Steps of Evidence Based PracticeBy

Dr. Hanan Said Ali

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.

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.

4. Integrate the evidence with one’s 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 .

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

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

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 ?

P new breast feeding mothers

I breast feeding complications

C those mothers who do not have

complication

O breast feeding duration.

In multiple clinical question, the priority should be given (most important or that occur most frequently)

For exampleIn 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?

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

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?

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.

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

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)

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.

3. Will the results of the study facilitate the care of the practitioner’s 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?

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.

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

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).

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.

A clinician’s assessment of healthcare resources that are

available to implement a treatment decision is a critical

part of the EBP decision- making process.

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 child’s unresolved ear infection.

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.

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 provider’s patients versus those used in the studies reviewed).

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.

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 patient’s unique clinical circumstances , his or her preferences and values and available health care resources.

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.

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

Finally:

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