evidence based practice in all
TRANSCRIPT
Building Evidence-Based Practice into All Areas of
Dietetics
Linda Farr RD/LDTDA Delegate 2007-2012 Owner Nutrition Associates of San [email protected]
Presentation Objectives Define Evidence-Based Dietetics
Practice
Discuss the benefits of using EBP
Outline the EBP process
Discuss areas for EBP implementation
Why is EBP important?
Evidence-based practice will position the profession for improved reimbursement, recognition, and quality
services.
What is Evidence-Based Practice?
• The use of systematically reviewed scientific evidence in making food and nutrition practice decisions
• Achieved by integrating best available evidence with professional expertise and client values to improve outcomes
Source: ADA Scope of Dietetics Framework Definition of Terms 2007
ADA Definition
Key Considerations1. EBP is based on the best available
evidence including research, national guidelines, policies, consensus statements, expert opinion and quality improvement data.
2. EBP involves continuing evaluation of outcomes.
3. EBP involves complex and conscientious decision-making based not only on the available evidence but also on client/customer/community characteristics, situations, and preferences.
Clinical Expertise
Client values
Clinical State
Evidence
Adapted from: IOM Model for Evidence-Based Clinical Decisions ACP Journal Club, March/April 2002
Clinical Setting
Code of Ethics Supports EBPPrinciple 12: The dietetics practitioner
practices dietetics based on evidence-based principles and current information.
Principle 13: The dietetics practitioner presents reliable and substantiated information and interprets controversial information without personal bias……
Nutrition Care Process supports EBP
March 2003
The Nutrition Care ProcessMiddle Ring:
Characteristics of the RD & DTR:
• Evidence-based Practice
• Code of Ethics – Principles 12 & 13
• Critical Thinking
• Skills/Competencies
• Critical thinking
The Nutrition Care Process
Relationship is based on:
• Understanding the client’s values and incorporating them into the intervention plan
•Client’s trust in our competence & our recommendations
The NCP Core: Relationship between the RD-DTR & the client
Why use Evidence-Based Practice?
Explosion of Literature
• Over 10,000 new research articles added to MedLine annually
• Estimated that clinicians must read ~20 articles a day to keep up!
Unmet Information Needs
Questions from clients and other stakeholders are continuously
being generated.
Implementation Delays
Research findings are often delayed in implementation. It can take 10 to 20 years for original research to be put
into clinical practice• http://www.ahrq.gov/RESEARCH/trip2fac.htm
Need for Data on MNT Effectiveness
There is limited data on MNT effectiveness beyond diabetes and lipid disorders.
Relatively speaking, there is limited nutrition research; especially that targets the RD.
Importance of collecting outcomes/data
Ensure progress of profession
Reimbursement
No data no research
No research no evidence
No evidence no basis for practice standards
Align our profession with other medical fields basing their practice on evidence
There is limited nutrition research
Standardization of Practice
There is a significant gap between best research evidence and application of
evidence to practice. Nutrition support is not always applied effectively or
consistently, despite available scientific evidence
that could be used to enhance a given treatment protocol.
Benefits of EBP• Provides RDs and DTRs with an overarching
foundation for patient care and customer service – a disciplined approach for how we practice
• Supports the relationship we have with our clients – they trust us & expect us to provide the “best care”
• Facilitates use of the rapidly expanding body of nutrition knowledge
• Reduces the gap between research and day-to day practice
Personal Benefits of EBP• Enhances our status on the health care team • Enhances our confidence – the EAL is a great resource to
support our recommendations to team members & payers
• Provides a sense of satisfaction – Measuring outcomes allows us to see that we make a difference
• Promotes effective time management
• Promotes compliance with regulations for MNT, e.g. Medicare part B
• Limits the basis for litigation
Bottom Line BenefitsEBP leads to:
• Improved quality of care • Increased patient safety • Decreased variation in practice • Efficient use of resources• Increased likelihood of achieving desired
patient outcomes• Improved client, provider & payer
satisfaction• Increased likelihood of coverage for MNT
The Development of EBP includes….
Five Fundamental Steps.
Evidence-Analysis Process Steps
1. Select topic & appoint expert work group
2. Define questions and determine inclusion/
exclusion criteria
3. Conduct literature review for each question
4. Analyze Articles/Critical Appraisal
5. Overview Table& Evidence summary
6. Develop conclusionstatement & assign grade
7. Publish to online EAL
Guidelines Methodologies Used
http://www.cebm.net/
http://www.nhlbi.nih.gov/
http://www.icsi.org/
Whenever possible we don’t “reinvent the wheel.”
Expert Workgroup
• Experts in field• Appointed by Evidence-
based Practice Committee (oversight group)
• Balance of researchers and practitioners
• Assists in question development
• Review work of analysts and provide final approval
Evidence Analysts
• Experts in critically analyzing articles
• Must have at least Master’s degree; many have PhD’s
• Trained at ADA’s EA workshop
• Mentored by ADA Staff and Lead Analysts
• Read and analyze articles
Step 4--Critical Appraisal of Each Article
• Completes worksheet• Completes quality criteria
checklist • Completes overview tables• Completes evidence
summaries.• Most detailed information
on EAL
Responsibility of analyst
• Reviewed by lead analyst
• Approved by workgroup
Step 5--Evidence Summary
• Summarize articles into Overview Table• Information synthesized from articles in
to narrative evidence summary
• Responsibility of Evidence Analyst
• Reviewed by Lead Evidence Analyst
• Reviewed and Approved by Work Group
Evidence Summary: narrative summary
Evidence Table
Step 6--Conclusion and Grade
• Drafted by Analyst• Reviewed, Approved and
Graded by Work Group
• Bottom Line – Answer to question based on the science
• Determined after research analyzed• Graded based on quality of supporting evidence
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Conclusion Statement Grading
Table
Guideline Development
Step 9--Recommendations
• Drafted by Lead Analyst• Reviewed, Approved and
Rated by Work Group
• Translation of the evidence into a course of action for the RD
• State “what to do” and “why” for the RD• Links to supporting analyzed evidence• Provides “transparency”• Conditional rating=for a specific population• Imperative rating=for a broad range
Recommendation Examples• Dietary sodium intake should be limited to no more
than 2300 mg sodium (100 mmol) per day. Reduction of dietary sodium to recommended levels lowers systolic blood pressure by approximately 2 - 8 mmHg.
Rating: StrongImperative
• If the critically ill ICU patient is hemodynamically stable with a functional GI tract, then EN is recommended over PN. Patients who received EN experienced less septic morbidity and fewer infectious complications than patients who received PN. In the critically ill patient, EN is associated with significant cost savings when compared to PN
Rating: Strong Conditional
Strong, Imperative
Recommendation on the EAL
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Toolkit Development
Features of Evidence-Based Toolkits
Set of companion documents for application of the practice guideline
Disease/condition specific
Include:• documentation forms• outcomes monitoring sheets• client education resources• case studies • MNT protocol for treatment of disease/condition
Incorporate Nutrition Care Process/SL as the standard for care
Electronic downloadable purchase item
Client Education Materials: 5-6th grade reading level
How do I implement Evidence-Based Practice?
Access EBP Resources ADA’s Evidence Analysis Library
www.adaevidencelibrary.com A compilation of systematic reviews on a
variety of topics
Evidence-based Nutrition Practice Guidelines
Free ADA member benefit ! (Cost to non-members-- $400)
Access Other EBP Resources
Society for Critical Care Medicine Clinical Guidelines
Canadian Clinical Guidelines UpToDate.com Clinical Reference Cochrane.org Database of
Systematic Reviews Zynxhealth.com Evidence NHLBI Clinical Guidelines
How do I practice when there’s no evidence?
-- Lack of evidence is NOT the same as lack of
effectiveness
Action Steps-Client Care Settings• Use critical thinking skills & clinical
expertise
• Make data-driven decisions• Use existing data• Collect data when none exist• Evaluate programs and services to make
improvements
• Contribute to the body of evidence through outcomes research• Publish and/or present results of outcomes
research
Is Evidence-Based Dietetics Practice for all ADA members?
A Role for All Members• ADA Code of Ethics – Principles 12 & 13
• Understand the importance of EBP to the profession• Foundation for our Future• Respect from policy makers, payers and other
providers
• Support other members in implementing & using EBP• Role as Delegates - Affiliates and DPGs• Mentor Students and Dietetic Interns (CADE
standards)• Students mentor your preceptor
A Role for All Members• Practice based on up-to-date
research
• Use evidence-based methods
• Use evidence-based resources:• ADA Position Papers• JADA articles – look for the EAL icon• On-line JADA – link to articles with EAL content
• Promote ADA’s use of EBP to others
Incorporate Research into EBP Develop research policy Create job responsibility requirement Insert research in evaluation process Schedule time to work on research Provide Collaborative Institutional Review
Board (IRB) Training Initiative (CITI) training, CITI training program log-on to www.citiprogram.org
Provide Institutional Review Board support
Incorporate Research into EBP Train a manager in research skills Create project accomplishment
reporting system Praise research accomplishments Become a DBPRN member Volunteer to be an ADA Evidence Analyst Develop a research culture
Examples of Practice Areas for Research Food service Community Research Clinical inpatient care Private practice Long term care Nutrition support
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EAL Tutorial Check out the EAL TUTORIAL
Complete the four 10-12 minute modules and receive 1 FREE CPE.www.eatright.org/ealtutorial
Evidence Analysis Training Workshops
VOLUNTEERS NEEDED! If you know someone who is interested in becoming an evidence analyst, please ask them to submit an application.
If you have questions, contact Toni Acosta at
Benefits:Professional DevelopmentProfessional ExposureContinuing Education Hours
Decide to Make a Difference!
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Questions?