Distinguishing Tradition-Based and Evidence-Based Care Eleanor S. McConnell, PhD, RN, GCNS-BC Duke...
Transcript of Distinguishing Tradition-Based and Evidence-Based Care Eleanor S. McConnell, PhD, RN, GCNS-BC Duke...
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Distinguishing Tradition-Based and Evidence-Based Care
Eleanor S. McConnell, PhD, RN, GCNS-BCDuke University School of NursingDurham Veterans Affairs Medical CenterGeriatric Research, Education and Clinical CenterNovember 2013
http://coegne.nursing.duke.edu
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Think of a situation when….
You were afraid you were going to do more harm than good…..Examples…•Should I give a 45 year old woman with abdominal pain morphine in the ED?•Should I give Herpes Zoster vaccine to someone who has already had shingles?•Should I use a falls alarm to prevent falls….•What is your example?
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Evidence-based Practice Defined“..the integration of clinical expertise, patient values,
and the best evidence into the decision making process for patient care. “• Clinical expertise: the clinician's accumulated experience,
education and clinical skills. • The patient brings to the encounter his or her own
personal and unique concerns, expectations, and values. • Best evidence is usually found in clinically relevant
research that has been conducted using sound methodology. (Sackett, 2002)
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EBP – Begins and Ends with a Patient
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Case 1
Mrs. A is a 45 y.o. woman recently admitted to your Emergency Department with acute abdominal pain.
• One member of the treatment team wishes to give her morphine to relieve her pain
• A second member of the treatment team believes that morphine is contraindicated, because it will mask the signs needed to make an accurate diagnosis
• What would you do?
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Cycle of Evidence-based Practice
To learn more, go to these 2 sites: • http://www.hsl.unc.edu/services/tutorials/ebm/welcome.htm
OR
• http://www.cebm.utoronto.ca/practise/
Ask Pertinent question in area of uncertainty @ practice
Acquire Best available scientific evidenceComputers make this possible in “real time”
Appraise
Not all evidence is created equal
Apply Based on clinical experience, patient preference
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Cycle of Evidence-based Practice
Ask In a 45 y.o. woman with acute abdominal pain will MS04 compared to no Rx result in inaccurate dx ?
Acquire Medline Search:Abdominal pain OR Acute abdomen AND adult AND diagnosis AND RCT search filter
Appraise
9 RCTs – latest, 20061 review paper (2003)
Apply VAS improved 31 mm MSO4 v. placebo
Difference in clinically important diagnostic outcome was 1%
(95% confidence interval [CI] -11% to 12%).
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Search comes up with good answer because of “well-built” question &
EBM search filters
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Notice that most articles have abstracts that are available for free – in real time
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Case 2
Mrs. J is an 82 y.o. woman who comes to your clinic for her annual evaluation.
• She tells you she has seen recent advertisements on TV for medicines that can prevent dementia.
• Her mother died with dementia 20 years ago, and she does not want to be a burden on her family.
• What would you recommend?
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Cycle of Evidence- based Practice
Ask Among healthy 80 year old women what preventive approaches to dementia are effective?
Acquire Pub-Med Search: Dementia & Prevention – filter by systematic review
Appraise Systematic Review examining prevention of vascular dementia
ApplyApply
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Sample Review Paper
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Risk factors for vascular dementia (VaD), Alzheimer disease (AD), unspecified dementia, and Cognitive Impairment.
Copyright © American Heart Association
Risk Factor Vascular Alzheimer’s Dementia Cognitive Impairment
1. Non-modifiable: age & genetics (APO-E)
Yes Maybe
YesYes
YesYes
YesYes
2. Lifestyle factors:• Education• Smoking• Diet• Physical Activity• Obesity
NoYesYesYesYes
YesYesYesYesYes
YesYesYesYesYes
YesYesYesYesYes
3. Physiological Risk Factors:• Hypertension• Hyperglycemia &
Diabetes• Lipids
YesYesMaybe
MaybeYesMaybe
YesYesMaybe
YesYesMaybe
4. Vascular Disease:• Stroke• Coronary artery disease• Atrial fibrillation
YesYesYes
YesNoMaybe
YesYesMaybe
YesYesYes
Dichgans M , and Zietemann V Stroke 2012;43:3137-3146
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Temporal relationship between the critical period for elevated blood pressure and randomized trials of blood pressure-lowering treatment.
Dichgans M , and Zietemann V Stroke 2012;43:3137-3146
Copyright © American Heart Association
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Now really..Who has time for this?
• Realistic concern given our busy lives• One answer:
• Substitute for continuing education or haphazard journal article reading
• Just-in-time education• Another answer:
• Consider using pre-appraised evidence
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Pre-appraised Literature Sources
Type Example SourceGuidelines AMDA Guideline
for Pressure Ulcers
www.guidelines.gov
Journals Evidence-based Nursing
http://ebn.bmj.com/
Bibliographic Search Engines
Pub-Med http://www.ncbi.nlm.nih.gov/pubmed/
Workshops & Learning Networks
Evidence-Based Practice in Geriatric Care Settings
http://cgne.nursing.duke.edu/
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Source 1: Guidelines
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Search Results from www.Guidelines.gov
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Source #2: Pre-appraised Evidence: Journals
Source: Evid Based Nurs 2009;12:2 55 10.1136/ebn.12.2.55
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Final Step: Apply Evidence
Easier said than done! 1. Learning Collaborative:
• Institute for Health Care Improvement• Carolinas Center for Medical Excellence – QAPI in LTC
2. Evidence Based Practice Committee• Journal Clubs• Other strategies….
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Summary
• Tradition-based?• Few experts, may be biased, out of date
• Evidence-based?• Many experts, procedures to limit bias• Begins and ends with patient• Growing trend, accelerates access to scientific
discoveries• Helps free us from doing more harm than good
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To learn more:
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To learn more: http://www.hsl.unc.edu/services/tutorials/ebm/index.htm
Very well-doneself-instructionalmodule
You can start and
Stop where you wish!
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To learn more… www.mclibrary.duke.edu
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So what about that zoster vaccine???? Go to PubMed and put
“herpes zoster vaccine in search box…”
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And you’re really thinking…..• Who has time to look at 1116 citations?????• And we would say…..no one! What about 32? Or 3?
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Which one to pick? Sort by Relevance
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What did we learn?
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What else did we learn?