Evidence Based Practice: An introduction for new

librarians

GLIS 671February 18, 2015

Presenter: Pamela HarrisonEmail: pamela.harrison@mcgill.ca

Session objectivesBy the end of this session, you will be able to: Articulate the role of the librarian in evidence-

based practice Formulate a searchable clinical question Identify the best type of evidence for your

question Practice using following EBP resources:

UpToDate Dynamed Turning Research Into Practice Joanna Briggs Institute EBP Database

Why Evidence Based Practice (EBP)?• EBP is a highly accepted idea that better

evidence in practice leads to improved patient outcomes

• EBP has increased emphasis worldwide on improving patient safety and quality of care

• EBP provides the need to continue to advance healthcare delivery with well-equipped, knowledgeable health care providers and patients

EBM

Clinical expertise

Patient values

Best availabl

e evidenc

e

Your time to shine…“[W]hen clinicians use information resources to answer clinical questions, the resources they choose provide the best evidence only about 50% of the time” (McKibbon et al., 2008)

Librarians enable users to navigate, and benefit from, a growing body of evidence-based information.

Evidence-based practice cycle (and where librarians fit in)

Appraising the evidence

Incorporating evidence into decision-making

Evaluating the Process

Formulating the clinical question

Searching the evidence

Your patient for whom you are uncertain about therapy, diagnosis, or prognosis

1

2

3

Evidence-based practice cycle (and where librarians fit in)

Appraising the evidence

Incorporating evidence into decision-making

Evaluating the Process

Formulating the clinical question

Searching the evidence

Your patient for whom you are uncertain about therapy, diagnosis, or prognosis

What is a clinical question?

A question that is “directly relevant to the problem at hand… [and] phrased to facilitate searching for a precise answer.”

(Richardson, Wilson, Nishikawa & Hayward, 1995)

Can a 70-year old

with suspected

receive platelets before undergoing a

lumbar puncture?

pancytopenic patient

meningitis

How many questions do you see?

Image source: http://pixabay.com/en/question-stickman-stick-figure-151792/

Background and foreground questions

Source: (Guyatt et al., 2008) Chapter 3: Background and Foreground Questions

What is pancytopenia?

What is meningitis?

Can a 70-year old pancytopenic

patientwith suspected

meningitis receive platelets before undergoing

a lumbar puncture?

WhoWhatWhereWhyHow

Verb

ConditionTreatment

Background questionsWhat are they?

• Where do you search?Textbook collections: AccessMedicine, STAT!Ref

Foreground questionsTend to be more specific and complex

compared to background questions.

Ask for specific knowledge to inform clinical decisions. Questions typically concern a specific patient (eg: elderly) or particular population (eg: patient with diabetes).

Review: What is one tool that is useful for searching foreground questions?

P

I

C

O

Patient problemor Population

Intervention

Comparison, if any

Outcome

Recall the definition of a clinical question:

“phrased to facilitate searching for a precise answer”

(Richardson, Wilson, Nishikawa & Hayward, 1995)

Example scenarioMs. X is a 25 year old woman diagnosed with bulimia nervosa. She is reluctant to take medication and does not believe in psychotherapy. She has mixed feelings regarding her eating behaviors and any form of treatment and is afraid to relinquish control. There is no imminent risk. You consider recommending self-help programs as an initial treatment.

Background questions:What is bulimia nervosa?What are standard treatments for

this condition?What synonyms do I need to know

for my search?

Foreground question:

P:

I:

C:

O:

Patient with bulimia nervosa

Self-help

Psychotherapy

Reduced binging and purging

In patients with bulimia nervosa, is self-help as effective as psychotherapy in reducing binging and purging?

Your turn!

Working in pairs,

Ask 1 background question

Identify the PICO for this scenario

Mr. N is a 34-year-old diagnosed with multiple sclerosis, who is experiencing increasing levels of fatigue. He lives in a rural area, and is unable to attend the energy management classes in the closest city. Your colleague has mentioned online energy management support groups. You wonder whether these groups might provide similar help for Mr. N in managing his energy levels.  

Evidence-based practice cycle (and where librarians fit in)

Appraising the evidence

Incorporating evidence into decision-making

Evaluating the Process

Formulating the clinical question

Searching the evidence

Your patient for whom you are uncertain about therapy, diagnosis, or prognosis

Types of evidenceType of Question Best Evidence

Health care interventions: treatment, prevention

Quantitative: Systematic review of randomized control trials (RCTs); or a single RCT

Harm or Etiology Quantitative: Observational study - cohort or case control

Prognosis Quantitative: Observational study - cohort, case control

Diagnosis or Assessment

Quantitative: Comparison to the current gold standard

Economics Quantitative: Cost-effectiveness study

Meaning Qualitative: case study, ethnography, grounded theory, phenomenologic approach

Source: http://researchguides.dml.georgetown.edu/ebmclinicalquestions

Levels of Evidence (resource dependent) Ia: Evidence obtained from a meta-analysis or

systematic review of RCTs.

Ib: Evidence obtained from at least one RCT.

IIa: Evidence obtained from at least one well-designed controlled study without randomization.

IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization.

III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.

IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

Helpful explanation of study design

Check out the study design illustrations at http://library.downstate.edu/EBM2/research.htm

Point of Care ResourcesThe “go to” resources for health professionals, including medical students and residents, when seeking answers to clinical questions

Dynamed: provides clinically-organized (ie. disease) summaries for more than 3,400 health topics. DynaMed editors monitor the content of over 500 medical journals on a daily basis. Each article is evaluated for clinical relevance and scientific validity. The new evidence is then integrated with existing content, and overall conclusions are changed as appropriate, thus representing a synthesis of the best available evidence. Level of evidence

UpToDate: is an evidence-based, physician-authored clinical decision support resource which helps health professionals and students to make the right point-of-care decisions. Similar to Dynamed, editors and peer reviewers use a rigorous editorial process to synthesize the most recent medical information into evidence-based recommendations that are proven to improve patient care and quality. Level of evidence

TRIP: Turning Research into Practice

TRIP is a clinical search engine designed to allow users to quickly and easily find and use high-quality research evidence to support their practice and/or care.

Online since 1997, TRIP has developed into an authoritative source of evidence-based content. Their motto is “Find evidence fast”

Users can search across a variety of content types including images, videos, patient information, educational courses and even news.

Joanna Briggs Institute EBP DatabaseJoanna Briggs Institute EBP Database is produced in Adelaide, Australia and is largely used by nursing and allied health professionals. It provides a wide range of resources including over 3,000 records across seven publication types:

Systematic Reviews and Protocols (SRs in preparation)Best Practice Information Sheets and Technical ReportsEvidence-Based Recommended Practices Evidence SummariesConsumer Information Sheets

Arranged into 14 subject based “nodes” which allow users to filter information

JBI levels of evidence -> find at joannabriggs.org

Your turnYou are interested in dressings for venous ulcers

(leg ulcers). Using different EBP resources, what types of evidence can you find?

Want to learn more about EBP?

Life sciences librarians have produced an extensive list of EBP resources located at

http://www.mcgill.ca/library/find/subjects/health/evidence

Works cited Guyatt, G., Meade, M.O., Richardson & S., Jaeschke, R.

(2008). Chapter 3. What is the question? Three ways to use the medical literature. In: Guyatt G, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. New York, NY: McGraw-Hill; 2008. Retrieved from http://www.jamaevidence.com/content/334813

McKibbon A, Wyer P, Jaeschke R, Hunt D. (2008). Chapter 4. Finding the evidence: Four categories of information sources and how clinicians use them. In: Guyatt G, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. New York, NY: McGraw-Hill. Retrieved from http://www.jamaevidence.com/content/3348229

Richardson, W. S., Wilson, M. C., Nishikawa, J., & Hayward, R. S. (1995). The well-built clinical question: a key to evidence-based decisions. ACP J Club, 123(3), A12-3. Retrieved from http://www.lusiada.br/cursos/posgraduacao/mestrado-clinica-medica/images/artigos/key-evidence-based-decisions.pdf

Thank you! Any questions?