Stillwell, Susan B, MSN, RN, CNE

English

Lehigh Valley Health Network: LVHN Scholarly Works

Copyright, Susan B Stillwell, 20071Copyright, Susan B Stillwell, 2007Knowledge Mastery…Improving Patient OutcomesBringing Evidence to the Point of CareSusan B Stillwell MSN RN CNEEBP MentorClinical Associate ProfessorCenter for the Advancement of Evidence-based PracticeArizona State University College of Nursing & Healthcare Innovation© Stillwell 2007Rule 5 of the 10 Rules for Healthcare in Crossing the Quality Chasm is evidence-based decision making(IOM, 2001)Why Evidence-Based Practice?© Stillwell 2007The 5 core competencies deemed necessary by the recent Summit on Healthcare ProfessionsEducation include:Provide patient-centered careWork in interdisciplinary teamsEmploy evidence-based practiceApply quality improvementUtilize informatics(Greiner & Knebel, 2003,  p.46)Why Evidence-Based Practice?Copyright, Susan B Stillwell, 20072Copyright, Susan B Stillwell, 2007Evidence-based PracticeA problem-solving approach that ● incorporates the best available scientific evidence● clinicians’ expertise● and patients’ preferences and values(Melnyk & Fineout-Overholt, 2004)© Stillwell 2007The Merging of Science and Art: EBP within a Context of Caring Results in the Highest Quality of Patient CareClinical Decision-making QualityPatient OutcomesResearch Evidence & Evidence-based TheoriesClinical Expertise and Evidence from assessment of the patient’s history and condition as well as healthcare resourcesPatient Preferences and ValuesContext of Caring© Melnyk & Fineout-Overholt, 2003© Stillwell 2007EBP ProcessClinical Issue of InterestFormulate a Searchable, Answerable QuestionStreamlined, Focused SearchRapid Critical Appraisal & Synthesis of EvidenceApply Valid, Relevant EvidenceGenerate  Evidence Internal: OM, QIExternal: ResearchEvaluate Outcomes based on EvidenceCopyright, Susan B Stillwell, 20073© Stillwell 2007What’s the Strongest Evidence?1. Ask the burning clinical question in PICO format2. Collect the best evidence.  Search first for systematic reviews (e.g., the Cochrane Database of Systematic Reviews) and evidence-based clinical practice guidelines (www.guideline.gov)3. Rapidly critically appraise the evidence4. Integrate evidence, clinical expertise, and patient factors/preferences to implement a decision5. Evaluate the outcome© Stillwell 2007Pre-appraised Literature● Systematic reviews ● Evidence-based Guidelines ● Single study reviews© Stillwell 2007Systematic ReviewsWhere Do You Find Them?Cochrane CollaborationCochrane Database of Systematic Reviews (CDSR)Database of Abstracts of Reviews of Effectiveness (DARE)Health Technology Assessment (HTA)www.cochrane.orgNational Library of Medicine PubMed/ MEDLINE          www.ncbi.nlm.nih.gov/entrezCINAHLCopyright, Susan B Stillwell, 20074© Stillwell 2007Blobbogram© Stillwell 2007•burden•beliefs •bargain•barriersStraus, Richardson, Glasziou, Haynes (2005) Evidence-based medicine: How to practice and teach EBM. Elsevier© Stillwell 2007EBP ….essential for establishing what effect nurses have on patient outcomes (Richardson Miller, & Potter, 2002, p 44)….improves cost-effectiveness of patient care (Kitson, 2000; Madigan, 1998; Rosenfeld, Duthie, Bier, Bower-Ferres, Fulmer Lervolino et al., 2000; Selig, 2000; Winch, Creedy, & Chaboyer, 2002).Copyright, Susan B Stillwell, 20075© Stillwell 2007Kristie Newton RN, BSNApril 2007 http://nursing.asu.edu/caep/ebpstories/featuredstory.htm● For as long as I have been a nurse, I have used baby powder when bathing my patients. I have used it to freshen up patients, rub their backs, and sometimes as an air freshener. So you can imagine my confusion when baby powder disappeared from the supply room. At first, I figured we were just out of it, since other items were on back order. However, when I noticed they had eliminated the bin used for baby powder, I began asking questions. All I was told was we were not using baby powder anymore, “it causes infections.” I could not believe this explanation. What does baby powder have to do with infections? After all, it is safe for babies, why not patients?© Stillwell 2007why, after 20 years of nursing, was this the first time I had ever heard about baby powder being bad for patients …….Kristie Newton RN, BSNApril 2007 http://nursing.asu.edu/caep/ebpstories/featuredstory.htm© Stillwell 2007PICOT● In caring for hospitalized patients, does using baby powder compared to not using baby powder increase the rate of infection?Kristie Newton RN, BSNApril 2007 http://nursing.asu.edu/caep/ebpstories/featuredstory.htmCopyright, Susan B Stillwell, 20076© Stillwell 2007study after study linking baby powder to topically yeast infections and fungal infections in immunocompromised patients, and how it was detrimental when talc was inhaled for respiratory patients, i.e. asthmatics. I was speechless. Why had I never heard of this before? Apparently, these studies had been available for years….Kristie Newton RN, BSNApril 2007 http://nursing.asu.edu/caep/ebpstories/featuredstory.htm© Stillwell 2007It's NOT Funny● Central Venous Catheter Removal60 y/o patient had been receiving IV fluids via a central line. A 4X4 gauze with silk tape was applied after removing the catheter. Soon after, the clinician told a very funny story and the patient burst into laughter. The patient stopped laughing, slumped over and fell to the floor. The patient was unresponsive and a code was called.  The resuscitation effort was unsuccessful.(Massoorli, 1999)© Stillwell 2007EvidenceIn God we trust. Everyone else must bring data.By: Sid Peimerhttp://www.bizcommunity.com/Article/196/19/2967.htmlCopyright, Susan B Stillwell, 20077© Stillwell 2007Evidence: Clinical Decision Making to Improve Patient OutcomesInternal●Risk management data●Quality improvement data: pressure ulcer rates, falls, VAP●Benchmarks●Staffing levels●Nurse satisfaction data●Patient satisfaction dataExternal●Original researchQualitativeQuantitative ●Pre-appraised ●Systematic reviewsMeta-analysis© Stillwell 2007The Leapfrog Group© Stillwell 2007AHRQ Quality Indicators http://www.qualityindicators.ahrq.gov/psi_overview.htm● Complications of Anesthesia● Pressure Ulcer● Failure to Rescue● Post-op Hemorrhage● Post-op Respiratory Failure● Post-op PE/DVT● Post-op Sepsis● Post-op Wound DehiscenceCopyright, Susan B Stillwell, 20078© Stillwell 2007National Quality Forum (NQF)http://www.qualityforum.org/nursing/● Failure to Rescue● Pressure Ulcer● Falls● Falls with Injury● Restraints ● Urinary Catheter Associated UTI● Central Line Blood Stream Infection● VAP● Smoking Cessation Counseling: AMI, HF, Pneumonia© Stillwell 2007National Database of Nursing Quality Indicators (NDNQI) - examples● Pediatrics IV infiltration rate● Pediatric pain assessment (AIR)● Nurse Turnover● RN education/certificationhttp://www.nursingquality.org/© Stillwell 2007IHI 5 Million Lives Campaignhttp://www.ihi.org/ihi● Pressure Ulcers● Decreasing MRSA● High Alert Medications● Surgical Complications● EBP for CHF● Rapid Response Team● Medication ReconciliationCopyright, Susan B Stillwell, 20079© Stillwell 2007EBP Outcomes: Outcomes reflect IMPACT!● EBP’s effect on patients:PhysiologicPsychosocial Functional improvement.● EBP’s effect on the health system:Decreased cost, length of stay;Nursing retention / job satisfaction;  Interdisciplinary collaboration.© Stillwell 2007The 4-StepStep OneWhat is the clinical problem?What is the desired outcome?What instruments can measure the outcome?Baseline  DataAdapted from Anne Wojner-Alexandrov, EBP Outcomes Model© Stillwell 2007Step TwoAppraise the evidence e.g. reliable, valid, applicableWho are the stakeholders involved?What will be the new practice?Establish integrity of the practice to be implementedCopyright, Susan B Stillwell, 200710© Stillwell 2007Step ThreeCommunicate, educate, communicateRole model the changeCollect Data© Stillwell 2007Step FourTerminate data collection cycleAnalyze the impactCommunicate findings Revision? Return to Step TwoAdopt the practice change and continue to monitor outcome© Stillwell 2007"It is wise to keep in mind that neither success nor failure is ever final." Roger BabsonCopyright, Susan B Stillwell, 200711© Stillwell 2007Evidence:   HOW to keep upEvidence:  WHERE to access it© Stillwell 2007A Systematic Evaluation of Evidence Based Medicine Tools for Point-of-Care● SCC/MLA 2006● Texas Health Science Libraries Consortium© Stillwell 2007http://ils.mdacc.tmc.edu/papers.htmlEvidence Matters Prodigy Knowledge* Prodigy Knowledge* Evidence Matters Harrison's Practice: Answers on Demand Evidence Matters Harrison's Practice: Answers on Demand Prodigy Knowledge* Prodigy Knowledge* Harrison's Practice: Answers on DemandEvidence Matters Harrison's Practice: Answers on Demand FirstConsultZynx EvidenceZynx EvidenceZynx EvidenceUpToDateFirstConsult FirstConsult InfoPOEMS/InfoRetriever Clinical Resources @ Ovid InfoPOEMS/InfoRetrieverInfoPOEMS/InfoRetriever FirstConsult eMedicine UpToDateDiseasedex – General Medicine Diseasedex – General Medicine Zynx EvidenceClinical Resources @ Ovid UpToDate UpToDate InfoPOEMS/InfoRetriever Diseasedex – General Medicine eMedicine Clinical Resources @ Ovid DynaMed eMedicine Clinical Resources @ Ovid Clinical Evidence* Diseasedex – General Medicine DynaMed DynaMed DynaMed Clinical Evidence* Clinical Evidence* Clinical Evidence* eMedicine ACP PIER ACP PIER ACP PIER ACP PIER LevelsImportant/Not As ImportantEvidenceRawCopyright, Susan B Stillwell, 200712© Stillwell 2007ACP Journal Club● http://www.acpjc.org/Biomedical literature articles that report original studies and systematic reviews Summarized in abstracts Commented on by clinical experts Subscription required© Stillwell 2007InfoPOEMs● http://www.infopoems.com/Patient-Oriented Evidence that MattersPICO question, answer, citation, study design, funding source, setting and summaryInfoRetriever – search engine Subscription required $24930 day free trial© Stillwell 2007http://www.uptodate.com/UpToDate● a comprehensive evidence-based clinical information resource available to clinicians on the Web, desktop, and PDA. Subscription required  $495Trial availableCopyright, Susan B Stillwell, 200713© Stillwell 2007National Guideline Clearinghouse for PDAs● http://www.guideline.gov/resources/pda.aspxGuideline Summaries in a text format can be downloaded© Stillwell 2007Institute for Clinical Systems● http://www.icsi.org/Guidelines, order sets and protocolsSubscription required© Stillwell 2007Sumsearchhttp://sumsearch.uthscsa.edu/● SUMSearch combines searching in order to automate searching for medical evidence. ● SUMSearchselects the best resources for your questionformats your question for each resource makes additional searches based on resultsCopyright, Susan B Stillwell, 200714© Stillwell 2007University of Minnesota Biomedical Library● http://www.biomed.lib.umn.edu/help/guides/primary/ebp#toc36025Multiple EBP Resources and DatabasesPICOmaker© Stillwell 2007TIGER initiativehttp://www.umbc.edu/tiger● enable practicing nurses and nursing students to fully engage in the unfolding digital electronic era in healthcare● identify information/knowledge management best practices and effective technology capabilities for nurses. ● create and disseminate local and global action plans that can be duplicated within nursing and other multidisciplinary healthcare training and workplace settings.© Stillwell 2007http://www.cpmrc.com/● The Clinical Practice Guidelines support the interdisciplinary team in delivering their scope of practice accountability while integrating services at the point of care.● Clinical Practice Resource Model (subsidiary of Eclipsys)Copyright, Susan B Stillwell, 200715© Stillwell 2007Connecting the DotsKnowledge Mastery…Improving Patient Outcomes© Stillwell 2007Perseverance●How do YOU face the tough challenges?●Who do you call?Rapid response team for EBP!!© Stillwell 2007Strategies for Advancing Evidence-Based Practice in Clinical Settings (Fineout-Overholt, Levin, Melnyk 2004/2005 Journal of the New York State Nurses Association.28-32)● EBP rounds● STEPS of EBP● PICOT boxes● Posters of critically appraised topics of              interest to population● Journal Club● Self –directed learning with educational      prescriptions● EBP Workshops● EBP Mentorship ProgramsCopyright, Susan B Stillwell, 200716© Stillwell 2007PerseverancePersistencePatiencePracticePossibilities© Stillwell 2007Role Modeling is the Most Powerful Variable in SuccessWhat is experienced and seen in the clinical area is what will likely predict future behavior.Bob Berenson© Stillwell 2007Belief at the beginning of an endeavor is the one thing that will ensure successWilliam JamesImplement and Teach Evidence-Based PracticeYOU CAN DO IT!

Bringing Evidence to the Point of Care

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1132&context=research_day

Bringing Evidence to the Point of Care

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Lehigh Valley Health Network: LVHN Scholarly Works