Dr. Hala Gabr EBP & Patient Safety PDF

Evidence-Based Quality & Patient Safety Management 1  Introduction to Evidence-Based Practice and Inquiry Part I: Brief History of EBP Evolution from Research Utilization to Evidence-Based Practice Definition of evidence-based practice. Evide...

Evidence-Based Quality & Patient Safety Management 1  Introduction to Evidence-Based Practice and Inquiry Part I: Brief History of EBP Evolution from Research Utilization to Evidence-Based Practice Definition of evidence-based practice. Evidence-Based Practices versus Practice Based Evidence Comparison between EBP, research, and QI process Importance of EBP to practice The Principles of Evidence-Based Practice Component of evidence-based practice. 5 Main Components of Evidence-Based Practice The Four Elements of Evidence-Based Practice Advantages of evidence-based practice. Disadvantages of evidence-based practice. The Benefits of Evidence-Based Practice Part II: Barriers of evidence-based practice. Strategies for overcoming barriers to adopting an EBP. Sources of EBP 5 Main Skills Required for Evidence-Based Practice Major Challenges Face in the Implementation of EBP Problems faced with implementing evidence-based practice. 2  Brief History of EBP A cornerstone of the evidence-based movement was laid by Dr. Archie Cochrane, a British epidemiologist. Cochrane struggled with the efficacy of health care and challenged patients to pay only for care that was judged effective through proven methods. In 1972, Cochrane published a landmark book, Effectiveness and Efficiency: Random Reflections on Health Services that criticized the medical profession for not conducting rigorous reviews of research evidence, so that organizations and policymakers could reach valid decisions about health care. Cochrane strongly advocated determining preferred treatment and practice by using evidence from randomized clinical trials (RCTs). His support of the development of a system to systematically organize this information led to the creation of the Cochrane library (www.cochranelibrary.com/). In 1993, the Cochrane Collaboration was established to support international efforts to improve health care throughout the world. More than 11,000 people have contributed to the collaboration. Cochrane reviews bring together research on the effects of health care and are considered the gold standard for determining the effectiveness of different interventions (Cochrane Collaboration, 2015a). During the 1980s, the term “evidence-based medicine “emerged to describe the approach that used scientific evidence to determine the best practice. Later, the term shifted to become “evidence-based practice “as clinicians other than physicians recognized the importance of scientific evidence in clinical decision-making. Various definitions of evidence-based practice (EBP) have emerged in the literature, but the most commonly used definition is, “the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients”(Sackett, Rosenberg, Gray, Hayes, & Richardson, 1996). Subsequently, experts began to talk about evidence-based healthcare as a process by which research evidence is used in making decisions about a specific population or 3 group of patients. Evidence-based practice and evidence-based healthcare assume that evidence is used in the context of a particular patient’s preferences and desires, the clinical situation, and the expertise of the clinician. They also expect that healthcare professionals can read, critique, and synthesize research findings and interpret existing evidence-based clinical practice guidelines. Definition of evidence-based practice. Evidence-based practice (EBP) is an approach that aims to improve the process through which high-quality scientific research evidence can be obtained and translated into the best practical decisions to improve health. Evidence-based practice is the use of the best scientific evidence integrated with clinical experience and incorporating patient values and preferences, in the practice of professional patient care. 4  Evidence-Based Practices versus Practice Based Evidence : Practices that integrate the best research evidence with clinical expertise and patient values. : A range of treatment approaches and supports that is derived from, and supportive of, the positive cultural of the local society and traditions. Comparison between EBP, research, and QI process 5  Importance of EBP to practice It results in better patient outcomes It keeps practice current and relevant It increases confidence in decision-making Policies and procedures are current and include the latest research, thus supporting JCAHO-readiness Integration of EBP into nursing practice is essential for high-quality patient care and achievement of ANCC Magnet Recognition Program® (MRP) designation. 6  The Benefits of Evidence-Based Practice The importance of evidence-based practice is undeniable, especially as we continue to gather new research and test theories related to patient care. EBP aids health care providers in pinpointing strategies to patient care and has become a vital component of high-quality patient care. Below, you will find the top five benefits of evidence-based nursing practices as they apply to patients, nurses, and healthcare organizations. Top 5 Benefits to The Patient 1. Evidence-based practice promotes positive patient outcomes by supporting a shared decision-making approach. 2. Reduced Risk of Hospital-Acquired Infections: One of the most common, yet preventable problems associated with hospital admissions is the risk of hospital-acquired infections. When health care providers implement proven, evidence-based infection control measures, the risk of patients developing HAIs is greatly reduced. 3. EBP allows nurses to involve patients in their care planning, promoting patient autonomy, which is a patient right. 4. Another benefit of evidence-based practice is that it prompts to alter methods of care if the current care plan contradicts best evidence-based practices, contributing to improved patient care. 5. Reduced Cost of Healthcare: Because evidence-based practices aim to prevent complications or unforeseen patient issues, they are instrumental in reducing healthcare costs. 7 Increased Patient Safety Patient safety is a paramount concern in care, and evidence-based practice plays a vital role in ensuring safe and effective care delivery. By incorporating evidence-based guidelines, protocols, and interventions, HCP can minimize errors, prevent adverse events, and promote a culture of safety. Evidence-based nursing practice provides nurses with up-to-date information on best practices and strategies that have been proven to enhance patient safety. This includes protocols for medication administration, infection control practices, fall prevention strategies, and more. By following evidence-based guidelines, nurses can reduce the risk of harm to patients and create a safer healthcare environment. Top 5 Benefits to the health care providers 1. Evidence-based practice provides health care providers with scientifically supported research to help them make well-educated decisions. 2. EBP helps health care providers stay up-to-date about new nursing interventions and protocols used in patient care. 3. Evidence-based practice for health care providers enhances critical thinking among health care providers. 4. Another benefit of evidence-based practices is that they promote strong decision-making skills. 5. Because evidence-based practices are based on research, the use of EBP encourages lifelong learning. Top 5 Benefits to The HealthCare Organization 1. EBP helps promote consistent care to patients based on evidence-driven research findings. 8 2. With the use of evidence-based practice, more favorable patient outcomes are achieved, resulting in increased patient satisfaction. Patient satisfaction scores are important to healthcare organizations because they impact reimbursement from financial institutions. 3. When implemented properly, evidence-based practices can reduce the demand for healthcare resources, making it possible to allocate resources where they will be most effective. 4. Evidence-based practices help reduce healthcare costs by utilizing relevant research to determine the most appropriate and cost-effective treatment options for patients. 5. Healthcare organizations benefit from evidence-based interventions by having knowledgeable health care providers, capable of understanding and implementing the best methods of patient care for clients. The Principles of Evidence-Based Practice Evidence-based practice is based on two principles: 1. Understanding that scientific evidence alone is insufficient to guide decision-making, 2. Within all the available sources of evidence, hierarchies exist - some types of evidence are seen as more valid or carry more weight than others Component of evidence-based practice. Health care practitioners work in a range of clinical environments that are likely to influence decision-making using EBP model. This model depicts the 9 three core components of EBP (best available research evidence, clinical expertise, and patient’s preferences). 5 Main Components of Evidence-Based Practice Evidence-based practice involves several components such as creating answerable clinical questions, using resources to find the best evidence to answer the clinical question(s), assessing the validity and usefulness of the evidence, deciding whether to apply results of the research into practice, and evaluating the effectiveness of the plan. Below is a detailed explanation of the 5 main components of evidence-based practice. 1. Clinical Expertise: The health care providers' clinical experience, education level, and licensure determine their scope of practice. The scope of practice dictates activities the nurse may undertake within their body of knowledge and based upon education, clinical training, and competency. Strong clinical reasoning and decision-making skills and research competency are essential components needed to understand and implement EBP. 2. Management of Patient Values, Circumstances, and Wants When Deciding to Utilize Evidence for Patient Care: 10 A key component of evidence-based practices is consideration of the client’s wants, needs, and values. Health care providers must consider all aspects of the patient’s individuality to provide best practice care. This means incorporating the client’s personal, religious, and cultural preferences when developing a care plan based on EBP. Evidence regarding benefits and risk factors should be disclosed to the patient or responsible party so they can make an informed decision about care. By disclosing information and allowing the patient/family to be involved in decision-making, the health care providers promote a therapeutic alliance between themselves and the patients, which aligns with the fundamental principle of evidenced-based practice, “the integration of good evidence with clinical expertise and patient values.” 3. Practice Management: Practice management related to EBP is a combination of the clinical experiences of the health care providers care team, research evidence, and interdisciplinary collaborative efforts to create strategic plans for implementing effective patient care plans. 4. Decision-Making: Evidence-based decision-making is the approach to patient care based on patient preferences, the health care providers' clinical experience, and research evidence within the context of validated resources. 5. Integration of Best Available Evidence: The final component of evidence-based practices is the act of integrating best available research evidence into clinical practice. 11  Four Elements of Evidence-Based Practice Recently however evidence-based medicine has become seen as a conflation or union of four elements: 1. The best research evidence available 2. The expertise and experience of the clinician 3. The patient's or customers values and preferences 4. As well as the environment or background existing at the moment. Advantages of evidence-based practice. The widespread promotion and adoption of EBP is due to its perceived advantages, in particular the goal of facilitating care based on the best evidence and available to everyone, rather than being locality specific due to knowledge, expertise, or funding. The advantages of EBP include: better informed practitioners EBP guidelines, enabling consistency of care across professional boundaries. client-focused care pathways structured processes for dissemination of the best evidence explicit and transparent ways of working with less scope for misinterpretation. information available to the public so that they can be genuinely involved in the decision-making processes about their care. clarification of what is known and what is not known to target further research. Increase confidence in decision-making. Generalized information. Contribute to science of health care. 12  Provide guideline for further research. Help HCP to provide high quality of service care. Disadvantages of evidence-based practice. The arguments highlighted by them remain the key concerns and include: o takes time and resources to develop the skills to undertake EBP. o not enough evidence about EBP o reduced client choice o does not cater for unique clients with complex and multifaceted needs. o reduced professional judgment/autonomy. o suppression of creativity o undermining perceived value of forms of evidence not at top of hierarchy of evidence o Influences legal proceedings. o Not enough evidence for evidence-based practice. o Time consuming o Reduce client choice. o Reduced professional judgment and autonomy o Suppress creativity. Barriers of evidence-based practice. lack of Value for research in practice Difficulty in bringing changes. Lack of administrative support Lack of knowledge mentors 13  Lake of time for research Research reports not easily available. Complexity of research report Lack of knowledge about EBP Strategies for overcoming barriers to adopting an EBP 14 15  Sources of EBP Before making an important decision, an evidence-based practitioner starts by asking, ‘What is the available evidence?’ Instead of basing a decision on personal judgment alone, an evidence-based practitioner finds out what is known by looking for evidence from multiple sources. According to the principles of evidence base practice, evidence from four sources should be taken into account: 16 The scientific literature Findings from empirical studies published in academic journals. The first source of evidence is scientific research published in academic journals. There is also much relevant research from outside the management discipline, since many of the typical problems that managers face, such as how to make better decisions, how to communicate more effectively and how to deal with conflict, are similar to those experienced in a wide range of contexts. The organization Data, facts and figures gathered from the organization. A second source of evidence is the organization itself. Whether this is a business, hospital or governmental agency, organizational evidence comes in many forms. It can be financial data such as cash flow or costs, or business measures such as return on investment or market share. It can come from customers or clients in the form of customer satisfaction, repeat business or 17 product returns statistics. It can also come from employees through information about retention rates or levels of job satisfaction. Evidence from the organization is essential to identifying problems that require managers’ attention. It is also essential to determining likely causes, plausible solutions and what is needed to implement these solutions. Practitioners The professional experience and judgment of practitioners. A third source of evidence is the professional experience and judgment of managers, consultants, business leaders and other practitioners. Different from intuition, opinion or belief, professional experience is accumulated over time through reflection on the outcomes of similar actions taken in similar situations. Stakeholders The values and concerns of people who may be affected by the decision. A fourth source of evidence is stakeholder values and concerns. Stakeholders are any individuals or groups who may be affected by an organization’s decisions and their consequences. Internal stakeholders include employees, managers, and board members. Stakeholders outside the organization such as suppliers, customers, shareholders, the government, and the public at large may also be affected. 5 Main Skills Required for Evidence-Based Practice Health care providers learn several skills essential to providing high-quality, safe patient care. The following are five main skills required to implement evidence-based practice in nursing. 18 1. Critical Thinking: Evidence-based practices require having the ability to evaluate data logically and weigh the evidence. 2. Scientific Mindset: Being scientifically minded means the nurse has a willingness to engage in research and inquiry. It involves not only empirical literature, but consideration of evidence as its available from patients, healthcare professionals, and research. 3. Effective Written and Verbal Communication: Solid, valid research involves utilizing various sources of information. Therefore, nurses must learn to effectively communicate with others. 4. Ability to Identify Knowledge Gaps: A knowledge gap is the difference between evidence and actual policy- making or clinical practice. Health care providers must identify knowledge gaps and implement measures to help reduce or eliminate the gaps. 5. Ability to Integrate Findings into Practice Relevant to the Patient’s Problem: Finding research data and discussing the information with patients and the interdisciplinary team is not the only part of EBP. Health care providers must integrate those findings into practice in ways that are most beneficial to the patient and aimed at helping resolve the patient’s issues. Major Challenges Health care providers Face in the Implementation of EBP Although the concept of evidence-based practice is not new, health care providers still face challenges when it comes to implementing EBP. 19 1. Not Understanding the Importance of the Impact of Evidence-Based Practice: Perhaps the most significant challenge to implementing EBP is the health care providers lack of understanding about how important evidence- based findings are in relation to patient care. 2. Fear of Not Being Accepted: In facilities where nurses feel their practices are different from the organizational or practice culture, they may feel apprehensive about introducing and implementing evidence-based practices. This challenge often arises when health care providers change jobs or move to a different specialty area and are not well-established. 3. Negative attitudes about research and evidence-based practice in nursing and its impact on patient outcomes: Although the implementation of EBP has grown in recent years, some health care providers continue to have difficulty appreciating its importance and impact on patients and the profession. 4. Lack of knowledge on how to carry out research: Many health care providers do not know how to carry out effective research, which leads to ineffective implementation of EBP. 5. Resource constraints within a healthcare organization: Health care providers need access to adequate research sources such as books, journals, and other credible research findings or sources. However, one of the most significant challenges health care providers faces in the implementation of evidence-based practice is the lack of resources from which they can gather data. 20 6. Work overload: Several reasons contribute to health care providers feeling overloaded at work. Work overload that results from callouts and increased numbers of patients requiring care 7. Inaccurate or Incomplete Research Findings: Unfortunately, data may be reported differently from one source to the next. Inaccurate or incomplete findings can be confusing for health care providers, making it difficult to identify which EBP to utilize. 8. Patient Demands Do Not Align with Evidence-Based Practices: It is not uncommon for patients seeking healthcare services to come with preconceived ideas about which treatment may be most effective. 9. Lack of Internet Access While in the Clinical Setting: Implementing evidence-based practices requires research. To perform adequate research, health care providers need access to up-to-date information. In the clinical setting, nursing may not have access to the internet, even for research purposes, which could make implementing EBP challenging. 10. Some Supervisors/Managers May Not Support the Concept of Evidence- Based Practices: Lack of support for EBP may occur for a few reasons. Some supervisors/managers, especially older nurses, express feeling comfortable with doing things the way they did before evidence-based practice became well-known. Problems faced with implementing evidence-based practice. The four major barriers to successful implementation have been found to be: 21  has been cited as a primary problem for many individuals and organizations. Access to professional resources required to develop EBP is often quite difficult and time consuming. In some cases, this just means the use of textbooks and Web sites. are regularly cited in every profession as being a key barrier to the application of EBP. For instance, in education, research indicates that teachers and instructors suggest that they are generally pushed to the limit and that the time needed to do research and introduce best practice is difficult to find. to give people the time to engage with the research needed to implement EBP properly. This can be overcome through the introduction of reliable administrative support in the organization and a careful consideration of priorities.. Individuals and organizations are often completely unaware of the new developments in their field, or the scientific evidence available to them that could completely revolutionize their organization, outcomes and thinking. Preparing and Sustaining Staff Knowledge about EBP Health care providers’ Role in evidence-based practice 22  Reasons Why health care providers’ Do Not Use Research Findings in Their Practices How do researcher/ Practitioners Participate in EBP? Developing the skills, attitudes, behaviours & knowledge required of EBP 4 Stages of implementation evidence-based practice in Organization Health care providers’ Role in evidence-based practice - Generate important questions. 23  - Know basis for nursing practice. - Expect that evidence is the foundation of practice. - Participate in EBP projects. - Disseminate project findings in various forums. - Collaborate with the healthcare team to provide quality care. Reasons Why health care providers’ Do Not Use Research Findings in Their Practices 1. They may not know or be aware of research findings. 2. They in practice do not usually associate or communicate with those who produce research findings. 3. They lack the ability to locate and find relevant research reports. 4. Research is often in language that is not clinically meaningful. 5. They do not understand research methods and have never had formal research classes in their nursing schools. 6. They lack the value for research in practice. 7. Computer databases are not readily accessible to the nurse. 8. They lack the basic knowledge to use information technology. 9. They have no time to obtain this information. 10. They do not understand exactly what EBP is. 11. People have a fear of the unknown and a fear of change. By understanding these processes, fear can be alleviated. 24 Think of a clinical situation that generated questions in his mind for which he had no answers. There are several ways that he might try to find an answer to his question(s), including: Asking an authority or expert in the field Consulting a textbook Looking for an article in a nursing journal Looking for an article in a scholarly journal Asking a nursing peer Using simple trial and error Using his intuition, judgment, or reasoning skills to solve the problem himself Developing the skills, attitudes, behaviors & knowledge required of EBP There are a series of six distinct skill sets EBP practitioners need such as: " 1. Asking: translating a practical issue or problem into an answerable question 2. Acquiring: systematically searching for and retrieving the evidence 3. Appraising: critically judging the trustworthiness and relevance of the evidence 4. Aggregating: weighing and pulling together the evidence 5. Applying: incorporating the evidence into the decision-making process 6. Assessing: evaluating the outcome of the decision taken to increase the likelihood of a favorable outcome. 25  24 Evidence-based practice competencies 13 are basic level competencies and the remaining 11 are advanced level competencies: 1. Questions operational practices for the purpose of improving the quality operations. 2. Describes problems using internal evidence (internal evidence* = evidence generated internally using internal assessment data, outcomes management, and quality improvement data). 3. Participates in the formulation of critical questions using PICOT* format (*PICOT = Population; Intervention or area of interest; Comparison intervention or group; Outcome; Time). 4. Searches for external evidence to answer focused questions (external evidence = evidence generated from research). 5. Participates in critical appraisal of pre-appraised evidence (such as practice guidelines, evidence‐based policies and procedures, and evidence syntheses). 6. Participates in the critical appraisal of published research studies to determine their strength and applicability to operational practice. 7. Participates in the evaluation and synthesis of a body of evidence gathered to determine its strength and applicability to practice. 26 8. Collects practice data (e.g. individual patient/customer data, quality improvement data) systematically as internal evidence for decision making in the care of individuals, groups, and populations. 9. Integrates evidence gathered from external and internal sources in order to plan evidence‐based practice changes. 10.Implements practice changes based on evidence and clinical expertise and patient preferences to improve care processes and customer outcomes. 11.Evaluates outcomes of evidence‐based decisions and practice changes for individuals, groups, and populations to determine best practices. 12.Disseminates best practices supported by evidence to improve quality of service and customer outcomes. 13.Participates in strategies to sustain an evidence‐based practice culture. 4 Stages of implementation evidence-based practice in Organization A number of studies have developed stages of implementation as a way of working out the order evidence-based practice implementation should occur in. This is in essence a proto-strategy or first level strategy. A normal stage model of EBP implementation involves the following stages of implementation: 1. Exploration 2. Preparation / adoption 3. Implementation 4. Sustainment 27 The EPIS framework The EPIS framework is based on the four stages of implementation (Exploration, Preparation, Implementation and Sustainment) and separates or highlights two types of implementation activity: The 2 types of implementation activity 1. Strategic processes and 2. Operational processes or activities EPIS framework is an holistic approach to the implementation of evidence- based practice and takes into consideration four sets of factors that need to be taken into account when involved in getting EBP integrated into an organizations working and decision-making practices. 28 The 4 implementation factors 1. Outer or external context factors 2. Bridging factors 3. Innovation factors 4. The inner organizational context Outer / external context factors Each of the following series of factors has been found in previous studies to have an impact on the implementation and functioning of evidence-based practice schemes and their impact on the implementation of evidence-based practice need to be understood and taken into consideration, particularly in understanding which factors will cause problems and which factors can be leveraged or used to assist with the implementation: The market environment Funding Inter organizational environment networks. Client or customer characteristics Client or customer advocacy Social perspectives Stakeholder understanding Bridging factors The following bridging factors have been found to have a significant impact on evidence-based practice implementation and functioning: 1. Partnership with academic institutions 2. Purveyors and intermediaries 29 In particular having a partnership with academic institutions like universities and other organizations that are evidence-based have been found to be key success factors for the implementation of evidence-based practice. Innovation factors The following innovation factors have been found to have a significant impact on the success of the implementation of evidence-based practice: The innovation/evidence-based practice fit. Innovation generation systems within the organization Client/customer interaction The understanding of innovation practitioners and evidence-based practice developers The characteristics of the evidence-based process and the innovation processes within the organization Inner context The following inner context factors or internal organizational issues have all been found to have a significant impact on the implementation of evidence- based practice: 1. Organizational leadership and management understanding 2. A range of organizational characteristics 3. The level of quality monitoring and support 4. Organizational staffing processes 5. Characteristics of individuals engaging with, or in, evidence-based practice 30 Implementation recommendations 1. Implementation of evidence-based practice should start with exploration and preparation, including having the question of how evidence-based practice is going to be sustained within the organization beyond the implementation phase. 2. That the exploration phase which starts the EPIS framework is both about gaining knowledge around the subject of evidence-based practice and, critically, around how the organization, people and external stakeholders are likely to perceive and orient themselves towards knowledge and evidence-based practice. Having this understanding means that the preparation phase is significantly more informed. 3. That the preparation phase is significantly more than drawing up a set of plans for implementation. It is, in fact, the phase in which the organization is prepared both cognitively, operationally, and emotionally for the change that is about to occur when evidence-based practice starts being implemented. 31 4. That implementation is seen as a series of experiments and knowledge creation events about how evidence-based practice will work best within this particular organization. EPIS is actually an invitation to engage in evidence-based practice for implementing and sustaining evidence-based practice in the unique and individual organization. This means that there needs to be a series of properly informed, rigorous, and thoughtful trials conducted within the organization and that the data is collected and analyzed as part of the implementation process. 5. That sustainment of evidence-based practice within any organization is a dynamic ongoing process of knowledge creation within itself. 32  Process of Evidence-Based Practice & critical appraisal of evidence Process of Evidence-Based Practice Rating strength of the scientific evidence Hierarchy of evidence Steps to the perfect PICOT search 33  Process of Evidence-Based Practice The EBP process can be considered as a series of steps: 1. Ask practice-focused questions, and frame the questions to find an answer 2. Search, identify and access the potential evidence 3. Evaluate the quality of evidence and decide what is best evidence 4. Apply best evidence to the specific case 5. Evaluate the EBP care provided, and the processes by which care decisions were reached. 1◆The EBP question Questions are most likely to come directly from clients or arise as practitioners provide care. It is also important to frame the question so it answerable. This is most easily achieved if the question is objective and clearly stated. Including the following four components helps achieve this: 34 ◆ a clearly identified client/group or condition ◆ an intervention or issue (diagnostic test, care option) ◆ a baseline or comparison point ◆ an outcome or result. To help recall these four features the mnemonic PICO may help: P = person (originally patient) or target population I = issue/intervention C = comparison O = outcome. 35 2◆ Having defined the question, the next step is to locate all the evidence that may be pertinent. This can be very time-consuming, but with practice it does get easier. Librarians, researchers, educationalists and practitioners who have themselves undertaken EBP searches are good resources for help and advice. This activity is an important part of any research process and is also crucial when developing clinical guidelines. There are two sources of evidence, people, and literature. Accessing people means participating in professional and interprofessional conversations, talking to consumer groups, attending conferences, and engaging with researchers, educationalists, managers, and those who shape policy at all levels. Online networks, general email communication networks, make this possible on a national and global scale previously unheard of. Types of literature Literature is classified as primary or secondary. Primary literature refers to original sources of information. Secondary literature includes systematic reviews, reviews, guidelines/policies, editorials, opinions, critiques, and any information that is a reconsideration of primary data. Some types of literature can be either primary or secondary. Hierarchy of evidence Primary sources of evidence are considered superior to other forms of evidence and the most important primary source is research findings. However, not all research is valued to the same degree. This led to the development of a hierarchy of evidence, with an expectation that 36 practitioners will base their practice on the best evidence as described by a hierarchy of evidence. One of the most cited hierarchies is: 1. systematic reviews and meta-analyses 2. randomized controlled trials with definitive results 3. randomized controlled trials with non-definitive results 4. cohort studies 5. case control studies 6. cross-sectional studies 7. case reports. A hierarchy of evidence is the same as levels of evidence and provides guidance about the types of research studies, if well done, that are more likely to provide reliable answers to a specific clinical question (Figure 5.2). 37 There are various hierarchies, or levels, of evidence, which hierarchy is appropriate depends on the type of clinical question being asked. For intervention questions, the most appropriate hierarchy of evidence ranks quantitative research designs (e.g., a systematic review of RCTs) at the highest level of confidence compared with designs that give lower levels of confidence (e.g., descriptive studies). Other types of questions are best answered by other hierarchies. The higher a methodology ranks in the hierarchy, if well done, the more likely the results accurately represent the actual situation, and the more confidence clinicians can have that the intervention will produce the same health outcomes in similar patients for whom they care. An RCT is the best research design for providing information about cause-and-effect relationships. A systematic review of RCTs provides a compilation of what we know about a topic from multiple studies addressing the same research question, which ranks it higher in the hierarchy than a single RCT. A systematic review (i.e., a synthesis of these studies) of many high-quality RCTs of similar design (i.e., have homogeneity) is the strongest and least biased method to provide confidence that the intervention will consistently bring about a particular outcome. Such systematic reviews have been considered the “heart of evidence-based practice” for some time. However, as EBP increasingly becomes the basis for achieving healthcare outcomes, the conduct and use of systematic reviews will be essential as the mainstay of evidence for decision making. 38 ❑ Case control studies are studies in which patients who already have a specific condition are compared with people who do not have the condition. The researcher looks back to identify factors or exposures that might be associated with the illness. They often rely on medical records and patient recall for data collection. These types of studies are often less reliable than randomized controlled trials and cohort studies. ❑ Cohort studies Identify a group of patients who are already taking a particular treatment or have an exposure, follow them forward over time, and then compare their outcomes with a similar group that has not been affected by the treatment or exposure being studied. Cohort studies are observational and not as reliable as randomized controlled studies, since the two groups may differ in ways other than in the variable under study. ❑ A Meta-analysis Will thoroughly examine a number of valid studies on a topic and mathematically combine the results using accepted statistical methodology to report the results as if it were one large study. ❑ Randomized controlled clinical trials. Are carefully planned experiments that introduce a treatment or exposure to study its effect on real patients. They include methodologies that reduce the potential for bias (randomization and blinding) and that allow for comparison between intervention groups and control (no intervention) groups. A randomized controlled trial is a planned experiment and can provide sound evidence of cause and effect. ❑ Systematic Reviews Focus on a clinical topic and answer a specific question. An extensive literature search is conducted to identify studies with sound methodology. The studies are reviewed, assessed for quality, and the results summarized according to the predetermined criteria of the review question. 39  Summary Studies definition ❀ Meta-analysis: is a systematic review that uses quantitative methods to synthesize and summarize results. ❀ Systematic review: is a summary of the literature that uses explicit methods to perform a comprehensive literature search & critical appraisal of individual studies. ❀ Randomized controlled trial: is a study where participants are randomly allocated into experimental, or control groups, and are followed over time for the variables/outcomes of interest. ❀ Cohort study: is a study which identifies participants who currently have a certain condition, receive a treatment, and are followed over time & compared with another group of people who are not affected by the condition. ❀ Case control study: which identifies participants who have a certain outcome (cases) & participants without this outcome (controls). ❀ Case report/case series: a report on one or more participants with a particular outcome. 3◆ The next stage is to read the identified papers. It is always worth checking the references in these sources as they should confirm that you have found all the related evidence or may highlight other resources that you have not come across. Make sure you understand all the concepts and underpinning research and topic theory, then make notes or highlight key points. This entails reading each paper several times. Creating cross- tabulated tables of authors against themes or research methods/tool/outcomes may help and can be done on large sheets of paper, or in word processing packages. This activity has the dual benefit of making sure you are familiar with the papers, enables you to easily check your understanding, compare papers, and helps when several individuals are 40  working together. This is a preliminary activity to critical appraisal of the literature, which is the process by which the quality of the evidence selected is assessed in a way that is transparent and open to review by others. This is the third step in the EBP process. 4◆ When you have decided what the best evidence is, review it remembering definition of EBP. This means ensuring that the evidence is applicable to the practice context. Application to practice may also raise management and service provision issues, including: ◆ resources: staff, equipment, environment, time, funding ◆ health and safety implications ◆ guidelines developed/needed ◆ compatibility/consistency with the wider service philosophy/provision demands ◆ whether or not this form of care has implications for other provision and needs to be reviewed in light of the EBP processes. Literature summary table Author/ Theoretical Research Methodology Analysis Conclusions Implications Implication Date / Question(s)/ & for for practice Conceptual Hypotheses Results future Framework Research 41 42 43  Quality: the extent to which a study’s design, conduct, and analysis have minimized selection, measurement, and confounding biases (internal validity) 44  Quantity: the number of studies that have evaluated the clinical issue, overall sample size across all studies, magnitude of the treatment effect, and strength from causality assessment for interventions, such as relative risk or odds ratio. Consistency: whether investigations with both similar and different study designs report similar findings (requires numerous studies) 45 46 47 Steps to the perfect PICO search 48 ❀ The first step "Ask" involves developing a clear, focused, and searchable question that will lead to find a relevant research literature. ❀ The first step in doing this is to determine the type of question: background or foreground. "Background" questions which ask for general knowledge while "Foreground" questions which ask for specific knowledge to inform clinical decisions ❀ PICO is a format for developing a good clinical research question prior to starting the research. It is a mnemonic which used to describe the four elements of a sound clinical foreground question. The question needs to identify the patient or population who intended to be studied, the intervention or treatment planned to be used, the comparison of one intervention to another (if applicable) , and the anticipated outcomes. These make up the four elements of the PICO model: Patient/ Problem, Intervention, Comparison and Outcome. PICO format P: Population/patient or problem should carefully be specified: ✓ Are they individual persons, families, communities, or groups? ✓ What are their specific characteristics (age, sex)? ✓ What is their specific health problem which means the statement of a question that needs to be answered or a situation that needs a solution ? I: Intervention/indicator It is the management strategies which researcher is interested in comparing. It may include the treatment strategy, exposure, or test that is needed to find out about what is in relation to the clinical problem. This might be: 49  Type of service or intervention of interest which may be (preventive or therapeutic) which may be a drug treatment, surgery, or diet. An indicator: which is an exposure to an environmental hazard, a physical feature such as being overweight, or a factor that might influence a health outcome. An index test: is a diagnostic test such as a blood test or brain scan C: comparator or control is an alternative intervention, control strategy, exposure, or test. O : outcome Which means consequences of intervention or exposure of interest (which is the patient's -relevant consequences about happening, or preventing happening). Steps to the perfect PICO search 1. Formulate the PICO question 2. Identify keywords for each PICO element 3. Plan the search strategy 4. Execute the search 5. Refine the results 6. Review the literature 7. Assess the evidence 50 Case Scenario: A registered nurse working on a urology unit. One of the patients is a 55-year-old man who is recovering from abdominal surgery ( a laparoscopic prostatectomy). The patient complained from abdominal pain and nausea. His abdomen is distended, and he has no bowel sounds. The physician suspects a paralytic ileus and confirms the diagnosis based on the combination of clinical features and imaging. At the next evidence-based nursing practice committee meeting, this case was discussed. The committee decides to do a case study to determine if there is evidence to suggest that a simple intervention such as chewing gum post-operatively can prevent a post-operative ileus following abdominal surgery. Based on this scenario, the research question may be “In patients undergoing abdominal surgery, is there evidence to suggest that chewing gum post-operatively compared with not chewing gum post- operatively affects post-operative ileus? “In patients undergoing abdominal surgery, is there evidence to suggest that chewing gum post-operatively compared with not chewing gum post- operatively affects post-operative ileus?” 51 Plan a search strategy by the following: o Determining which database(s) to search through it o Identifying the major elements of the question o Translating natural language terms into subject descriptors as CINAHL headings, or synonyms. Where synonyms, words or phrases that mean exactly or nearly the same as another word or phrase help to expand the search appropriately. Adding synonyms will help to expand results to those articles that are still relevant but might not include the words ‘abdominal surgery’. Before beginning searching, ensuring the search mode is set to Boolean/Phrase. The reason is important because this option allows for “exact phrase” searching. For example, during searching for the phrase, heart disease, the system will search for records where the two words 52  (heart and disease) appear together, as a phrase, and not simply records where the two words appear separately. To begin the search. Each PICO Element (P, I, C, O) will be searched individually using the correlating search strategy. After each search, researcher should clear the screen and start a new search before beginning your next search. P (patient or population): Begin the search with the patient or Population, which are those patients undergoing abdominal surgery to increase the search results, try to add less descriptive terms that have the same meaning, such as surgery, postoperative or recovery. Note: Be sure to use the Boolean operator “Or” so that each result contains at least one of these search terms is an example of this search strategy shown on EBSCOhost as shown in the following figure. I (Intervention): Start a new search for the intervention, which is chewing gum or gum and be sure to use the Boolean operator. O (Outcome): a search can be conducted for the outcome, which is post- operative ileus. Add the synonyms paralytic ileus or ileus. the goal is to determine whether chewing gum postoperatively affects postoperative ileus, positively or negatively. Click search and note the number of results. 53  Combine searches: To complete the search, the researcher will combine the Population (those patients undergoing abdominal surgery), the intervention (chewing gum),and the outcome (post-operative ileus/paralytic ileus) by using the database’s search history should be able to combine these searches into one search which show results from all three of the previous searches. The search results can be refined by adding limiters. Applying limiters to the search will allow to focus the results to the most pertinent and relevant content. The results may be limited by date and type: Published date – this option is used to search for articles within a specified date range. Example: Evidence-based practice to limit the articles to those which are evidence-based. When searching an EBSCO host database for example, the evidence-based practice limiter searches the special interest field for the value “evidence-based practice.” Applying this limiter allows limiting results to: ▪ Articles from evidence-based practice journals ▪ Articles about evidence-based practice ▪ Research articles (including systematic reviews, clinical trials, meta- analyses, etc.) ▪ Commentaries on research studies (applying practice to research) ▪ To find the required articles by limiting the results to evidence-based practice can instead choose any or all of the following publication types: 1. Case study 54 2. Clinical trial 3. Meta-analysis 4. Randomized controlled trial. 5. Research 6. Systematic review Researcher should choose and review articles that are most relevant to the PICO question , find an article that is particularly relevant to the search , and check with the library to locate the full text of the article The final step to the perfect PICO search is to determine the level of evidence within each relevant article. In searching for the best available evidence, a hierarchy exists regarding the level and strength of evidence should be used. As review of the journal articles, selection of studies/articles that are based on highest level of evidence such as a meta- analyses or a systematic review should be used and maintained. 55  Hierarchy of evidence Studies definition ❀ Meta-analysis: is a systematic review that uses quantitative methods to synthesize and summarize results. ❀ Systematic review: is a summary of the literature that uses explicit methods to perform a comprehensive literature search & critical appraisal of individual studies. ❀ Randomized controlled trial: is a study where participants are randomly allocated into experimental, or control groups, and are followed over time for the variables/outcomes of interest. ❀ Cohort study: is a study which identifies participants who currently have a certain condition, receive a treatment, and are followed over time & compared with another group of people who are not affected by the condition. 56 ❀ Case control study: which identifies participants who have a certain outcome (cases) & participants without this outcome (controls). ❀ Case report/case series: a report on one or more participants with a particular outcome. Examples:……………………………………… Once the clinical question in PICO (T) format was made, there are two additional facts that should be considered: 1. The type of the questions which asked 2. The type of study will provide the best answer for the question (as present in the hierarchy of evidence ). Example for prognosis/ prediction question For patients 65 years and older (P), how does the use of an influenza vaccine (I) Compared to not received the vaccine (C) influence the risk of developing pneumonia (O) during flu season (T)? The PICO(T) of this situation is Patient: patients 65 years and older Intervention: using of an influenza vaccine Comparator: not using the influenza vaccine Outcome: decrease the risk of developing pneumonia Time : during flu season Example for prediction question In patients who have experienced an acute myocardial infarction (P), how does being a smoker (I) compared to a nonsmoker (C) influence death and 57 infarction rates (O) during the first 5 years after the myocardial infarction (T)? The PICO(T) of this situation is Patient: patients who have experienced an acute myocardial infarction Intervention: smoker Comparator: non smoker Outcome: influence death and infarction rates Time : during the first 5 years after the myocardial infarction Examples for different PICO worksheet 58 59 60 61 62 63 64 Ensuring Patient Safety: Strategies and Best Practices for Healthcare Providers Strategies for Improving Patient Safety Best Practices for Healthcare Providers Resources and Tools for Improving Patient Safety Advancing Evidence-Based Policies to Reduce Medical Errors Improving patient safety and quality improvement is a critical topic in healthcare today. The Patient Safety Authority and Institute of Healthcare Improvement are just a few organizations dedicated to advancing health care quality and promoting patient safety. In this context, healthcare providers must prioritize patient safety by following evidence-based practices that aim to prevent harm to patients. They should use quality indicators to evaluate their performance, define and assess preventable patient harm, and regularly connect with patients and their families to improve the quality of patient care. Healthcare providers must adopt a comprehensive approach to improving patient safety that includes the following strategies: Evidence-based practices for advancing patient safety: Healthcare providers must use evidence-based practices to advance patient safety. These practices include identifying and addressing patient safety risks, 65  promoting a culture of safety, and engaging patients and families in their care. Addressing medical errors and preventing harm: Healthcare providers must address medical errors promptly and develop strategies to prevent harm to patients. This requires identifying and reporting adverse events, analyzing the root cause of the event, and implementing measures to prevent future occurrences. Improving patient safety in healthcare settings: Healthcare providers must ensure patient safety across all healthcare settings, including hospitals, clinics, and long-term care facilities. This requires implementing policies and procedures that prioritize patient safety, such as hand hygiene protocols, infection prevention measures, and medication safety initiatives. Policy and procedure updates to prioritize patient safety: Healthcare providers must update policies and procedures regularly to reflect new evidence and best practices for patient safety. This requires staying up to date with the latest research and guidelines and implementing changes to policies and procedures accordingly. Ensuring healthcare for all patients: Healthcare providers must ensure access to safe and high-quality care for all patients, regardless of their background or social status. This requires a focus on health equity and addressing disparities in healthcare delivery. Highlighting the importance of patient safety across the care continuum: Healthcare providers must prioritize patient safety across the care continuum, from prevention and diagnosis to treatment and 66  follow-up care. This requires a comprehensive approach to patient safety that involves all members of the healthcare team. Implementing best practices for patient safety and quality improvement is crucial in preventing patient harm and ensuring high-quality care. Healthcare providers should prioritize the following best practices: Utilizing Evidence-based Practices Healthcare providers should use evidence-based practices to prevent medical errors and improve patient safety. This includes adopting standardized protocols for medication administration, hand hygiene, and infection prevention. Providers can access clinical performance measures, evaluation frameworks, and guidance on the Institute of Medicine’s website to ensure they are implementing best practices. Investing in Staff Training and Development Healthcare providers should invest in staff training and development to ensure that all members of the healthcare team are equipped with the knowledge and skills needed to provide safe and high-quality care. Providers can access webinars, publications, and newsletters to stay up to date on best practices and expand upon their clinical knowledge. Promoting a Culture of Safety Healthcare providers should promote a culture of safety that prioritizes patient safety and encourages reporting of adverse events and near- misses. Providers can utilize case studies and assessments to identify areas of improvement and eliminate improper practices. 67 Emphasizing communication and Teamwork Healthcare providers should prioritize effective communication and teamwork to ensure patient safety. This includes utilizing tools like checklists, huddles, and debriefs to facilitate communication and collaboration among team members. Implementing Strategies to Prevent Healthcare-associated Infections (HAIs) Healthcare providers should implement strategies to prevent HAIs, such as proper hand hygiene and timely removal of surgical dressings. Providers can access resources from the Centers for Disease Control and Prevention to ensure that they are implementing best practices. Monitoring and Improving Performance Healthcare providers should continuously monitor and improve their performance to ensure patient safety. This includes using performance measures to track progress and identify areas for improvement. By implementing these best practices, healthcare providers can improve patient safety, prevent harm, and enhance the well-being of the population they serve. Improving patient safety is a top priority for healthcare providers and organizations across the United States. To support this effort, there are many valuable resources and tools available. Here are some of the most helpful: 1. Institute of Medicine (IOM): The IOM is a non-profit organization that provides guidance and recommendations to 68  improve the safety and quality of healthcare. They offer webinars, publications, and case studies to support healthcare providers and organizations in establishing safe and effective practices. 2. Healthcare Facilities Accreditation Program (HFAP): The HFAP is a non-profit accreditation organization that helps healthcare facilities establish and maintain safe and effective practices. They offer assessments and analyses to identify areas for improvement and provide recommendations to enhance patient safety. 3. Diagnostic Error in Medicine (DEM): The DEM is a web-based resource that provides education and tools to support healthcare professionals in reducing diagnostic errors, which are a leading cause of injury in healthcare. 4. Patient Safety Movement Foundation: The Patient Safety Movement Foundation is a non-profit organization that focuses on eliminating preventable patient harm. They offer webinars, newsletters, and performance measures to support healthcare providers and organizations in implementing best practices to make care safer. 5. Healthcare Provider Education and Training Programs: Education and training programs are available for nurses, practitioners, clinicians, and other healthcare professionals to improve their knowledge and skills in patient safety. These programs can help establish a culture of safety and promote timely identification and resolution of patient safety risks. 69 By implementing these resources and tools, healthcare providers and organizations can establish and maintain a safe and effective healthcare environment, ultimately reducing the risk of injury and improving patient outcomes. Medical errors remain a significant challenge for healthcare providers and organizations, posing a threat to patient safety and quality of care. To address this issue, healthcare organizations must prioritize evidence-based policies that can effectively reduce medical errors and improve patient outcomes. The Agency for Healthcare Research and Quality (AHRQ) has been at the forefront of advancing evidence-based policies to reduce medical errors. AHRQ provides resources and tools for healthcare providers and organizations to improve patient safety and reduce medical errors. These resources include evidence-based guidelines, and educational materials that are essential in developing and implementing effective policies. One critical policy area that has shown promise in reducing medical errors is improving nurse staffing. Studies have shown that low nurse staffing levels are associated with an increased risk of adverse patient outcomes and medical errors. By establishing policies that prioritize adequate nurse staffing, healthcare organizations can help reduce the risk of medical errors and improve patient safety. Another policy area that has gained attention is the use of technology to reduce medical errors. Electronic health records (EHRs), barcoding systems, remote patient monitoring technology, and patient safety alert 70  systems are examples of technologies that can improve patient safety by reducing the risk of errors and improving communication among healthcare providers. Healthcare organizations must prioritize the implementation of these technologies to improve patient safety. Research Question (PICOT) The research question for this project is Improving Patient Safety, Evaluation of a Fall Prevention Program in Assisted Living. Population (P), Intervention (I), Comparison (C), Outcome (O), and Time (T)- known as PICOT is a unique way of structuring components of clinical issues to guide evidence for solution. The PICOT for this project is outlined as follows: P- Older adults at least 65 years of age living in Assisted Living Facility I- Evidence Based Fall Prevention Measure C- Comparing outcomes before and after fall prevention programs O- Decrease in falls and injury T- Occurring over 12 weeks of study 71