EBP 循证医学课件

1、EVIDENCE-BASED PRACTICE: WHATS IN IT FOR YOU? SO MANY QUESTIONS . . . Evidence-Based Practice (EBP): What is the best approach for managing neuropathic pain in the terminally ill patient?What research has been done that could provide clinical practice guidelines?Quality Improvement (QI): Are we doin

2、g the right things to appropriately manage patients neuropathic pain?How do we know? How are we measuring patient outcomes? Research (R): What is it like to live with neuropathic pain?Does drug “A” work better than drug “B?” Whats been studied? Where are the gaps? COMMONALITIES PROVIDE STRUCTURE!Evi

3、dence-based practice (EBP) utilizes the best clinical evidence in making patient care decisions typically from research. EBP translates knowledge into practiceQuality improvement (QI) - utilizes a system to monitor and evaluate the quality and appropriateness of care (outcomes) based on EBP and rese

4、arch Research (R) - applies a methodology whether quantitative or qualitative to develop, uncover, create, find, add new nursing knowledgeCOMMONALITIES IMPROVE CARE DELIVERY! Involve teamwork not done in isolationCall for critical thinking and creativityCommitment to improve care One informs the oth

5、erNurses base their practice on emerging evidence from research (EBP) Research starts in practice and ends in practice Quality improvement evaluates and monitors care, and identifies opportunities to improve care as the processes and outcomes of care are measured, continuously evaluated and improved

6、 WHAT IS EVIDENCE-BASED PRACTICE?Conscientious use of current best evidence to make decisions about patient careA problem-solving approach to clinical practiceBased on:1.systematic search for and appraisal of most relevant evidence to answer questions2.ones clinical experience and expertise3.patient

7、 preference and values EVIDENCE-BASED PRACTICEThe process of doing the “right thing” Standards of care Baseline description of quality- may be discipline focused AANP standards of NP practiceClinical guidelines Broad-based recommendationsCritical pathways Identify key/critical activities that must o

8、ccur in predictable fashionProtocols Detailed procedures on how to proceed with evaluation and treatment NONPFFIVE STEPS OF EVIDENCE-BASED PRACTICE Ask the burning clinical question (Picot format)Search for and collect the most relevant and best evidenceCritically appraise the evidenceIntegrate all

9、evidence with ones clinical expertise, patient preferences and values in making a practice decision or changeEvaluate the practice decision or change (Disseminate) Unlike research utilization (info from a single study), EBP - takes into account expertise of the practitioner and patient preferences /

10、 values Melnyk & Fineout-Overholt 2005 STAR MODEL FIVE STAGES: EBPDepicts 5 major stages of knowledge in a relative sequence as research evidence is moved through several cycles, combined with other knowledge and integrated into practiceConverting knowledge into practiceProvides a framework for syst

11、ematically putting evidence-based practice processes into operation Stevens 2004 () Reference: Haynes (1998). Barriers and bridges to evidence-based clinical practice. BMJ, 317:273-276. QUALITY IMPROVEMENTProcess that utilizes a system to monitor and evaluate the quality and appropriateness of care

12、based on evidence-based practice and researchQUALITY IMPROVEMENT: FOCUS Questions (3)1. What are we trying to accomplish?2. How will we know a change is an improvement?3. What changes can we make that will result in improvement?Rapid Improvement or PDSA cyclesPDSA: THE DEMING MODELPlan- Test objecti

13、ves- Who will do what- Predict outcomesDo- What happened- Did it workStudy- Analyze outcomes in context of predicted- Summarize lessons learnedAct- What modification needs to be made- Statement of new plan . PDSA cycle repeatsBARRIERS TO EVIDENCE-BASED PRACTICEOverwhelming patient workloadsMispercep

14、tions about EBP and researchLack of time and resources to search for and appraise evidenceOrganizational constraints lack of supportPeer pressure to continue with practices that are steeped in tradition “weve always done it this way and we are not changing now”Melnyk & Fineout-Overholt 2005BARRIERS

15、TO EVIDENCE-BASED PRACTICEKnowledge lack of knowledge/awareness . unfamiliar with guidelines and guideline accessibilityAttitudes . lack of confidence in the guideline developer, lack of motivation to perform the guideline recommendationsBehaviors . inability to incorporate patient preferences into

16、the clinical decision making process Melnyk & Fineout-Overholt 2005WHAT ARE YOUR EXPERIENCES WITH CHANGE?Have you ever tried to change a practice at your work site?What worked?What didnt?What was the final outcome?What would you do differently?Do facts (evidence) change behavior?RESEARCH: WHEN EVIDE

17、NCE IS NOT THERE/NOT SUFFICIENTConduct a research study to determine the “what is it we want to know”Nature of the question will determine the level of the research study1 - What is the nature of the phenomenon?2 - Who, what, how many, how much?3 - What are the relationships among the variables?4 -

18、Does one variable cause the other?RESEARCH QUESTIONS.First three questions - reflect levels of research seeking descriptive knowledge of the variables under studynon-experimental designFourth question reflects a level of research that examines cause and effectexperimental designBefore one conducts a

19、n experimental research study, one must have data from the three previous levels to support such a studythe preliminary work! Value of researchadds new knowledgeto guide and improve nursing practice QI VS. RESEARCHIntervention may be multifactorial represents best practicesRapid improvement cyclesNo

20、 risk to patientsAudience is organizationData source: organizationDesign - no controlsNot generalizable NONPFUntried intervention being testedRisk may be presentComplex protocolAudience is scientific communityData source randomized population, multiple sitesDesign focus on controlsGeneralizableQUALI

21、TY IMPROVEMENT (QI) VS. PERFORMANCE IMPROVEMENT (PI)Often used interchangeably Useful to think of PI as a “drill down process” to look at a specific problem that occurs with the implementation of EBP OTHER THOUGHTS.Research, quality improvement and evidence based practice are integral to the delivery of quality patient careEach informs the other and improves upon the otherEach requires commitment, team work, vision, critical thinking, creativity, leadership, energy and endurance“Doing the right thing” in each of t