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Geetanjli Kalyan
Clinical Instructor
National Institute of Nursing Education
PGIMER, Chandigarh
EVIDENCE BASED PRACTICE
IN
PEDIATRIC CRITICAL CARE
3/10/2017
Research-Practice Gap
Much of what is known from research has not
been applied in practice.
This is known as
EBP is…
Needed to help bridge the research-practice gap by:
Strengthening the evidence base in order to know
 what works and what doesn’t work in providing patients with the best outcomes.
Standardizing evidence across fields
Housing evidence in online databases providing reviews of the evidence
base. (PGIMER has started Remotex service, uptodate)
Translating and consolidating state of the science into clinical
recommendations.
(Stevens, 2004)
Evidence-Based Practice
Integration of best research evidence, clinical expertise, and
patient values in making decisions about the care of individual
patients (Institute of Medicine, 2001).
A. Levels of Evidence
I : Systematic reviews, meta-analysis, EB clinical practice
guidelines based on RCTs
II : One well designed RCT
III : Control Trials without randomization
IV : Well-designed case control or cohort
studies
V : Systematic reviews of descriptive or
qualitative studies
VI : Single descriptive or qualitative study
VII : Opinions of authorities, reports of
experts
Meta-analysis is not the final decision
DARE
Ebp in pcc
Ebp in pcc
American College of physcian
JAMA
One website developed to help clinicians practice EBM in
the PICU and other specialties
Ebp in pcc
UpToDate
Other Sources To practice
guidelines/Evidence
 Acta pediatrica
 Cochrane
 National Institute for Health and Care Excellence (NICE)
 NICE guidelines
 WHO
 Guidelines of organization : AAP, IAP, NNF, ESPEN
 Journal with high impact factor : Nature Journal, NEJM, AAP
 TRIP Search Engine
 SUMSearch2 (University of Kansas)
 ProQuest Nursing & Allied Health Source
 ClinicalTrials.gov
 University of medicine and health sciene (UMHS)
High impact factor/cochrane reviews
Ebp in pcc
Ebp in pcc
B. Clinical Expertise
Knowledge gained from practice over
time
Inductive reasoning
C. Patient Values, Circumstances
Unique preferences
Concerns
Expectations
Financial resources
Social supports
SIX STEPS OF EVIDENCE-BASED PRACTICE
Ask the burning clinical question (PICOT format)
Search for and collect the most relevant and best evidence
Critically appraise the evidence
Integrate all evidence with one’s clinical expertise, patient preferences and values in
making a practice decision or change and apply on patient
Evaluate the practice decision or change
Disseminate
Melnyk & Fineout-Overholt 2005
Research utilization vs EBP vs Quality
improvement
Research utilization: Using info from a single study (Chlorhexidine
vs gel/alcohol)
EBP - takes into account expertise of the practitioner and patient
preferences / values (ability of nurses/cost/patients likes/)
Quality improvement : utilizes a system to monitor and evaluate
the quality and appropriateness of care (outcomes) based on EBP
and research
In pediatric critical care
Challenges to implement EBP in PCC by
nurses
It is likely that as few as 20 % of effective interventions actually
reach patients
time constraints, a knowledge deficit, and organizational culture.
Poor leadership
Jean-Paul Collet, etal Engaging Pediatric Intensive Care Unit (PICU) clinical staff to lead practice improvement: the PICU
Participatory Action Research Project (PICU-PAR) https://doi.org/10.1186/1748-5908-9-6
All nurses are not sensitize to EBP and many don’t know from
where to find the answer of problems encountered in day to day
practice
Changing behavior of HCP is the most difficult
Challenges to implement EBP in PICU by
nurses …. Contd…
Most clinical interventions have a modest effect yielding a 25
% or lower relative risk reduction.
Uninformed colleagues sometimes misinterpret EBM and
accuse it of being “cookbook medicine” and potentially
harmful to the patient.
developers of guidelines and protocols rarely graded the
level of evidence underlying each recommendation.
Oral care
Bed sore
Saturation targets
VAP
Enlist the major problem
Primary Validating criteria for the addressing the prevention,
management treatment guideline
Oral care
Risk factors for VAP in Indian Children
NPPCM in infant and young children
Use of antenatal steroids
Ebp in pcc
Ebp in pcc
Benefits for pediatric critical care nurses
Fewer Errors –
Type 1 – Acceptance of a practice that is incorrect. Example:
Administration of a wrong dose, using the wrong procedure, teaching patients
using the wrong information.
Type 2 – Rejection of a practice that is correct. Example: Failing to
screen patients for fall or pressure ulcer risks; failing to wash hands before and
after patient contact; failing to provide patients with smoking cessation
information.
(Aherns, 2005)
Better Care
Less variation in care among caregivers where knowledge for
improvement is already available.
More predictable health outcomes.
Less waste and inefficiency yielding fewer delays in diagnosis and
treatment and fewer complications.
Greater professional satisfaction from working as part of a team and
experiencing effective practice.
Benefits for pediatric critical care nurses
JOIN IHI and learn QI science
10 steps of changing behaviour to
implement EBP
Ebp in pcc
Effective literature search and internal
motivation is the key to omplement EBP
in any area of practice
So
Let us begin it from PICU
Ebp in pcc

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Ebp in pcc

  • 1. Geetanjli Kalyan Clinical Instructor National Institute of Nursing Education PGIMER, Chandigarh EVIDENCE BASED PRACTICE IN PEDIATRIC CRITICAL CARE 3/10/2017
  • 2. Research-Practice Gap Much of what is known from research has not been applied in practice. This is known as
  • 3. EBP is… Needed to help bridge the research-practice gap by: Strengthening the evidence base in order to know  what works and what doesn’t work in providing patients with the best outcomes. Standardizing evidence across fields Housing evidence in online databases providing reviews of the evidence base. (PGIMER has started Remotex service, uptodate) Translating and consolidating state of the science into clinical recommendations. (Stevens, 2004)
  • 4. Evidence-Based Practice Integration of best research evidence, clinical expertise, and patient values in making decisions about the care of individual patients (Institute of Medicine, 2001).
  • 5. A. Levels of Evidence I : Systematic reviews, meta-analysis, EB clinical practice guidelines based on RCTs II : One well designed RCT III : Control Trials without randomization IV : Well-designed case control or cohort studies V : Systematic reviews of descriptive or qualitative studies VI : Single descriptive or qualitative study VII : Opinions of authorities, reports of experts
  • 6. Meta-analysis is not the final decision
  • 11. JAMA One website developed to help clinicians practice EBM in the PICU and other specialties
  • 14. Other Sources To practice guidelines/Evidence  Acta pediatrica  Cochrane  National Institute for Health and Care Excellence (NICE)  NICE guidelines  WHO  Guidelines of organization : AAP, IAP, NNF, ESPEN  Journal with high impact factor : Nature Journal, NEJM, AAP  TRIP Search Engine  SUMSearch2 (University of Kansas)  ProQuest Nursing & Allied Health Source  ClinicalTrials.gov  University of medicine and health sciene (UMHS)
  • 18. B. Clinical Expertise Knowledge gained from practice over time Inductive reasoning
  • 19. C. Patient Values, Circumstances Unique preferences Concerns Expectations Financial resources Social supports
  • 20. SIX STEPS OF EVIDENCE-BASED PRACTICE Ask the burning clinical question (PICOT format) Search for and collect the most relevant and best evidence Critically appraise the evidence Integrate all evidence with one’s clinical expertise, patient preferences and values in making a practice decision or change and apply on patient Evaluate the practice decision or change Disseminate Melnyk & Fineout-Overholt 2005
  • 21. Research utilization vs EBP vs Quality improvement Research utilization: Using info from a single study (Chlorhexidine vs gel/alcohol) EBP - takes into account expertise of the practitioner and patient preferences / values (ability of nurses/cost/patients likes/) Quality improvement : utilizes a system to monitor and evaluate the quality and appropriateness of care (outcomes) based on EBP and research
  • 23. Challenges to implement EBP in PCC by nurses It is likely that as few as 20 % of effective interventions actually reach patients time constraints, a knowledge deficit, and organizational culture. Poor leadership Jean-Paul Collet, etal Engaging Pediatric Intensive Care Unit (PICU) clinical staff to lead practice improvement: the PICU Participatory Action Research Project (PICU-PAR) https://doi.org/10.1186/1748-5908-9-6 All nurses are not sensitize to EBP and many don’t know from where to find the answer of problems encountered in day to day practice Changing behavior of HCP is the most difficult
  • 24. Challenges to implement EBP in PICU by nurses …. Contd… Most clinical interventions have a modest effect yielding a 25 % or lower relative risk reduction. Uninformed colleagues sometimes misinterpret EBM and accuse it of being “cookbook medicine” and potentially harmful to the patient. developers of guidelines and protocols rarely graded the level of evidence underlying each recommendation.
  • 25. Oral care Bed sore Saturation targets VAP Enlist the major problem
  • 26. Primary Validating criteria for the addressing the prevention, management treatment guideline
  • 28. Risk factors for VAP in Indian Children
  • 29. NPPCM in infant and young children
  • 30. Use of antenatal steroids
  • 33. Benefits for pediatric critical care nurses Fewer Errors – Type 1 – Acceptance of a practice that is incorrect. Example: Administration of a wrong dose, using the wrong procedure, teaching patients using the wrong information. Type 2 – Rejection of a practice that is correct. Example: Failing to screen patients for fall or pressure ulcer risks; failing to wash hands before and after patient contact; failing to provide patients with smoking cessation information. (Aherns, 2005)
  • 34. Better Care Less variation in care among caregivers where knowledge for improvement is already available. More predictable health outcomes. Less waste and inefficiency yielding fewer delays in diagnosis and treatment and fewer complications. Greater professional satisfaction from working as part of a team and experiencing effective practice. Benefits for pediatric critical care nurses
  • 35. JOIN IHI and learn QI science
  • 36. 10 steps of changing behaviour to implement EBP
  • 38. Effective literature search and internal motivation is the key to omplement EBP in any area of practice So Let us begin it from PICU