EVIDENCE BASED

PRACTICE
DR. CAROLINE S. SAN JUAN
Learning Objectives:
 After this session, the students will be able to:
1. Define Evidence & Evidence Based Practice
2. Enumerate the Quadruple (four) Aims of
Evidence Based Practice.
3. Describe the Differences of Evidence Based
Practice, Research and Quality improvements
 What is Evidence?
 Evidence is a collection of facts that are believed to be true.
 Types of Evidence:
1. External evidence - is generated through rigorous research (e.g., RCTs or
predictive studies) and is intended to be generalized and used in other
settings. An important question when implementing external evidence is
whether clinicians can achieve the same results with their patients that were
obtained in the studies they reviewed (i.e., can the findings from research be
translated to the real-world clinical setting with the same outcomes?). This
question of transferability is why measurement of key outcomes is necessary
when implementing practice changes based on evidence.
2. Internal evidence - is typically generated through practice initiatives, such
as outcomes management or evidence-based QI projects.
 Researchers generate new knowledge through rigorous research (i.e.,
external evidence), and EBP provides clinicians the process and tools to
translate the external evidence into clinical practice and integrate it with
internal evidence to improve quality of healthcare, patient outcomes, and
cost reductions.
 Definition
 Evidence Based Practice (EBP)- is defined as the conscientious
use of current best evidence in making decisions about patient
care. ( Sackett, et al; 2000)
 EBP is also referred to as a lifelong problem-solving approach to
clinical practice that integrates the following:
• A systematic search for and critical appraisal of the most relevant
and best research (i.e., external evidence) to answer a burning
clinical question;
• One’s own clinical expertise, including use of internal evidence
generated from outcomes management or evidence-based
quality improvement projects, a thorough patient assessment,
and evaluation and use of available resources necessary to achieve
desired patient outcomes;
• Patient/family preferences and values
The components of evidence-based practice. (From
Melnyk, B. M., & Fineout-Overholt, E. [2011].
ORIGINS OF THE EVIDENCE-BASED
PRACTICE MOVEMENT
 The EBP movement was founded by Dr. Archie Cochrane, a British
epidemiologist, who struggled with the effectiveness of healthcare and
challenged the public to pay only for care that had been empirically
supported as effective (Enkin, 1992).
 In 1972, Cochrane published a landmark book criticizing the medical
profession for not providing rigorous reviews of evidence so that policy
makers and organizations could make the best decisions about
healthcare.
 Cochrane was a strong proponent of using evidence from RCTs
(Randomized Critical Trials), because he believed that this was the
strongest evidence on which to base clinical practice treatment
decisions. He asserted that reviews of research evidence across all
specialty areas need to be prepared systematically through a rigorous
process, and that they should be maintained to consider the generation
of new evidence (The Cochrane Collaboration, 2001).
 FOUR (4) AIMS OF EVIDENCE BASED
PRACTICE

1. Enhances health care quality;

2. Improves patient outcomes;
3. Reduces costs, and
4. Empowers clinicians
 This is known as the quadruple aim in
healthcare
 DIFFERENCES AMONG EBP, RESEARCH, AND QUALITY
IMPROVEMENT
RESEARCH EVIDENCE BASED PRACTICE QUALITY IMPROVEMENT

Uses scientific process Involves critical appraisal A systematic process that

to generate new including synthesis and often uses the plan, do, study,
knowledge/external recommendations for act (PDSA) model, is used by
evidence and research practice, of a body of healthcare systems to improve
utilization frequently evidence comprised of their processes or outcomes
operationalized as the multiple studies and for a specific population once
use of knowledge combines it with the a problem is identified.
typically based on a expertise of the clinician as Often confused with EBP
single study well as patient/family
preferences and values to
make the best decisions
about patient care.
 An example of a QI initiative would be triggered
by a sudden increase in ventilator-associated
pneumonia that, when practice data were
evaluated, indicated that an oral care protocol
was not being implemented on a regular basis.
The PDSA cycle culminated in an educational
booster for the staff about the oral care protocol
and further monitoring of the process to reduce a
high rate of ventilator-associated pneumonia in
critically ill patients.
 Quality Improvement and Evidence
Based Quality Improvement
• Quality Improvement relies primarily on internal
evidence and often does not involve a systematic
search for and critical appraisal of evidence
• Evidence Based Quality Improvement include
both internal and external evidence in decision
making about a practice change to be
implemented to improve an important clinical
outcome. The goal is for all QI to become
evidence-based.
 IMPORTANCE OF EVIDENCE BASED
PRACTICE
 The most important reasons for consistently
implementing EBP are:
1. It leads to the highest quality of care and the best
patient outcomes.
2. Reduces healthcare costs and geographic variation
in the delivery of care
3. Clinicians are more empowered and have higher
job satisfaction when they engage in EBP.
4. Reduces the escalating turnover rate in certain
healthcare professions.
 Barriers to evidence-based practice
 Nurses, physicians, and other health professionals cite a number of
barriers to EBP including the following:
1. Lack of EBP knowledge and skills;
2. Cultures steeped in tradition (e.g., that is the way it is done here);
3. Misperceptions or negative attitudes about research and evidence-based
care;
4. Lack of belief that EBP will result in more positive outcomes than
traditional care;
5. Voluminous amounts of information in professional journals;
6. Lack of time and resources to search for and critically appraise evidence;
7. Overwhelming patient loads;
8. Organizational constraints, such as lack of administrative support or
incentives;
Barriers to evidence-based practice (cont’d)
9. Lack of EBP mentors;
10. Demands from patients for a certain type of treatment (e.g., patients
who demand antibiotics for their viral upper respiratory infections
when they are not indicated);
11. Peer pressure to continue with practices steeped in tradition;
12. Resistance to change;
13. Lack of consequences for not implementing EBP;
14. Peer and leader/manager resistance;
15. Lack of autonomy and power to change practice;
16. Inadequate EBP content and behavioral skills building in educational
programs along with the continued teaching of how to conduct
rigorous research in baccalaureate and master’s programs instead of
teaching an evidence-based approach to care.
 Overcoming barriers to evidence- based
practice
 The following facilitating conditions have been found to enhance
EBP:
1. Support and encouragement from leadership/administration that
foster an EBP culture with expectations for EBP;
2. Alignment of stakeholders;
3. Time to critically appraise studies and implement their findings;
4. Clearly written research reports;
5. EBP mentors with excellent EBP skills as well as knowledge and
proficiency in individual and organizational change strategies;
6. Proper tools to assist with EBP at the point of care (e.g., computers
dedicated to EBP; computerbased educational programs);
7. Integrating EBP into health professions curricula;
8. Clinical promotion systems and performance
evaluations that incorporate the EBP competencies;
9. Evidence-based clinical practice policies and
procedures;
10. EBP models that can guide implementation and
sustainability of EBP;
11. Journal clubs and EBP rounds;
12. A certification credential and high level of
education.
 Rating System for the hierarchy of evidence
(melnyk & fineout-overholt,2015
Level I. Evidence obtained from a systematic review or meta-
analysis of all relevant, randomized clinical trials (RCTs), or
clinical practice guidelines based on systematic reviews of RCTs

Level II. Evidence obtained from at least one well-designed

RCT/Random Clinical Trial.

Level III. Evidence obtained from well-designed controlled trials

without randomization (quasi-experimental).

Level IV. Evidence from well designed case-control and cohort

studies.
 Rating system…(con’t)
Level V. Evidence from Systematic Reviews of
descriptive and qualitative studies.

Level VI. Evidence from a single descriptive or

qualitative study.

Level VII. Evidence from opinion of authorities

and/or reports of expert committees.
 Definition of evidence synthesis
1. Randomized Controlled Trial (RCT): A true experiment
(i.e., one that delivers an intervention or treatment in
which participants are randomly assigned to control and
experimental groups); the strongest design to support
cause-and-effect relationships.
2. Systematic review: A summary of evidence, typically
conducted by an expert or expert panel on a particular
topic, that uses a rigorous process (to minimize bias) for
identifying, appraising, and synthesizing studies to
answer a specific clinical question and draw conclusions
about the data gathered.
 Definition… (con’t)
3. Meta-analysis: A process of using quantitative methods to
summarize the results from the multiple studies, obtained and
critically reviewed using a rigorous process (to minimize bias) for
identifying, appraising, and synthesizing studies to answer a
specific question and draw conclusions about the data gathered.
The purpose of this process is to gain a summary statistic (i.e., a
measure of a single effect) that represents the effect of the
intervention across multiple studies.
4. Clinical Practice Guidelines: Systematically developed statements to
assist clinicians and patients in making decisions about care; ideally,
the guidelines consist of a systematic review of the literature, in
conjunction with consensus of a group of expert decision makers,
including administrators, policy makers, clinicians, and consumers
who consider the evidence and make recommendations.
 Definition… (con’t)
5. Quasi-experiments: A type of experimental design that tests the effects of
an intervention or treatment but lacks one or more characteristics of a true
experiment (e.g., random assignment; a control or comparison group).
6. Case–control study: A type of research that retrospectively compares
characteristics of an individual who has a certain condition (e.g.,
hypertension) with one who does not (i.e., a matched control or similar
person without hypertension); often conducted for the purpose of
identifying variables that might predict the condition (e.g., stressful
lifestyle, sodium intake).
7. Cohort study: A longitudinal study that begins with the gathering of two
groups of patients (the cohorts), one who received the exposure (e.g., to a
disease) and one who does not, and then following these groups over time
(prospective) to measure the development of different outcomes
(diseases); an observational study.
 Definition… (con’t)
8. Descriptive studies: Those studies that are
conducted for the purpose of describing the
characteristics of certain phenomena or selected
variables.
9. Qualitative research: Research that involves the
collection of data in non-numeric form, such as
personal interviews, usually with the intention of
describing a phenomenon or experience seeking
an in-depth understanding within a natural
setting.
Rule of Thumb to Determine Whether a
Practice Change Should Be Made
The level of the evidence + quality of the evidence = strength of
the evidence → Confidence to act upon the evidence and
change practice!
 The SEVEN (7) Steps of the Evidence-
Based Practice Process
0. Cultivate a spirit of inquiry within an evidence-based practice
(EBP) culture and environment.
1. Ask the burning clinical question in PICOT format.
2. Search for and collect the most relevant best evidence.
3. Critically appraise the evidence (i.e., rapid critical appraisal,
evaluation, and synthesis).
4. Integrate the best evidence with one’s clinical expertise and
patient/family preferences and values in making a practice
decision or change.
5. Evaluate outcomes of the practice decision or change based on
evidence.
6. Disseminate the outcomes of the EBP decision or change.
MCQ:
1. It Involves critical appraisal including synthesis and recommendations for
practice, of a body of evidence comprised of multiple studies and combines it
with the expertise of the clinician as well as patient/family preferences and values
to make the best decisions about patient care:
a. Research
b. Evidenced Based Practice
c. Quality Improvement
d. Evidence Based Quality Improvement
2. _________ is a summary of evidence, typically conducted by an expert or expert
panel on a particular topic, that uses a rigorous process (to minimize bias) for
identifying, appraising, and synthesizing studies to answer a specific clinical
question and draw conclusions about the data gathered:
a. Systematic Review
b. Meta-analysis
c. Randomized Controlled Trials
d. Clinical Practice Guidelines
Detailed discussion of the seven steps of the
evidence base practice process shall be next
week…