is there evidence for evidence-based practice there evidence for evidence-based practice daiwai m....
TRANSCRIPT
Is There Evidence for
Evidence-Based Practice
DaiWai M. Olson PhD RN CCRN, FNCS Associate Professor of Neurology & Neurotherapeutics
Associate Professor of Neurosurgery Director, of the Neuroscience Nursing Research Center
University of Texas Southwestern, Dallas TX
Objectives
• The participant will be able to differentiate between Evidence-based practice and practice based on evidence
• The participant will be able to understand the most common mechanisms for evaluating and grading evidence
• The participant will be able to develop an individualized approach to incorporating EBP into daily care.
? Systematic
Review
Randomized Clinical Trial
Non-experimental research
Clinical Reports
Nursing Experience
Textbooks
The Religion of Science “opinions & beliefs”
In SCIENCE every opinion is NOT
ACTUALLLY seen as of EQUAL value.
In fact, science prefers a biased weighting of the evidence. Biased in that the tie goes to the current paradigm.
In scientific experiments (perfect world) we always start with the assumption that whatever we are doing – it will not change the outcome.
This is the basic tenet of the null hypothesis
We assume “Ho” or “null” or “there is no difference ” between group A and group B … and your magical intervention (drug) will not change that.
However….if you provide me with so much compelling evidence that I am
simply can no longer believe that the two groups are the same…then I am forced to reject my null hypothesis.
Error & Power
Truth
H0 is true H0 is false
Decision
Reject H0
Type I error
(sig. level)
Correct decision
(1 - ) = Power
Fail to reject H0
Correct decision
(1-)
Type II error
A Type I error is like convicting an Innocent man
Guilty Not Guilty
Hang Him
Let Him
Go Free
But the jury has the POWER to hang him if he did in fact commit the crime
Timed Up and Go (TUG) test
Sit Stand walk to line turn walk back sit
10 feet
Not as much fun as putting grandma on a rotarod….but high validity
Hypothesis Testing
Criminal trial - Presumed innocent. Declared guilty
when the evidence leading towards guilt is “beyond a
reasonable doubt”
H0: Defendant is not guilty
vs.
HA: Defendant is guilty
U.S.P.S.T.F. Recommendations
DaiWai’s personal interpretation
of the USPSTF grade schema
GRADE Suggestion
A B C D “I”
Offer this Offer this Offer for
some Discourage
Confusion reigns
Leve
l of
Ce
rtai
nty
High RCT multiple Population
Mod Size is ‘okay’ Inconsistent Not general
Low Small N Flawed study Varied results
http://www.uspreventiveservicestaskforce.org/uspstopics.htm
GRADE criteria
* This is the “DaiWai version” there are many others
EBP is not BPoE PBoE (Practice Based on Evidence)
I think this is the way it should be done. I looked in the literature and I found a paper where they did it this way.
EBP (Evidence-Based Practice)
The sum of the currently available evidence leads me to the conclusion that for now, this is the way we should this.
Nursing Care in TTM
This is just ‘one’ example
The Evidence Base for Nursing Care and
Monitoring of Patients During Therapeutic
Temperature Management
DaiWai Olson Jana L. Grissom
Keith Dombrowski
(2011) THERAPEUTIC HYPOTHERMIA AND TEMPERATURE
MANAGEMENT Volume 1, Number 4
DOI: 10.1089/ther.2011.0014
Methods
• Reviewed for title and abstract to evaluate inclusion.*
• 165 articles were then reviewed for full-text read.
Three new “nursing” studies
1. Barringer, L. B., Evans, C. W., Ingram, L. L., Tisdale, P. P., Watson, S. P., & Janken, J. K. (2011). Agreement between temporal artery, oral, and axillary temperature measurements in the perioperative period. J
Perianesth Nurs, 26(3), 143-150. doi: 10.1016/j.jopan.2011.03.010
2. Block, J., Lilienthal, M., Cullen, L., & White, A. (2012). Evidence-based
thermoregulation for adult trauma patients. Crit Care Nurs Q, 35(1), 50-63. doi: 10.1097/CNQ.0b013e31823d3e9
3. Jardeleza, A., Fleig, D., Davis, N., & Spreen-Parker, R. (2011). The
effectiveness and cost of passive warming in adult ambulatory surgery patients. AORN J, 94(4), 363-369. doi: 10.1016/j.aorn.2011.03.010
Nine ‘distinct-ish’ Domains
1. Cooling method 2. Nursing monitoring & assessing
temperature 3. Neurologic system nursing care 4. Cardiac system nursing care 5. Pulmonary system nursing care 6. Integumentary system nursing care 7. GI/endocrine system nursing care 8. Laboratory (nursing-driven) 9. Other (you always need an ‘other’ category)
Template for
Recommendation: All of the recommendations are based on Evidence of nursing care & TTM ….additional evidence may (does) exist, but is not focused on TTM or does not include nursing activities.
Category Class IIa – Evidence Level B
DATA: How many articles were used for the recommendation Were any of the new articles informative (FYI-none of the
new material was strong enough to alter recommendations).
Thread: What is the most notable message ‘across’ studies
1. Cooling Method
Recommendation: Nurses should develop protocols that employ a variety of TTM interventions including both surface and intravascular at the same institution.
Category Class IIa – Evidence Level B
DATA: 15 articles in the original review 1 new addition (Jardeleza – warm blankets)
Thread: Multiple sources to manage temp (not just machines)
2. Monitoring & Assessing Temperature
Nurses should use instruments that provide continuous temperature monitoring.
Category Class I – Evidence Level C The site of temperature monitoring should include bladder > brain > esophageal monitoring.
Category Class IIa – Evidence Level C
DATA: 10 articles in the original review 1 new addition (Barringer – oral/axillary = Temp Artery)
Thread: Pulmonary Artery was most often ‘gold’ standard Bladder & Esophageal are being used a lot more often
3. Neurologic DATA: 12 articles in the original review New addition (Block –protocols are good)
Thread: Sedation is often required and limits exam & shivering
increases CMRO2 which may impact perfusion Nurses should monitor for shivering during TTM.
Category Class IIa – Evidence Level B Nurses should monitor sedation using validated observation scales or physiologic monitors.
Category Class IIb – Evidence Level C Nurses should develop and adhere to shivering reduction protocols.
Category Class IIb – Evidence Level C
4. Cardiac DATA: 7 articles in the original review
Thread: There are cardiac changes, no mention of how new non-
invasive monitors impact (are impacted by) TTM Nurses should monitor for cardiac arrhythmias.
Category Class IIa – Evidence Level B Nurses should monitor blood pressure from an intra-arterial line.
Category Class IIa – Evidence Level C Nurses should include measures of circulatory volume such as CVP and SVR during TTM.
Category Class IIb – Evidence Level C
5. Pulmonary DATA:
4 articles in the original review New addition (Block –protocols are good)
Thread: Some association of prolonged mechanical ventilation &
need for adjusting ventilator settings Nurses should include and employ pneumonia prevention strategies for patients during TTM.
Category Class IIa – Evidence Level B Nurses should coordinate care with MDs and RTs to change vent settings during the induction phase of TTM.
Category Class IIa – Evidence Level C Nurses should include frequent ABG monitoring in TTM protocols.
Category Class IIb – Evidence Level C
6. Integumentary DATA:
2 articles in the original review Thread:
The skin and subcutaneous tissue is sensitive to temperature
Nurses should reposition patients at least once every 2 hours during TTM.
Category Class IIa – Evidence Level C Nurses should monitor for skin breakdown associated with TTM.
Category Class IIa – Evidence Level B Consider counter-warming measures to reduce shivering associated with TTM.
Category Class IIa – Evidence Level C
7. GI / Endocrine DATA: 5 articles in the original review Thread: No common thread Nurses should frequently monitor blood glucose during TTM.
Category Class IIa – Evidence Level C Nurses should treat abnormal blood glucose using established IV insulin therapy protocols.
Category Class IIb – Evidence Level C Nurses should initiate, maintain and monitor the nutritional status of patients during TTM.
Category Class IIa – Evidence Level C Nurses should develop protocols that include monitoring of liver enzymes and amylase.
Category Class IIa – Evidence Level C
8. Laboratory DATA: 7 articles in the original review Thread: Temperature causes changes in electrolytes & coagulation
Nurses should employ strategies to monitor laboratory values that signal increased risk of bleeding.
Category Class IIb – Evidence Level C Nurses should employ strategies to monitor laboratory values associated with electrolyte changes.
Category Class IIa – Evidence Level C
9. Cornucopia DATA: 7 articles in the original review New addition (Block –protocols are good) Thread: TTM is process driven
Work assignments should be adjusted for patients undergoing TTM.
Category Class IIb – Evidence Level C Nurses should use sedation assessment and treatment algorithms.
Category Class IIb – Evidence Level C
23 Recommendations Class
Only 1 Class I recommendation continuous temperature
monitoring Level C EVIDENCE
14 Class IIa recommendations 8 Class IIb recommendations
Evidence 0 Level A 5 Level B 18 Level C
PRACTICAL APPLICATION – for YOU
1. Narrow your topic
2. Search for evidence
3. Score / grade / evaluate evidence
4. Summarize the evidence
5. Follow the summary
