distinguishing tradition-based and evidence-based care eleanor s. mcconnell, phd, rn, gcns-bc duke...
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Distinguishing Tradition-Based and Evidence-Based Care
Eleanor S. McConnell, PhD, RN, GCNS-BCDuke University School of NursingDurham Veterans Affairs Medical CenterGeriatric Research, Education and Clinical CenterNovember 2013
http://coegne.nursing.duke.edu
Think of a situation when….
You were afraid you were going to do more harm than good…..Examples…•Should I give a 45 year old woman with abdominal pain morphine in the ED?•Should I give Herpes Zoster vaccine to someone who has already had shingles?•Should I use a falls alarm to prevent falls….•What is your example?
Evidence-based Practice Defined“..the integration of clinical expertise, patient values,
and the best evidence into the decision making process for patient care. “• Clinical expertise: the clinician's accumulated experience,
education and clinical skills. • The patient brings to the encounter his or her own
personal and unique concerns, expectations, and values. • Best evidence is usually found in clinically relevant
research that has been conducted using sound methodology. (Sackett, 2002)
EBP – Begins and Ends with a Patient
Case 1
Mrs. A is a 45 y.o. woman recently admitted to your Emergency Department with acute abdominal pain.
• One member of the treatment team wishes to give her morphine to relieve her pain
• A second member of the treatment team believes that morphine is contraindicated, because it will mask the signs needed to make an accurate diagnosis
• What would you do?
Cycle of Evidence-based Practice
To learn more, go to these 2 sites: • http://www.hsl.unc.edu/services/tutorials/ebm/welcome.htm
OR
• http://www.cebm.utoronto.ca/practise/
Ask Pertinent question in area of uncertainty @ practice
Acquire Best available scientific evidenceComputers make this possible in “real time”
Appraise
Not all evidence is created equal
Apply Based on clinical experience, patient preference
Cycle of Evidence-based Practice
Ask In a 45 y.o. woman with acute abdominal pain will MS04 compared to no Rx result in inaccurate dx ?
Acquire Medline Search:Abdominal pain OR Acute abdomen AND adult AND diagnosis AND RCT search filter
Appraise
9 RCTs – latest, 20061 review paper (2003)
Apply VAS improved 31 mm MSO4 v. placebo
Difference in clinically important diagnostic outcome was 1%
(95% confidence interval [CI] -11% to 12%).
Search comes up with good answer because of “well-built” question &
EBM search filters
Notice that most articles have abstracts that are available for free – in real time
Case 2
Mrs. J is an 82 y.o. woman who comes to your clinic for her annual evaluation.
• She tells you she has seen recent advertisements on TV for medicines that can prevent dementia.
• Her mother died with dementia 20 years ago, and she does not want to be a burden on her family.
• What would you recommend?
Cycle of Evidence- based Practice
Ask Among healthy 80 year old women what preventive approaches to dementia are effective?
Acquire Pub-Med Search: Dementia & Prevention – filter by systematic review
Appraise Systematic Review examining prevention of vascular dementia
ApplyApply
Sample Review Paper
Risk factors for vascular dementia (VaD), Alzheimer disease (AD), unspecified dementia, and Cognitive Impairment.
Copyright © American Heart Association
Risk Factor Vascular Alzheimer’s Dementia Cognitive Impairment
1. Non-modifiable: age & genetics (APO-E)
Yes Maybe
YesYes
YesYes
YesYes
2. Lifestyle factors:• Education• Smoking• Diet• Physical Activity• Obesity
NoYesYesYesYes
YesYesYesYesYes
YesYesYesYesYes
YesYesYesYesYes
3. Physiological Risk Factors:• Hypertension• Hyperglycemia &
Diabetes• Lipids
YesYesMaybe
MaybeYesMaybe
YesYesMaybe
YesYesMaybe
4. Vascular Disease:• Stroke• Coronary artery disease• Atrial fibrillation
YesYesYes
YesNoMaybe
YesYesMaybe
YesYesYes
Dichgans M , and Zietemann V Stroke 2012;43:3137-3146
Temporal relationship between the critical period for elevated blood pressure and randomized trials of blood pressure-lowering treatment.
Dichgans M , and Zietemann V Stroke 2012;43:3137-3146
Copyright © American Heart Association
Now really..Who has time for this?
• Realistic concern given our busy lives• One answer:
• Substitute for continuing education or haphazard journal article reading
• Just-in-time education• Another answer:
• Consider using pre-appraised evidence
Pre-appraised Literature Sources
Type Example SourceGuidelines AMDA Guideline
for Pressure Ulcers
www.guidelines.gov
Journals Evidence-based Nursing
http://ebn.bmj.com/
Bibliographic Search Engines
Pub-Med http://www.ncbi.nlm.nih.gov/pubmed/
Workshops & Learning Networks
Evidence-Based Practice in Geriatric Care Settings
http://cgne.nursing.duke.edu/
Source 1: Guidelines
Search Results from www.Guidelines.gov
Source #2: Pre-appraised Evidence: Journals
Source: Evid Based Nurs 2009;12:2 55 10.1136/ebn.12.2.55
Final Step: Apply Evidence
Easier said than done! 1. Learning Collaborative:
• Institute for Health Care Improvement• Carolinas Center for Medical Excellence – QAPI in LTC
2. Evidence Based Practice Committee• Journal Clubs• Other strategies….
Summary
• Tradition-based?• Few experts, may be biased, out of date
• Evidence-based?• Many experts, procedures to limit bias• Begins and ends with patient• Growing trend, accelerates access to scientific
discoveries• Helps free us from doing more harm than good
To learn more:
To learn more: http://www.hsl.unc.edu/services/tutorials/ebm/index.htm
Very well-doneself-instructionalmodule
You can start and
Stop where you wish!
To learn more… www.mclibrary.duke.edu
So what about that zoster vaccine???? Go to PubMed and put
“herpes zoster vaccine in search box…”
And you’re really thinking…..• Who has time to look at 1116 citations?????• And we would say…..no one! What about 32? Or 3?
Which one to pick? Sort by Relevance
What did we learn?
What else did we learn?