Translating Best Practice into Better Clinical Practice

Joseph E Pellegrini, PhD, CRNADeputy Director, Nurse Anesthesia Program

University of Maryland

Evidenced-Based Practice

Practice anesthesia based on: What we were taught in training What we learned through personal trial & error What we learned from other people’s mistakes and

misadventures What we read about or seen in a conference

Does this give us the whole picture?? Evidenced-Based Practice

What is best practice & how does it relate to the field of nurse anesthesia? An approach in which the practice of nurse

anesthesia is governed by the best evidence to dictate clinical decision making No longer practice norms dictated by experience

and textbook Places less emphasis on “expert opinion” and more

emphasis on “body of evidence” Uses a “holistic” approach to care in which

multiple factors are taken into account Includes individual patient factors

Evidenced-Based Practice (origins) Started in UK by Dr. Archie Cochrane who criticized physicians for lack of

critical appraisal & synthesis of research in their practices Recommended systematic reviews to govern practice

Cochrane Collaboration Promoted more active evidence-based guidelines to be formulated

AHCPR Guidelines (RU principles) Evidenced-Based Medicine coined in 1990 by Dr. Guyatt of McMaster

University Guidelines provided regarding evidence

Metaanalysis (quantitative systematic reviews) of 2 or more RCTs viewed as gold standard of evidence

Nursing guidelines established by McMaster’s University for Evidenced-based Nursing (EBN) through consultation and publications Evidenced-Based Nursing

Does it really fit into everyday anesthesia practice?? Anesthesia Patient Safety Foundation (APSF) Departmental Clinical Practice Guidelines

Evidenced-Based Practice: What is it?

“EBP is a framework for clinical practice that incorporates the best available

scientific evidence coupled with experience and patient preferences & values to make decisions about health

care”

Evidenced-based Anesthesia

Evidenced-based anesthesia is a clinical decision making process that is based on the best clinical and epidemiological research

combined with your own clinical experiences and patient preferences

How do you link EBP to a Clinical Anesthesia Practice? Evidenced-based practice has been shown to

improve outcomes, improve patient satisfaction and decrease morbidity and mortality

Anesthesia is a practice of repetition and expertise Often clinicians can stagnate in their practice

“It isn’t broken so why fix it”? While this is a sound policy is it the best policy for our

patients and practice? Often practice is dictated by surgeons preferences etc.

CRNAs will often submit to surgeon preferences etc. because they don’t have valid argument to change practice Instituting EBP principles can supply the surgeon etc. with a

valid argument to change practice or at least offer up a sound basis for the argument

Ask yourself these questions to determine if EBP is right for your practice If your child was in a motor vehicle accident and sustained a

sustained head injury, would you want the CRNA caring for him or her to provide care from the most effective, empirically supported treatment(s) established from randomized controlled trials to decrease his or her intracranial pressure?

If you are having a major orthopedic procedure would you want the anesthesia provider to not only make sure that your were comfortable for the procedure etc. but also provide an anesthesia care plan that leads to better short term and long term postoperative outcomes?

Obviously the answer to these questions is “yes” but how do you go about implementing these into your clinical practice?

Introduction of EBP into clinical practice

Application into Practice

Challenging Requires a structured approach to care Requires a knowledge as to the quality of evidence

Often clinical trials in anesthesia lack validity, randomization Decisions in OR often are based on pathophysiological

reasoning, animal studies or paid volunteers Little evidence to application to everyday clinical practice Often decisions need to be made rapidly not allowing for adequate

application of EBP principles EBP approach can be used for both new investigations or to

supplant existing practice models or guidelines Many anesthesia practices do not have clinical practice

guidelines

So where do you start?

Finding a Topic Problem Focused

Is current practice adequate to address concerns or problems?

Knowledge Focused New information out regarding a practice

area Knowledge AND Problem Focused

Need to formulate topics that are focused on both the problem (s) identified in clinical practice & the knowledge available

Knowledge in the literature and from experiences in the practice

Questions & Problem Focus using EBP Format & Application into Practice

Begin by defining relevant clinical questions to identify the problem: Identify whether it is a “simple” or “complex” question Areas where questions are most typically identified:

M&M Conferences/Anesthesia Lounge discussions Determine whether the questions are simple or complex in nature

Simple question – “How much bicitra should a patient with GERD receive prior to GETA?” Based on evidence clinical question can include more information

i.e. Concomitant administration of metoclopramide Complex question – “What is the best approach to preoperatively

evaluate a patient who presents with CAD?” After the question & problem is identified is formulated

further define the problem: Place question (s) into a workable format that make it easier to review

the literature using a PCD or PICO Format

PCD & PICO Formats for defining the clinical questions Format used to formulate clinical questions related

to patient clinical problems: Using PICO format-

Patients or Populations (P) Interventions (I) Comparison group (C) or “gold standard” Outcomes (O) of interest

Can be reformatted into PCD format Population (patient population) or Problem Cues or cues clusters (behaviors or clinical scenarios) Differential Diagnosis (what is currently done and what else

can be done based on a body of evidence)

Questions using the PICO format

P I C O Ask yourself:

Population

(patient/condition)

•How would you describe a group of patients similar to yours? •What are the most important characteristics of the patient? •This may include the primary problem, disease, or co-existing conditions. •Sometimes the sex, age or race of a patient might be relevant to the diagnosis or treatment of a disease.

Intervention(drug, procedure, diagnostic test)

•Which main intervention, prognostic factor, or exposure are you considering? •What do you want to do for the patient? Prescribe a drug? Order a test? Outline a specific method of anesthesia? •What factor may influence the prognosis of the patient? Age? Co-existing problems? What factors will impact your anesthesia? •What was the patient exposed to? Asbestos? Cigarette smoke?

Comparison •What is the main alternative to compare with the intervention? •Are you trying to decide between two drugs, a drug and no medication or placebo?•Your clinical question does not always need a specific comparison.

Outcome •What can you hope to accomplish, measure, improve or affect? •What are you trying to do for the patient? Relieve or eliminate the symptoms? •Reduce the number of adverse events? Improve postoperative function?

Strategies to Incorporate EBP into Practice

It all starts with the library Collaboration with the reference librarian

Begin search strategies by using hierarchy of evidence Use Focused, Clinical Question to guide the search

The Pyramid of Evidence

Randomizedcontrolled trials

Cohort studies

Case control studies

Case series

Case reports

Editorials, opinions

Animal research

In vitro “ test tube ” research

Metaanalysis or Systematic Reviews

IncreasingClinical Relevance

Once important questions have been formulated, what are the best sources for evidence to answer the question? An important principle of EBP is that the quality

(strength) of the evidence is based on a hierarchy of evidence. In descending order, this hierarchy consists of: Systematic review of well-designed clinical trials (meta-

analysis) Results of 1 or more well-designed studies Results of large case series Expert opinion Personal experience

Searching the Literature

Synthesizing the Evidence

Separating the “apples from the oranges” Begin by scrutinizing the abstracts

Identify: Clinical Problem as identified by the author

Is the clinical problem similar in each study Dependent variable(s) & Independent variable(s)

Is the dependant and independent variables the same Population being studied

Is the population the same or similar in each study

Critical Appraisal of an Article about Therapy

Once abstracts identified as possible candidates to include in evidence data file then scrutinize the articles to determine validity Answer the following questions to validate validity:

Was the assignment to the patients to treatments randomized (was the list concealed)?

Were all clinically relevant outcomes reported? Were the study patients recognizably similar to those you see in your clinical

practices? Were both clinical & statistical significance considered? Is the therapeutic maneuver feasible in your clinical practice? Were all patients who entered the study (s) accounted for at the conclusion of the

study?

Grade the level of evidence found in the articles using an established grading criteria and Evidence critique forms To further separate the “apples” from the “oranges”

Evidence Grading Evidence Grading SummarySummary

Types of Research: Evidence Hierarchies

Agency for Healthcare Research and Quality (AHRQ)

Level I Meta-Analysis (Combination of data from many studies)

Level II Experimental Designs (Randomized Control Trials)

Level III Well designed Quasi Experimental Designs (Not randomized or no control group)

Level IV Well designed Non-Experimental Designs (Descriptive-can include qualitative)

Level V Case reports/clinical expertise

Strength of Evidence

United States Preventive Services Task Force (USPSTF) Grading

A Strongly recommended; Good evidence

B Recommended; At least fair evidence

C No recommendation; Balance of benefits and harms too close to justify a recommendation

D Recommend against; Fair evidence is ineffective or harm outweighs the benefit

I Insufficient evidence; Evidence is lacking or of poor quality, benefit and harms cannot be determined

Article Info

Title: Author(s) Date and Journal: Vol, No, Pages:

Research Questions/ Hypothesis

Methods Design: Setting: Sample:

Study Variables Independent: Dependent:

Measures/ Reliability/ Validity

Instruments: Methods of Data Collection:

Results

Strengths

Limitations

Summary: Decision/ Reservations

Level of Evidence: Strength of Recommendation:

Evidence Critique FormEvidence Critique Form

Synthesizing the Literature

GOOD Evidence

NOT SO GOOD Evidence

RISK

BENEFIT

Change vs. Further Research ?

Is sufficient evidence available to answer question?

Can the methods used in the evidence be applied to current clinical practice setting? If insufficiency noted:

RCT warranted

QualityClinicalPractice

IdentifyQuestions

EvaluateChange

ApplyFindings

in Practice

DisseminateKnowledge

GenerateNew

Knowledge

The Approach & ChallengeThe Approach & Challenge

Review Literature

Conduct Research Or

EBP Practice Change

Each step requiresa Clinical Decision &

Generates New Knowledge to hopefully

result in improvedClinical Practice

If sufficient evidence available Coordinate best evidence into a 3-5 page synopsis of RCTs,

metaanalysis or systematic reviews Based on grading & synopsis sheets

Develop implementation strategy to implement into practice Use multi-disciplinary approach Set implementation goals Ensure key stakeholders are “all on board” with change

Shortly following implementation collect baseline data to determine if changes needed to strategy etc.

Implementation Develop strategies to implement findings into

clinical practice Based on results of the evidence discovered- changes

in clinical practice are proposed to the departments, and after agreement is reached practice changes are implemented

May involve several sessions with departmental personnel that include education instruction to the department and formulation of new guideline into policy & procedures manual

Implementing the ChangeComparison

Typically start with small pilot project in one small area or department before instituting the change institutionally Pilot the change to make required revisions

Make sure “key stakeholders” are involved in the process

EBP to Clinical Practice Examples of Clinically relevant practice change

questions “Does the incorporation of epidural anesthesia (with or

without general anesthesia) make a difference in relation to serious postoperative morbidity or mortality in the surgical patient population”?

Literature Review Findings; Found multiple references; 2 systematic reviews One analyzing specific question of morbidity and

mortality Liu SS, Wu CL. Effect of postoperative analgesia on major

postoperative complications: a systematic update of the evidence. Anes Analg 2007; 104(3):689-702

One analyzing multiple complications Rodgers, A. et al. BMJ 2000;321:1493

Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anes Analg 2007; 104(3):689-702

No conclusive evidence to indicate that use of epidural anesthesia better than general anesthesia with PCA Trend noted towards greater survival ability in epidural group

No conclusion secondary to small numbers of complications Evidence that blockade (especially via thoracic epidural placement beneficial

Effect of neuraxial blockade (NB) on postoperative mortality, by surgical group, type of neuraxial blockade, and use of general anaesthesia. Obstetrics and gynaecology trials are included with other surgery. One trial with unknown details of anaesthesia was grouped with lumbar epidural and neuraxial blockade plus general anaesthesia versus general anaesthesia comparisons. Diamonds denote 95% confidence intervals for odds ratios of combined trial results. The vertical dashed line represents the overall pooled result. 2 test for heterogeneity between different surgical groups, P=0.9

Rodgers, A. et al. BMJ 2000;321:1493

A total of 104 myocardial infarctions were reported in 30 trials. Overall, there were about one third fewer myocardial infarctions in patients allocated to neuraxial blockade

Rodgers, A. et al. BMJ 2000;321:1493

What to do with this information Present findings to anesthesia department,

surgical departments, nursing services departments

Garner buy-in and provide evidence Some arguments are easier than others

i.e. “Is regional anesthesia superior to general anesthesia alone for the hip surgery patient?”

Analysis of Evidence= Recommendations for Change

Parker MJ, Handall, HH, Griffiths R. Anaesthesia for hip fracture surgery in adults (Review) 11Copyright © 2008 The Cochrane Collaboration

Conclusions Incorporation of EBP into clinical practice

has been shown to lead to better outcomes Use of systematic reviews and meta-analysis

makes the review process easier Ensures that most comprehensive care is

standardized throughout departments Buy-in by surgeons and nurses often most

difficult task

E-mail: Pellegrini@son.umaryland.edu