Evidence-Based Evidence-Based Practice:Practice:

Course Examples Course Examples Curry College Curry College

Division of NursingDivision of NursingNSG 2200 Pathophysiolgy or your course

Spring 2007Elizabeth KudzmaElizabeth Kudzma

Evidence-Based Practice Evidence-Based Practice (EBP)(EBP)

Process by which health care Process by which health care providers know how to find, providers know how to find, critically appraise, and use the best critically appraise, and use the best evidenceevidence

Why Evidence-Based Practice Why Evidence-Based Practice (EBP) ??(EBP) ??

Health care delivery is filled with Health care delivery is filled with uncertainty and many questions arise in uncertainty and many questions arise in every day practice…every day practice…

What kind of guidance would be most What kind of guidance would be most helpful to my patients?helpful to my patients?

What clinical assessments and What clinical assessments and interventions are of the most benefit?interventions are of the most benefit?

Common questions that Common questions that arise in everyday practice:arise in everyday practice:

Which combination and sequence of Which combination and sequence of treatments is most effective?treatments is most effective?

Which patient symptoms predict Which patient symptoms predict better or worse outcomes?better or worse outcomes?

What is the experience of illness for a What is the experience of illness for a patient with this diagnosis?patient with this diagnosis?

Which treatment is most effective and Which treatment is most effective and will produce the best patient will produce the best patient outcome?outcome?

If a diagnosis is left untreated, what If a diagnosis is left untreated, what might be the outcome?might be the outcome?

Evidence to Support Best Evidence to Support Best Practices is Constantly Practices is Constantly

ChangingChanging

Formulating the Clinical Formulating the Clinical QuestionQuestion

The “PICO” format is used to The “PICO” format is used to construct the clinical question construct the clinical question specificallyspecifically

Using PICO format helps you find a Using PICO format helps you find a needle in a hay stack of research needle in a hay stack of research informationinformation

PICO FormatPICO Format

PPatient Populationatient Population IIntervention of Interestntervention of Interest CComparison intervention or statusomparison intervention or status OOutcomeutcome

Patient PopulationPatient Population

Consideration of the patient and Consideration of the patient and population of interestpopulation of interest

Limit to age group or subgroup if Limit to age group or subgroup if possiblepossible

InterventionIntervention

ExposureExposure TreatmentTreatment Patient perceptionPatient perception Diagnostic testDiagnostic test

ComparisonComparison

Could be true control, such as Could be true control, such as placebo or doing nothingplacebo or doing nothing

Could be another treatmentCould be another treatment Sometimes it is the usual standard of Sometimes it is the usual standard of

carecare

OutcomeOutcome

Outcome may be very specific, e.g. Outcome may be very specific, e.g. deathdeath

Outcome may be something that has Outcome may be something that has a variety of measures, e.g. a variety of measures, e.g. dehydration could be a measure, dehydration could be a measure, also tachycardia, dry mouth, fever, also tachycardia, dry mouth, fever, restlessness and irritabilityrestlessness and irritability

PICO format examplePICO format example

Are Are 35 to 55 year-old women35 to 55 year-old women (p) who (p) who have have high blood pressurehigh blood pressure (I) at (I) at increased risk for increased risk for acute myocardial acute myocardial infarctioninfarction (O) compared with (O) compared with women women without hypertension without hypertension (C)(C)

Rating System for Rating System for EvidenceEvidence

Level I: evidence from systematic review, randomized Level I: evidence from systematic review, randomized controlcontrol trials (RCTs), or evidence-based reviewstrials (RCTs), or evidence-based reviews

Level II: evidence from one well-designed RCTLevel II: evidence from one well-designed RCT Level III: evidence from well-designed studies without Level III: evidence from well-designed studies without

randomizationrandomization Level IV: evidence from other types of studies Level IV: evidence from other types of studies

including case-control and cohort studiesincluding case-control and cohort studies Level V: evidence from systematic reviews of Level V: evidence from systematic reviews of

descriptive and qualitative studiesdescriptive and qualitative studies Level VI: evidence from one descriptive or qualitative Level VI: evidence from one descriptive or qualitative

studystudy Level VII: evidence from the opinion of authorities Level VII: evidence from the opinion of authorities

and/ or reports of expert committeesand/ or reports of expert committees Meynyk, B. & Fine-Overholt, E.. (2005). Evidence-Based Practice in Nursing and Healthcare. Lippincott, Meynyk, B. & Fine-Overholt, E.. (2005). Evidence-Based Practice in Nursing and Healthcare. Lippincott,

Wiliams & Wilkins.Wiliams & Wilkins.

Siwek, J. et al. (2002). Am Fam Physician 65, 251-258.

A Rating System for A Rating System for Looking at Evidence in Looking at Evidence in

Individual StudiesIndividual Studies Level A: Randomized control trial (RCT)Level A: Randomized control trial (RCT) Level B: (other evidence)Level B: (other evidence)

Well-designed, nonrandomized trialWell-designed, nonrandomized trial Non-quantitative systematic reviewNon-quantitative systematic review Lower quality RCT’s, clinical cohort studies, Lower quality RCT’s, clinical cohort studies,

case-control studiescase-control studies High-quality historical, less controlled High-quality historical, less controlled

studies, well-designed epidemiological studies, well-designed epidemiological studiesstudies

Level C: consensus/expert opinionLevel C: consensus/expert opinion

Searching for the Best Searching for the Best Evidence: Searchable Evidence: Searchable

DatabasesDatabases CINAHLCINAHL MEDLINE: (PubMed) MEDLINE: (PubMed) National Guidelines Clearinghouse: National Guidelines Clearinghouse:

http://www.guideline.govhttp://www.guideline.gov Agency for Healthcare Research and Agency for Healthcare Research and

Quality: Quality: www.ahrq.gov/clinic/cpgsix.htmwww.ahrq.gov/clinic/cpgsix.htm

National Institute of Nursing: National Institute of Nursing: http://ninr.nih.gov/ninrhttp://ninr.nih.gov/ninr