What is the best way to care for X? What other nursing ... Titler, M. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin ...
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Evidence Based Practice: Changing Practice at the Bedside and Making it Stick “Notice all the computations, theoretical scribblings, and lab equipment, Norm. . . . Yes, curiosity killed these cats.”
??? Do all patients needs TEDS and Pneumatic Compression Stockings? What interventions decrease the incidence of falls? What interventions are effective in preventing/treating confusion? Are temperatures from the temporal artery equivalent to central body temperature?
How to Identify Topics/Triggers Knowledge Focused Triggers • National standards/guidelines • New research or other literature Clinical Questions – I wonder if…
Elizabeth Bridges, PhD RN CCNS Donna Berry, PhD RN AOCN
How to Identify Topics/Triggers Problem Focused Triggers • Risk Management/Process Improvement Data • Variances from clinical pathway outcomes Clinical Problems Benchmarking Data
Topic Generation High volume patients/problems/needs Age/Diagnosis/Gender/Symptoms Problems – decubiti, chronic pain, nausea/vomiting, falls Common nursing/collaborative interventions Symptom management (pain, N/V, fever, oral care) Patient/family education Catheter/tube management Common technologies used Blood pressure, glucose, pulse oximetry Laboratory tests Based on Granger & Chulay, M
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Med-Surg LPC - Examples COMMON DIAGNOSIS End Stage Liver Disease Hepatitis C R/O MI Diabetes Mellitus Multiple failed back surgery COMMON PROBLEMS/NEEDS Lab Values -Calcium -Potassium/Electrolytes Pain Control Drug Dependency Chronic Pain --Personality/Psychological Response to Chronic Pain -Pain - mobility Infection --Sternal wound infection CV related pain Demanding about process -Refusing to walk -Not flexible
Pulmonary – anxiety Confusion Altered Mental Status Immunosuppression or Immunocompromised (Renal/CA) Fluid Volume Excess Nutrition -On admission -Wait too long before TPN – “gut is going to wake up” Skin breakdown -Volume – edema -Occipital decubitus Knowledge deficit/Education -Discharge medications -Can’t take any more in -Multiple meds -Going home --Is it effective? -Early discharge – teaching in a day instead of a week -Non-English speaking
Topic Generation What frequency of a given intervention is necessary to decrease the incidence of …? Is a treatment that is effective in one patient population effective in another population?
Topic Generation What is the best way to care for X? What other nursing interventions might work? How do you manage this problem (e.g., post-op shivering, pain, nausea/vomiting)?
Confusion Families Is it appropriate to ask the family to stay? How to decide? Are all families appropriate? How do we care for family and respond to their expectations? Do rehab tools for short term memory work with confused patients? Calendars – Do they help?/Who do they work for? Reorient Memory Book - Staff education related to patient’s important information What is the appropriate content? How often? Should I force reorientation? How long does reorientation last?
What things can I do to make the environment better for them? Decrease stimulation • Who does this work for? • ? Close the door? Simplify/modify the environment – familiar/safe • Call light only • Keeping the clutter out of the room Sleep Deprivation Group activities Open/close blinds
Environmental consistency – stop moving patient from room to room Staff consistency
What are factors that made a difference (what do our patients tell us?)
When Reviewing Your Topics When Reviewing Your Topics Where is the nursing in the question? Not all questions are clinical research questions
Is the topic/question specific?
What is the best method to measure temperature? Is there a difference between temporal and core body temperature in febrile patients? For neonates is there a difference between axillary and rectal temperatures?
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When Reviewing Your Topics Is the topic/question specific
After implementation of the fall prevention protocol is there a difference in the rate of “Y”?
When Reviewing Your Topics At the end of the study I want to be able to answer the following question… (The 3-minute drill) Who Cares?/So What?
Prioritizing Is the change important to the patient? Are there enough patients? Do you have access to these patients? Does your team have the expertise? Can you measure the outcomes?
Based on Granger/Chulay, 2001
Plowing Through the Literature What do you want to know? (keep the topic narrow) What intervention? What outcome? What population?
Prioritizing $$$ Can you build on an already existing project? Institutional priorities Professional organization priorities Does the new intervention fit with existing unit schedules
Based on Granger/Chulay, 2001
Plowing Through the Literature Use resources that have already done some of the work for you Review Articles/Meta-analysis/ State-of-the-Science/CE articles What key words What references cited Collaborate with a research librarian or nurse researcher
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Plowing Through the Literature • National Library of Medicine (PubMed) • Agency for Healthcare Research and Quality (AHRQ) • Cochrane Library • Abstracts/Presentations from conference proceedings • Journals: Evidence-Based Nursing Journal Worldviews on Evidence-Based Nursing Excellence in Nursing Knowledge
Is there Sufficient Evidence to Change Practice? Is there consistency in findings? Types of studies • Randomized controlled Anecdotes Are the results clinically relevant?
• “UpToDate” (UW Library – Online) Titler, M. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am, 2001, 13(4), 497-509
Is there Sufficient Evidence to Change Practice?
Question Sufficient Evidence to Change Practice?
Are the samples similar to ours? Can we replicate results in our setting? Risk-benefit ratio for our patients
YES
NO/EQUIVOCAL
Consider Creation/ Implementation of EBP Guideline
Consider Research Study
Titler, M. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am, 2001, 13(4), 497-509
The disconnect No easy answers No “bridging the gap” • The gap is crap • If we bridge it, the gap stays there
Recreate the connection Get our feet wet SPAWN! • Science and Practice Aligned Within Nursing
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1999: Symptom Screening Question
Question
Sufficient Evidence to Change Practice?
Sufficient Evidence to Change Practice?
No
YES
NO/Equivocal
YES
NO/Equivocal
Consider Creation/ Implementation of EBP Guideline
Consider Research Study
Consider Creation/ Implementation of EBP Guideline
Consider Research Study
2001: develop and test new assessment
Examples from Oncology Patient Education Classic research program-Jean Johnson at University of Rochester • preparatory concrete objective information significantly decreased disruptions in daily activities of men with prostate cancer • Virtually every radiation clinic provides a scheduled RN teaching session with each patient
Examples from Oncology Symptom/QoL screening Based on findings from UWMC studies • UWMC RadOnc deleted 5 page text-intensive patient-report form • Overlake adopted computerized assessment for clinical practice
Examples from Oncology Patient Education When to give which information • Best all at the beginning? • Spread out? Which when then? ONS funded descriptive study SCCA RadOnc
Examples from Oncology Personal Protective Equipment Based on findings from other studies and OSHA guidelines • Policies revised • New equipment in place
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Examples from Oncology Discharge transitions from inpatient to ambulatory care Inconsistent practices in the SCCA • Study proposed to evaluate discharge medications knowledge and use by patients; knowledge and assessment by clinic nurses • Evidence in literature suggests positive outcomes when designated discharge planner role exists
Making it stick Education- the prerequisite • continuing education • works best for prescribing appropriate meds and prevention strategies in primary care
Making it stick Systematic processes • Organizational changes in staffing and resources most efficacious in making practice change “stick” • Financial incentives to patients Stone et al., 2002
Making it stick Education- the prerequisite Reminders Systematic processes Incentives Individuals
Making it stick Reminders for follow-up of follow-through • Providers: Strong effect in Grimshaw 2002 publication • Inconclusive evidence in 2004 review (Grimshaw) • Patients: strong effect • Computerized prompts and reminders effective 75% (Balas, 1996)
Making it stick Individual characteristics associated with research utilization (Estabrooks et al., 2001) • Current role: More RU with management or leadership role • Additional education, BSN, masters • Exposure to research studies • Availability of research resources Perceived support for research activities
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The view is great…
References Doran, DM. Nursing Sensitive Outcomes. State of the Science, 2003 Granger BB, Chulay M. Research Strategies for Clinicians, 1999 Jennings B, Loan L. Misconceptions among nurses about evidencebased practice. Image, 2001, 33(2), 121-127.
References Stetler, CB Updating the Stetler Model of Research Utilization to Facilitate Evidence-Based Practice. Nursing Outlook, 2001, 49(6), 272-279 Titler MG, et al. The Iowa Model of Evidence-Based Practice to promote quality care. Crit Care Nurs Clin North Am, 2001, 13(4), 497-509
References Titler MG. Translating research into practice. Crit Care Nurs Clin North Am, 2001, 13(4), 587-603 http://www.uihealthcare.com/dept s/nursing/rqom/evidencebasedprac tice/toolkits.html Vermeersch, P. Appraisal of tools to enhance evidence-based clinical practice. Clin Nurse Spec, 2004;18(4), 186-101
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