessEBP ProcessIgnite a Spirit of Inquiry: What Do Clinicians Care About?

Formulate a Searchable, Answerable Question: Using PICOT

Streamlined, Focused Search

Rapid Critical Appraisal, Evaluation & Synthesis of Evidence

Apply Valid, Reliable & Relevant Evidence

Generate Evidence Internal: OM, QI

External: Research

Evaluate Outcomes & Disseminate Results

Step 0: Step 0: Ignite a Spirit of InquiryIgnite a Spirit of Inquiry

Who can I seek out to assist me in enhancing my EBP knowledge and skills, and serving as my EBP mentor?

What practices of mine are currently evidence-based and which do not have any evidence to supportand which do not have any evidence to support them?

When and with whom is it the best time to question my current clinical practices?

Where can I find the best evidence to answer my clinical questions?

Why am a doing what I do with my patients?How can I become more skilled in EBP and mentor

others to implement evidence-based care?

Step 1:Step 1:Ask the PICOT QuestionAsk the PICOT Question

P P –– PPatient atient ppopulation opulation of of interestinterestI I –– IInterest area/nterest area/IInterventionnterventionC C CC i f i f C C –– CComparison group or area of omparison group or area of

interestinterestO O –– OOutcome utcome of interestof interestT T –– TTime for the intervention to ime for the intervention to achieve the outcomeachieve the outcome

The PICOT QuestionThe PICOT Question

In In premature infants premature infants (P), how (P), how does does musicmusic (I) compared to (I) compared to massagemassage (C) affect (C) affect oxygenationoxygenation

ii (O) d i d (O) d i d saturationsaturation (O) during and (O) during and immediately after a procedure immediately after a procedure (T)?(T)?

Patient Scenario: TherapyA 40 A 40 year old year old Asian man is admitted to Asian man is admitted to

the GI unit after 3the GI unit after 3--days of severe days of severe nausea and vomiting. His medical and nausea and vomiting. His medical and social histories are benign. The only social histories are benign. The only drug he is taking is acetaminophen, 1 drug he is taking is acetaminophen, 1 gram three times a day, for a backache gram three times a day, for a backache –– reportedly attributed to a vigorous reportedly attributed to a vigorous workout 3 days ago. His K+ is 3.0 and workout 3 days ago. His K+ is 3.0 and he is suffering from periods of he is suffering from periods of lightheadedness. Otherwise, lightheadedness. Otherwise, his his physical exam is benign. physical exam is benign.

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The The patient was found to have a hepatitis patient was found to have a hepatitis B infection, for which he will receive B infection, for which he will receive appropriate treatment. The patient’s appropriate treatment. The patient’s wife tells you she has heard that wife tells you she has heard that acetaminophen can cause liver acetaminophen can cause liver problems She wants him to stop problems She wants him to stop

Patient Scenario: Therapy

problems. She wants him to stop problems. She wants him to stop taking the drug, given his diagnosis, taking the drug, given his diagnosis, and wonders what alternatives exist for and wonders what alternatives exist for back pain. She has heard that yoga back pain. She has heard that yoga may be good, but thinks her husband may be good, but thinks her husband may not get “into it.” She asks you may not get “into it.” She asks you whether simple whether simple stretching exercises stretching exercises could work as well as yoga in improving could work as well as yoga in improving his back pain?his back pain?

PI

Middle aged Asian males

P I C O T

ICOT

Yoga

Stretching before working out

Back pain

After working out

Template: Formulating a Template: Formulating a Therapy/Intervention Therapy/Intervention QuestionQuestion

In In ___________________ ___________________ (P), how does (P), how does

(I) (I) compared to compared to ________(I) ________(I) compared to compared to ___________(C) ___________(C) affect affect _________ _________ (O)_____________ (T)? (O)_____________ (T)?

Searchable Question Searchable Question about Interventionsabout Interventions

InIn middlemiddle--aged Asian aged Asian malesmales, , how does how does yogayogamalesmales, , how does how does yogayogacompared to compared to sstretching tretching before working out before working out affect affect back pain after working back pain after working outout??

Levels Levels of of Evidence for InterventionsEvidence for Interventions

Evidence obtained from well-designed controlled trials

Systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), Evidence-based clinical practice guidelines based on systematic reviews of RCTs

Evidence obtained from at least one well-designed RCT

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without randomization and from well-designed case-control and cohort studies

Evidence from systematic reviews of descriptive and qualitative studies

Evidence from a single descriptive or qualitative study

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Evidence from the opinion of authorities and/or reports of expert committees

Patient ScenarioPatient Scenario: : MeaningMeaningYou are on the planning committee for You are on the planning committee for

developing family centered care in developing family centered care in your ICU. To design the most your ICU. To design the most responsive unit for families, you responsive unit for families, you would like to present the best and would like to present the best and would like to present the best and would like to present the best and latest evidence to the members of latest evidence to the members of your planning committee that your planning committee that support an environment that meets support an environment that meets the needs of the families who have a the needs of the families who have a relative hospitalized in the ICUrelative hospitalized in the ICU. .

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Identify the Elements of Identify the Elements of the Questionthe Question

PI

Family members

Critically ill patients

COT

N/A

Needs

During ICU LOS

Template: Formulating a Template: Formulating a Meaning Meaning QuestionQuestion

How do(How do(eses) __________(P) ) __________(P) i h (I) i h (I) with ____________ (I) with ____________ (I)

perceive ________ (O)perceive ________ (O)during____(T)? during____(T)?

Template: Formulating a Template: Formulating a Meaning Meaning QuestionQuestion

How do(How do(eses)family members)family members(P), (P), with with a relative hospitalized in the a relative hospitalized in the with with a relative hospitalized in the a relative hospitalized in the ICUICU (I )perceive (I )perceive their needstheir needs(O) (O) duringduring the hospitalization of their the hospitalization of their relativerelative(T)? (T)?

Levels of Levels of Evidence for MeaningEvidence for Meaning

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Evidence from systematic reviews of descriptive and qualitative studies

Evidence from a single desc ipti e o q alitati e

© Fineout-Overholt & Melnyk, 2008

© Fineout© Fineout--Overholt, Overholt, 20082008

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Evidence from the opinion of authorities and/or reports of expert committees

descriptive or qualitative study

Godiva Truffles

Donnelly Chocolates

Ghirardelli Chocolate Bars

Levels of… Levels of… ChocolateChocolate

Hershey Kisses

Fannie Farmer Sampler

Nestle’s Quik

“Inspirational quotes are fine, but you’ll motivate more people with chocolate.”

Your TurnYour Turn

Codes seem to be increasing Codes seem to be increasing on your unit and throughout on your unit and throughout the hospital. You have heard the hospital. You have heard ppthat a rapid response team that a rapid response team may be a good idea, but you may be a good idea, but you want to gather the evidence.want to gather the evidence.

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The The PICOT QuestionPICOT Question

What kind of question needs to be asked?What kind of question needs to be asked?What are the elements?What are the elements?How would you frame the question?How would you frame the question?What kind of study would you look for as What kind of study would you look for as What kind of study would you look for as What kind of study would you look for as best evidence to answer the question?best evidence to answer the question?

“In “In hospitalized adultshospitalized adults (P), how does a (P), how does a rapid response teamrapid response team (I) compared (I) compared with with no rapid response teamno rapid response team (C) (C) affect affect the number of cardiac arreststhe number of cardiac arrestsaffect affect the number of cardiac arreststhe number of cardiac arrests(O) and (O) and unplanned admissions to the unplanned admissions to the ICUICU (O) during a (O) during a threethree--month periodmonth period(T)?” (T)?”

Step 2: Search for the Step 2: Search for the Best EvidenceBest Evidence

The The Next Next

Step in EBPStep in EBP

Where to Search for EvidenceWhere to Search for EvidenceWebWeb--based based sitessites

PubMedPubMedhttphttp://www.pubmed.gov://www.pubmed.gov

National Guideline National Guideline Clearinghouse Clearinghouse

PrePre--appraised appraised LiteratureLiterature

http://ebn.bmjjournalhttp://ebn.bmjjournals.coms.com//

gghttp://www.guideline.govhttp://www.guideline.gov

Electronic Electronic databases databases

MedlineMedlineCINAHLCINAHLPsycInfoPsycInfoCochrane Cochrane DatabasesDatabases

Hand Hand searchingsearching

Search Techniques:database language

Enter the Enter the keywordkeyword guided by the guided by the PICOT questionPICOT question, then use , then use controlled vocabularycontrolled vocabulary, if , if

il blil blavailableavailableControlled vocabulary (Controlled vocabulary (MeSHMeSH) headings ) headings

((mhmh))Natural Natural language (language (twtw) or ) or KeywordsKeywords

Search Techniques: Limiting your final search

Language Language (English)(English)Human Human Abstract/Full textAbstract/Full textAbstract/Full textAbstract/Full text (PY) Publication year (PY) Publication year Age groupAge groupType of studyType of study

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Search Techniques: Combining Searches

AND

Rapid response

team

No rapid response team

Code ratesUnplanned ICU admissions

Non DNR/ICU mortality

AND

Find the DatabasesFind the Databases

CINAHLCINAHLCOCHRANECOCHRANEPUBMEDPUBMEDPUBMEDPUBMED

Searching Guided by the PICOT Searching Guided by the PICOT QuestionQuestion

Searching Guided by the PICOT Searching Guided by the PICOT QuestionQuestion

Searching Guided by the PICOT Searching Guided by the PICOT QuestionQuestion

Searching Guided by the PICOT Searching Guided by the PICOT QuestionQuestion

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Searching Guided by the PICOT Searching Guided by the PICOT QuestionQuestion

Searching Guided by the PICOT Searching Guided by the PICOT QuestionQuestion

Searching Guided by the PICOT Searching Guided by the PICOT QuestionQuestion

SummarySummaryStrategies for an Efficient Search Strategies for an Efficient Search

for Relevant Evidencefor Relevant Evidence

Formulate a well-built clinical

question Enter keyword and subject heading (if available) guided by PICOT

Determine type of database to provide best evidence (search at least

two)

Determine type of study design to best answer the question

Combine searches using Boolean connector AND

Limit final search by English, Human

Use other limits cautiously

Apply inclusion /exclusion criteria

NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, NEVER, QUIT!QUIT!

Winston ChurchillWinston Churchill

DREAM BIG, BELIEVE, DREAM BIG, BELIEVE, PLAN WELL & PERSIST THROUGH PLAN WELL & PERSIST THROUGH

THE CHARACTERTHE CHARACTER--BUILDING TIMESBUILDING TIMES

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Contact Information: Contact Information: Ellen.Fineout.Overholt@gmail.comEllen.Fineout.Overholt@gmail.com

Content of this presentation is copyrighted. Use without permission of the author is Content of this presentation is copyrighted. Use without permission of the author is prohibited. © Fineoutprohibited. © Fineout--Overholt, 2013Overholt, 2013