Susan Fowler, PhD, RN, CNRN, FAHA Director of Magnet, Education, Quality, & Research. Translating Evidence into practice: using a critical eye. At the end of this presentation, attendees will: Define evidence-based practice. Describe critical parts of a critique of evidence.
Director of Magnet, Education, Quality, & Research
Collect the best evidence.
Critically appraise the evidence.
Integrate the evidence, clinical expertise, and patient factors/preferences to implement a decision.
Evaluate the outcome.The Process of EBP
Practice Question, Evidence, Translation (PET)
(Newhouse, R.P., Dearholt, S., Poe, S., Pugh, L.C., White, K. 2005)
I – intervention of interest
C – comparison intervention or status
O – Outcome
In caring for disabled adults, does the use of level-access showers improve patient hygiene more than bed bathing???How Do I Ask an EBP Question?
Level l – experimental/RCT/meta-analysis of RCTs
Level II – quasi-experimental
Level III – non-experimental or qualitative
Level IV – opinion of experts and/or reports of nationally recognized expert committees, evidence from case reports
Level V – opinion of nationally recognized experts based on experience
Stevens (2005) Essential Competencies (20)From:Stevens, K. (2005). Essential competencies for evidence-based practice in nursing. (1st ed.). San Antonio, TX: ACE, UTHSCSA.
Related to Critical Thinking
Related to Provider of Care
Depicts 3 essential cornerstones that form the foundation for professional nursing
Nursing practice is the means by which a patient receives nursing care; education reflects the acquisition of the nursing knowledge and skills necessary to become a proficient clinician and to maintain competency; and research provides new knowledge to the profession and enables the development of practices based on scientific evidence.John Hopkins EBP Model & Guidelines
JHN Evidence-based Practice Conceptual Model for professional nursing
The Johns Hopkins Hospital/ The Johns Hopkins University
Step 1: Identify an EBP question
Step 2: Define scope of practice question
Step 3: Assign responsibility for leadership
Step 4: Recruit multidisciplinary team
Step 5: Schedule team conference
Step 6: Conduct internal and external search for evidence
Step 7: Critique all types of evidence
Step 8: Summarize evidence
Step 9: Rate strength of evidence
Step 10: Develop recommendations for change in processes of care or systems based on the strength of evidence
The Iowa Model of EBP; considers practice & organizational perspectives
Evidence-Based Practice to Promote Quality Care
Problem Focused Triggers
Knowledge Focused Triggers
Form a team
Assemble Relevant Research & Related Literature EBP; considers practice & organizational perspectives
Critique and Synthesize Research for Use in Practice
Pilot Change in
Base Practice on other
Types of Evidence
Should we EBP; considers practice & organizational perspectives
Adopt this change
Care and New
Monitor and Analyze
Structure, Process, and
Priority for EBP; considers practice & organizational perspectives
Improve Quality of care
Decrease LOS/ Contain Costs
Improve Patient Satisfaction
Body of Science
5=multiple studiesSetting priorities
A dog bit my mother-in-law three weeks ago. She has known the dog for many years, but the immunization status of the dog was unconfirmed. Her wound was small, so she did not seek treatment at that time. The biggest fear after a dog bite is contracting rabies. Rabies is a zoonotic disease (one transmitted to humans from animals) caused by a virus.
Last week she went to her primary care provider (PCP) for treatment, two weeks after the initial bite. Her PCP recommended rabies post-exposure immunization. My husband, a resident physician, and I were shocked as neither of us has ever recommended the rabies immunization for post-exposure treatment in a case like hers. We both quickly consulted our databases of choice for a quick look at what we thought were the recommendations for rabies treatment. I consulted www.emedicine.com and found “Human rabies immune globulin and vaccine are recommended for bites and exposures regardless of the period between exposure and treatment unless the individual is previously vaccinated and rabies antibodies can be detected.” (2007, 11).EBP Case Story from ASU College of Nursing & Health Innovation
Of note, the average delay in the United States between exposure and treatment is 5 days, which does not appear to compromise successful prophylaxis. My husband consulted the Up to Date database and found “for persons who have never been vaccinated against rabies, post-exposure antirabies vaccination should always include administration of both passive antibody (HRIG) and vaccine (human diploid cell vaccine [HDCV] or purified chick embryo cell vaccine [PCECV])”. Finally we looked at the Centers for Disease Control (CDC) website and found their recommendation to be “for persons who have never been vaccinated against rabies previously, post-exposure anti-rabies vaccination should always include administration of both passive antibody and vaccine”. Post-exposure prophylaxis is a series of multiple injections around the already painful wound and follow-up is generally poor for patients (Moran, G.J. Talan, D.A. Mower, W. Newdow, M., Ong, S., Nakase, J., et al., 2000).Case continues…
We were frustrated and confused. It seemed that all three databases recommended that the post-exposure vaccine be given. Yet in all of the nine facilities that we have worked in across three different states, this has never been standard of care.
Since I have been learning the process of evidence-based practice (EBP) and how to search the literature for the best evidence, I thought that I would apply it to this situation. A PICO question was developed to drive the search of the literature. In (p) patients with animal bites does the (i) administration of post-exposure prophylaxis (PEP) compared to (c) observation or testing of the animal only (o) provide the most appropriate treatment?Case continues…
I performed a quick search of the CINAHL, PubMed, and Google Scholar databases. After rapidly critically appraising the articles I found and synthesizing my findings, I know that I now have a validated response to my mother in law when I say that the post-exposure treatment of rabies is not warranted in her case. I can show her the evidence. There is even an easy algorithm to follow called the "Algorithm for Determining Appropriateness of Animal Exposure Treatments" (Moran, G.J. Talan, D.A. Mower, W. Newdow, M., Ong, S., Nakase, J., et al., 2000).
My “EBP Story” shows how I have taken what I have learned in the last five months and not only applied it to my practice, but also my personal life.
This week my mother-in-law’s dog drank antifreeze. Perhaps next week I will do a mini-synthesis of evidence for a recommendation on the treatment for that issue.Case…The End
Barriers/Challenges to EBP in Clinical Settings from Scholar databases. After rapidly critically appraising the articles I found and synthesizing my findings, I know that I now have a validated response to my mother in law when I say that the post-exposure treatment of rabies is not warranted in her case. I can show her the evidence. There is even an easy algorithm to follow called the "Algorithm for Determining Appropriateness of Animal Exposure Treatments" (Moran, G.J. Talan, D.A. Mower, W. Newdow, M., Ong, S., Nakase, J., et al., 2000). Pravikoff et al., (2005). Readiness of US Nurses for Evidence-Based Practice. AJN, 105.