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Evidence-Based Practice, PICO

Based on presentation by Averre

Francine Jensen

on 16 June 2015

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Transcript of Evidence-Based Practice, PICO

There will be 3 groups of four students and 2 groups of three students. You can choose your own groups. The sign-up sheet will be posted on the board in HS2 302.
EBP Project
Using EBP
Scenario #6
The common cold persists as one of the most frequent illnesses. Mrs. Harris visits the ambulatory care center with symptoms of a common cold. She has lost time from work due to a cough, nasal congestion, and malaise. You are interested in the use of Zinc to alleviate cold symptoms. Does taking oral zinc or nasal zinc effectively reduce the symptoms of the common cold in adults and which delivery method works best?
Create a PICO Question
Scenario #5
As a nurse on a pediatric medical surgical floor, you have noticed several nurses and nursing assistants inconsistently taking patient blood pressures. Sometimes they attach the cuff to the right arm, sometimes the left, and sometimes they apply the blood pressure cuff to a leg. You want to research if this affects the BP readings and is a sound clinical practice or if it should be done more consistently.
Create a PICO Question
Scenario #4
While in nursing school you were taught to insert IV needles with the bevel up. Several nurses that you work with consistently insert them bevel down. You want to determine if this is incorrect or if research has determined if it makes a difference.
Create a PICO Question
Scenario #2
As a nurse in a neonatal intensive care unit, you are always interested in identifying interventions that will assist these little patients to grow and thrive. You recently read an article about “kangaroo care” and wonder if it might benefit this population.
Create a PICO Question--
Your turn:
Scenario #1
As a nurse in an intensive care unit, you are concerned with the amount of ventilator-acquired pneumonia that patients contract. You have read that oral care may reduce the incidence of pneumonia in this group of patients.
Create a PICO Question--
Your turn:
Please get into groups of 3 students. You will be given a clinical situation. Please create a PICO question for each scenario.
Now it’s your turn!
Does exercise improve overall blood glucose levels in Type 2 Diabetes patients?
Does the use of chlorhexidine as a preoperative prep
reduce the incidence of surgical site infections?
Read widely and wisely (WHY?)
Attend professional conferences (WHY?)
Expect evidence that a procedure is effective
Seek environments that support research utilization
Become involved and communicate professionally
Participate in institutional research utilization and EBP projects where you work
Implications for Nurses: YOU
Studies at the top are considered more scientific than those toward the bottom:

Nope. It isn't....
Is all evidence created equal?
Models for Using Evidence-based Practice

The RCT has probably contributed more than any single scientific discovery to the improvement in medical care.

(Lancet, 1987)
Randomized Controlled Trial

problem-solving approach
to the delivery of health care that integrates
the best evidence
from studies and patient care data with
clinician expertise
patient preferences and values.

(Ingersoll, 2000; Melnyk, et al, 2009)
Evidence Based Practice--
What is it?
How would YOU define it?

Why should YOU learn about it?

Have YOU ever participated in it?

Will YOU ever participate in it?
“Evidence Based Practice”

Scenario #3
You are a nurse in a geriatric practice. Many of the patients take multiple prescriptions each day. They sometimes forget to take their medications or take them irregularly. You wonder if the use of compartmentalized pill boxes will increase medication compliance.
PICO Question
Practice--Your Turn:
Which of my current practices are supported by current evidence?
Why am I doing something the way that I am?
Could there be a better way?
Who could act as my EB mentor?
What is the preferred method to question policy?
Igniting a “Spirit of Inquiry”
Evidence-based practice incorporates all of the following EXCEPT

A. Expert clinical opinions
B. Teamwork
C. Client wishes
D. Credible research
True or False
A randomized, controlled study (RCT) is considered more rigorous scientific evidence that the opinion of an expert.

A. True
B. False
atients / Problem
P: Surgical patients
I: Chlorhexadrine prep used preoperatively
C: No chlorhexadine soap used preoperatively
O: Reduction in risk of surgical site infection
P: Patients with Type 2 diabetes
I: Exercise
C: No exercise
O: Benefit of exercise improving overall blood glucose levels
Going through the process of researching will introduce you to the practice of
reading research critically

So what?
You know you want to be a great, critical-thinking nurse!
will get you there.

So what?
You will begin to see this as a necessary step in changing and improving your clinical practice!!!

RCT Article Worksheet
Using EBP: A Story
Your Analysis of Research and
Application of EBP
(I, II, & III)
A question for you:
1. ACE Star Model (Stevens 2012)
2. Iowa Model
3. Models of Diffusion

EBP has been around since 1971
Archie Cochrane, a British Epidemiologist....
Was the first to say medical
professionals were not taking
advantage of the knowledge
that was already out there
about medicine.
Why are we medical professionals not working together?
Why don't we share research results better?
But very quietly....
Question for you:
Studies at the top produce evidence that can be relied on because of the way it was tested.
How do we go about
using EBP?
1. Identify a problem
2. Do research to see who else has looked at this problem!
3. Compile the results
4. Recommend changes to practice based on what you learn
First, you need to see that there is a problem of some kind.....
1. People?
2. Equipment?
3. Procedures?
4. Something else?
Research using key words.....

to see if what others have found
on this subject
you are having problems with.
(Schmidt and Brown, pg. 5)
3. Then,
the results of what you find
4. Recommend changes to practice and disseminate findings
Here is a way to approach research using
1. Identify the problem
2. Research to see who else
has looked at this problem!
These models all tell us how they think EBP can be used. (They say similar things in different ways; take a look at them.)
Last week in the emergency room, there were several people admitted with psychiatric emergencies (suicidal, severe depression needing medication adjustment, a manic episode, and a Borderline Personality patient in an acute phase of cutting herself).
The process of admitting them to the psychiatric unit took an average of nine hours for each patient. During this lag time, some patients became more agitated. Two patients actually wandered off the ED unit, an obvious safety issue.
Question: What is being done about long admission times for psych patients? What are other hospitals doing for their psych patients? Does anyone else think this is a problem? What's already been researched on this?
Answer: This is what the research showed:
I searched with key words and....
42,900,039 other results on this
and related topics.....

These great articles appeared:
"A plan to reduce emergency room 'boarding' of psychiatric patients" and
"Characterizing Waiting Room Time, Treatment Time, and Boarding Time in the Emergency Department Using Quantile Regression"
along with.....

Why would I ever start to do
my own research
unless I see
what is out there
By using EBP, we can:
see what is already out there
critically look at it
apply it to our own situations
and go forward!
to sort before searching:
42,900,039 reasons why not!
1: Systematic Reviews and Meta-Analysis
2: Randomized Controlled Trials
3: Controlled Trialss without randomization
4: Cohort Studies & Case Control Studies
5: Systematic Reviews of Qualitative Studies
6: Qualitative Studies
7: Expert Opinions & Reports of Experts
What's at the top is considered more scientific than what's at the bottom:
Question: What is the problem here?
Using EBP: A Story
So, What is PICO? Identifying the following before you start researching:
Clinical Question:
1. What is your Patient/problem?
2. Intervention?
3. Comparison
4. Outcome?
Clinical Question:
1. What is your Patient/problem?
2. Intervention?
3. Comparison
4. Outcome?
Let's apply PICO to this problem.
1. What is your Patient/problem?
2. Intervention?
3. Comparison
4. Outcome?
1. What is your Patient/problem?
2. Intervention?
3. Comparison
4. Outcome?
1. What is your Patient/problem?
2. Intervention?
3. Comparison
4. Outcome?
Remember Evidence Heirarchy:
Let's apply PICO here.
How do nurses choose what to do?
What do nurses cite as their sources for information?
Nursing School
"This is how we've always done it since I started working here."
"This is what I learned in school."
Books become outdated
"I watched some else do it this way"
Evidence-Based Practice
“This is the way we have always done it.”
Perpetuating outdated textbook information
Unit traditions
Advice of colleagues
Perpetuated myths

WHY would people avoid using EBP?
This is called
Individual Factors are involved:
Organizational Factors are involved
"I don't have enough time."
"I'm not really comfortable with the process of research."
"Who cares about research anyway?"
"I don't know how to look it up."
Lack of a culture that values EBP
"I'm really not a computer person."
"I don't like change."
What is a systematic review or meta analysis?
What is a randomized controlled trial (RCT)?
What is a controlled trial without randomization?
What is a case control study or cohort study?
What about evidence from a single qualitative study?
What about evidence from Opinion of Authorities or Expert Committees?
What about systematic reviews of qualitative studies?
Experts can weigh in on ideas, often talking about facts. This is the least rigorous level of evidence.
Qualitative studies explore what people feel about experiences they've been through. Sometimes used to find out things before a lot of specifics are known.
A Systematic Review takes lots of research studies set up the same way, and compares the results to see similariteis. It is like looking at lots of findings without doing the hard research yourself.
RCTs have two variables that are assigned randomly to two groups to test. Ex: One group with heartburn takes an antacid before bed, and one group takes no antacid. The two groups are randomly chosen, who gets the pill and who gets nothing.
See above example, but people are just assigned to an antacid group or no antacid group.
Two groups are compared, one with the condition, one without. Sometimes these are retrospective studies.
A review of several qualitative studies are done. See below.
And leads to
best patient care
, involving
patient preferences
, best
, and
practioner's expertise
Remember who cared first about evidence-based practice: Where is Archie Cochrane today?

Meet the Cochrane Collaboration
"Cochrane exists so that healthcare decisions get better...
As access to health evidence increases, so do the risks of misinterpreting complex content; meanwhile the likelihood of any one person getting a complete and balanced picture decreases. Our mission to provide accessible, credible information to support informed decision-making has never been more important or useful for improving global health."

Our mission is to promote evidence-informed health decision-making by producing
high-quality, relevant, accessible systematic reviews and other synthesized research evidence.
His passion for having people share research lives on.
Go here:
Full transcript