Continuous Education

Moving forward with Evidenced-Base Practice (EBP) at PPCS
Joan Chee, Honorary Advanced Oncology Certified Nurse
The multidisciplinary medical team at PPCS is working to incorporate EBP. We are doing this in many ways. One of the ways we learn to better understand research and how to apply it into our everyday practice was with an educational program by Dr. Sharifah Halimah Jaafar, Consultant Obstetrician and Gynaecologist at KPJ Ipoh Specialist Hospital. She is also a member of Malaysian-Australasian Cochrane Group and a lifetime member of PPCS. This educational program occurred March 19, 2014.
She presented “Making sense of Evidenced based practice in Palliative Care.” In the talk she:
1. Defined what is evidence-based practice
2. Answered the question of why we need evidence based practice in palliative care.
3. Described the process and outlined 5 steps of EBP
4. Explained how to understand PICO elements and search strategy
5. Identified resources to support EBP.

What is evidence-based practice?

Evidenced based medicine (EBM) is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research (Sackett et al, 1996). This allows for patient values/preferences, research evidence and professional experience merge to make optimal decisions in care (SEE FIGURE 1).
In the past healthcare professionals practiced patient care based on:
Ritual…accepted practices versus research proven practices….”That the way we have always done” syndrome
Tradition…”the way I learned how to do it”
Personal opinion. . . without assessment of underlying assumptions
Arrogance. . . “I have to be right” syndrome
Lack of concern… for the patient value
As long as it makes money…..lack of ethical value
PPCS is striving to move away from these to EBM.

Why we need evidence based practice in palliative care ?

Dr. Sharifah Halimah Jaafar continued her talk by outlining the reasons why EBP is important in palliative care and PPCS. She explained the following reasons in detail.
1. Good clinical care can prevent or alleviate suffering for many patients at the end of life through employment of proven effective treatment.
2. To standardize best and effective way to care for the terminally ill patient.
3. To optimize the quality of care for terminally ill.
4. Adherence to best practice.
5. Minimise error.
“Research shows that EBP leads to higher quality care, improved patient outcomes, and greater satisfaction that traditional approach to care” (Melnyk, 2010).
The process and 5 steps of EBP described.
The process of EBP requires of spirit of inquiry. We cannot be afraid of asking why. Why are we doing what we are doing? Where can we find the best evidence to answer those clinical questions? The 5 steps to EBP are:
1. Ask – ask/formulate clinical questions
2. Acquire – search for evidence
3. Appraise – appraise the evidence
4. Apply – incorporate evidence into decision-making
5. Assess – evaluate the process
Each step is important to be able to make sure that the research/evidence is the best available. She described how to rate the evidence from 1 – 5 (one being the most vigorous research and least bias to 5 where it is case reports). Although the evidence may not be level 1, if that is the best available, we are to start from there.
How to understand PICO elements and search strategy ?

PICO is a system of how to formulate clinical questions. This includes:
P = Patient or Problem
I = Intervention or Exposure
C = Comparison
O= Outcomes
T=Trials

At this point in Dr. Sharifah Halimah Jaafar’s talk, she taught us about the different types of research (this is helping us review the literature with intelligence). She discussed the importance of removing bias in studies and the levels of evidence that different types of trials have. All these factors affect the quality of the evidence to be incorporated into practice.
She explained the difference between primary and secondary research and how systematic reviews and meta-analysis with random control studies provide the least bias and strongest validity of evidence that one can incorporate into practice.

 

Resources to support EBP identified

Finally, Dr. Sharifah Halimah Jaafar gave us resources to support EBP and where to look for the best evidence. Practice guidelines formulated by experts are usually the most helpful but it is then important to ask:
Are the results of the study or systematic review valid?(Validity of the evidence)
What are the results and are they reliable/important? (Reliability of the evidence)
Are the findings clinically relevant to my patients? (Applicability of the evidence to your population)

In conclusion
Dr. Sharifah Halimah Jaafar discussed what EBP is and is not

NOT                                                       But it is . …

“Cookbook” medicine

Rigid adherence to clinical guidelines

 

A rigorously systematic way to:

  • Evaluate the strength of available evidence
  • Evaluate the appropriateness of available evidence for a particular clinical situation
Managed care

Cost-cutting measures

A way to avoid waste by considering both the efficacy and effectiveness of a particular intervention in a particular clinical setting.
The same thing as

  • clinical epidemiology
  • biostatistics
  • study design
Build on these concepts so you can better understand the strength of inferences from available evidence.

 

Limited to Randomized Controlled Trials Recognition that:

  • Some study designs (esp. RCTs) are less susceptible to bias than others, and therefore less likely to mislead.
  • RCTs are not always available (or are of poor quality) but other evidence can (and should) be used in clinical decision making as long as you understand its limitations.

 

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