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

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?

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)

EBP – Begins and Ends with a Patient

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?

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

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%).

Search comes up with good answer because of “well-built” question &

EBM search filters

Notice that most articles have abstracts that are available for free – in real time

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?

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

Sample Review Paper

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

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

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

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/

Source 1: Guidelines

Search Results from www.Guidelines.gov

Source #2: Pre-appraised Evidence: Journals

Source: Evid Based Nurs 2009;12:2 55 10.1136/ebn.12.2.55

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….

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

To learn more:

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!

To learn more… www.mclibrary.duke.edu

So what about that zoster vaccine???? Go to PubMed and put

“herpes zoster vaccine in search box…”

And you’re really thinking…..• Who has time to look at 1116 citations?????• And we would say…..no one! What about 32? Or 3?

Which one to pick? Sort by Relevance

What did we learn?

What else did we learn?