Evidence Informed Practice

Donna Ciliska, RN, PhD

May 2011

Objective

To understand the process of evidence-informed

practice.

Any current questions about what you are doing in practice?

Evidence-Based Practicea brief history….

1991 -a group at McMaster University coined the phrase "evidence-based medicine" to describe medical diagnoses and treatment based on the best research and clinical evidence available.

(Sackett, Haynes, Guyatt)

Evidence-Based Practice

“…the integration of best research evidence

with clinical expertise and patient values to

facilitate decision making”

Sackett et al, 2000

Evidence-Based Practicea brief history….

2007: BMJ• one of the 15 greatest medical breakthroughs since

the journal's launch in 1840 • along with the development of anaesthesia,

antibiotics, medical imaging, vaccines and the Pill

Evidence-Informed Practice

• Backlash to EBP• Jonathan Lomas, John Lavis and CHSRF

Clinical state, setting, and circumstances

Patient preferences and actions

Research evidence

Health care resources 

Clinical Expertise

Clinical Expertise

Evidence-Based Decision Making

Evidence of Gap in Acute and Primary Care

• 30-40% patients do not get treatments of proven effectiveness

• 20-25% patients get care that is not needed or potentially harmful

Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly

Grol R (2001). Med Care

Health-care

decisions

Evidence from

research

Evidence Transfer Gap

Why?

Stages in the process of

Evidence-Informed Practice

Step ‘0’Reflecting

• Examine practice critically.

• Acknowledge uncertainty in your practice.

(Johnston & Fineout-Overholt, 2005; Witmer & Cullum, 1999)

Stages in the process of

Evidence-Informed Practice

Questions

P opulation

I ntervention

C omparison

O utcome

ScenarioAN EXAMPLE!

• H1N1• What interventions help to prevent or reduce

the transmision of respiratory viruses?

Define the question

P hospital staff

I handwashing, sanitizers, masks

C usual routine

O respiratory illness

Stages in the process of

Evidence-Informed Practice

Efficiently search for research evidence

Evidence PyramidTypes of Resources Types of Resources

Computerized decision support Computerized decision support systemssystems

Evidence-based textbooksEvidence-based textbooks

Clinical practice guidelinesClinical practice guidelines

DARE, healthevidence.caDARE, healthevidence.ca

Systematic reviewsSystematic reviews

Evidence-based journal abstractsEvidence-based journal abstracts

Original published articles in Original published articles in journalsjournals

Systems

Synopses of Syntheses

Syntheses

Studies

Adapted from DiCenso, Bayley and Haynes (2009). Accessing pre-appraised evidence: Fine-tuning the 5S model into a 6S model. Annals of Internal Medicine, 151(6):JC3-2, JC3-3 OR Evidence-Based Nursing, 12,99-101

Summaries

Synopses of Studies

SearchingStart here with a clinical question

(prevent*) AND (respiratory) AND (virus OR viral)

(DiCenso et al., 2009; Haynes et al. 2005; Robeson et al., 2010)

0

142

2

10

25 SR, 3097

Google Scholar 322,000Google 17,300,000

Nursing +

Public Health +Nursing+Obesity+

• http://plus.mcmaster.ca/np/Default.aspx

• Sign up to be a rater: MOREebn@mcmaster.ca

Stages in the process of

Evidence-Informed Practice

Critically and efficiently appraise the research sources

www.nccmt.ca

Stages in the process of

Evidence-Informed Practice

Interpret/ form recommendations for practice or policy based on the

literature found

How do you decide which evidence you consider?

Which studies do you believe?

• Best quality• Most recent (especially if it is review)• Most applicable to your population/patients• Intervention for which you have resources

Stages in the process of

Evidence-Informed Practice

Adapt the information to a local context

• Is it applicable to your patient population?• Do the staff have the skills to do this

intervention?• Do we have enough staff to do this

intervention?• Do you have the resources for training?

• www.nccmt.ca

Applicability and Transferability tool

Clinical state, setting, and circumstances

Patient preferences and actions

Research evidence

Health care resources 

Clinical Expertise

Clinical Expertise

Evidence-Informed Decision Making

Stages in the process of

Evidence-Informed Practice

Decide whether to implement the adapted

evidence into practice or policy

Identify Strategies to Disseminate Information

•Policy change• Education • Academic detailing/outreach visits• Audit and feedback• Opinion leaders• Knowledge broker• Champions• Reminders: prompts; patient reminds staff• Interactive educational meetings/workshops • Multiple interventions

Guideline Dissemination & UptakeGrimshaw et al., 2006

• 309 comparisons from 235 studies

• 86% found improvements in care, median absolute improvement in performance:• 14% when reminders used• 8% when educational materials disseminated• 7% when audit and feedback used• 6% multifaceted interventions

Implementation

• What is the message?• To whom (audience)?• By whom (messenger)?• How (transfer method)?• With what expected impact (evaluation)?

(Institute of Work & Health with J. Lavis, 2006. www.iwh.on.ca)

Implementation Toolkit

• Available for free:

http://www.rnao.org/Page.asp?PageID=924&ContentID=823

• DiCenso A et al. A toolkit to facilitate the implementation of clinical practice guidelines in healthcare settings. Hospital Quarterly 2002;5(3):55-60.

• Dobbins M et al. Changing Nursing Practice: Evaluating the Usefulness of a Best-Practice Guideline Implementation Toolkit. Nursing Leadership 2005;18(1):34-45.

Stages in the process of

Evidence-Informed Practice

Evaluate the effectiveness of

implementation efforts

Evaluation

• How will you know if people are using the evidence? • Have they changed their practice? • Does it make any difference to patients?

• Decide on indicators (structure, process, outcome)• Gather baseline data

Stages in the process of

Evidence-Informed Practice

What can individual staff do?

• Develop your skills:• asking questions• develop efficient search skills• develop critical appraisal skills, or find and use pre-appraised

literature

• On-line learning modules

www.nccmt.ca

What Can Organizations Do?

ACCESS

TIME

time away from unit in library, reading

time to go to research/journal club meetings

time on computer to conduct searches

SKILLS• assist in search, critical appraisal skills, implementation, evaluation

What Can Organizations Do?

Get skills into:

job adds,

job descriptions

performance appraisals

Predicting Sustained Use of Evidence in Practice

• Ongoing & supportive leadership at front lines & at executive levels critical (staff champions, managers, senior executives)

• Organizational culture that supports use of evidence

• Continuing education

• Integration of guideline recommendations into organizational policies & procedures

Davies et al. Determinants of the Sustained Use of Research Evidence in Nursing, 2006(www.chsrf.ca)

Objective

To understand the process of evidence-informed

practice.