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
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
Step ‘0’Reflecting
• Examine practice critically.
• Acknowledge uncertainty in your practice.
(Johnston & Fineout-Overholt, 2005; Witmer & Cullum, 1999)
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
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
Public Health +Nursing+Obesity+
• http://plus.mcmaster.ca/np/Default.aspx
• Sign up to be a rater: [email protected]
Stages in the process of
Evidence-Informed Practice
Critically and efficiently appraise the research sources
Stages in the process of
Evidence-Informed Practice
Interpret/ form recommendations for practice or policy based on the
literature found
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
• 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
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
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)