Paper Presentations: Stephanie Schulte’s “Teaming Up with Nursing to Put Evidence into Action at an Academic Medical Center”

First, the abstract:

Teaming Up with Nursing to Put Evidence into Action at an Academic Medical Center
Michigan, 11:00am-11:50am
Presenter: Stephanie J. Schulte, Assistant Professor, Education & Reference Services Coordinator, OSU Health Sciences Library, Columbus, Ohio
Authors:

  • Stephanie J. Schulte, Assistant Professor, Education & Reference Services Coordinator, OSU Health Sciences Library
  • Susan Bejciy-Spring, Director, Nursing Evidence Based Practice and Standards, The Ohio State University Health System
  • Jill Niese, Manager, Nursing Evidence Based Practice and Standards, The Ohio State University Health System

Evidence in Action (EIA) Rounds is a clinical nursing initiative at The Ohio State University Health System that provides unit-based interactive forums to assist nurses in exploring best practices in the management of a selected patient. Facilitators of EIA Rounds include two health system nurse leaders in evidence based practice (EBP) and a nursing liaison librarian. Facilitators team up with unit nurses caring for the patient to define evidence-based practice, use an evidence-based approach to answer clinical questions, and explore the best available evidence related to a specific patient. Using nursing sensitive indicators and the Iowa Model of Evidence Based Practice as a guide, the facilitators review details of the case and note clinical questions from the care team, search appropriate internal and external resources for evidence, and return to discuss their findings. The evidence, or lack thereof, is placed in the context of the selected patient. Gaps in policies and procedures and evidence from the research literature are all discussed in a non-punitive manner. If gaps are identified, the EBP nurse leader facilitators have the authority and means to revise policies or create new policies if needed. This presentation will explore the librarian’s role in this unique collaboration aimed at putting best practices into action. It will buy lasix online usa also discuss the outcomes and challenges encountered in the process.

What follows are my notes from Stephanie’s awesome talk on her experience working with staff nurses in “Evidence in Action Rounds.” (Disclaimer: I took these on my 1st gen iPod Touch.  I’ve tried to clean them up somewhat.  If the presentations get posted at some point, we’ll be sure to link to them!  And if you attended the session and want to add anything, please feel free to do so in the comments!)

At Stephanie’s institution:

  • Culture of EBP
  • various nursing practices and positions and programs to support.
  • Clinical practice guidelines committe (Stephanie is on).
  • Lots of educational initiatives.

Stephanie provides nursing CME support.

“Evidence in Action” (EIA) nursing rounds:

  • A way to integrate internal & external best practices
  • These are non-punitive, which needs to be made very clear because there is some fear.
  • How it works: nurse leader identifies a unit to work with through staff nurse contacts.
    • Day 1: nurse leader and librarian meet with unit manager, who identifies a patient. Together they create clinical questions while looking at chart, using indicators. EBP nurse leader and librarian “divide and conquer” to search the literature.
    • Day 2: return with results, review indicators etc, with the unit nurses. Go over answers to the clinical questions and the resources used.  Usually there are still lots of gaps at the end – these can be addressed through policy changes etc.

EIA tools:

  • Nurse sensitive indicators
  • Iowa model of EBP: forming a question, forming a team (top half of model)
  • Johns Hopkins nursing EBP scale

How she got involved:

  • Result of construction, she had to get out of the space which provided an excuse to get out on the floors.
  • Contacted the director of EBP.

Example: “The power of 1”: one patient can influence the care of many.  Nephrostomy tube example led to policy change and a poster with the nurses involved.  The poster is being presented at national nursing conference!

Challenges:

  • Scheduling!! Turnaround time for searches is FAST.

The Level of Evidence Used to Answer General Practitioners’ Questions

Session 14: Karen Davies

Karen Davies presented her fascinating research on what level of evidence is most often used to answer general practitioners’ questions, done in the UK.

She started with a couple of thoughts/definitions: first was Venn diagram from Haynes (1996) that showed evidence-based practice as the over-lap of research evidence, patient preferences, and clinical expertise (which, she clarified, does not go away in EBP).  She also raised the question: if you can’t get level 1 or level 2 evidence, is it worth using evidence at all (case studies, e.g.)?  Her response–yes.  She also raised a point I found intriguing: perhaps we should question meta-analysis’s position at the top level, since they’re often inconsistent and even the statisticians can’t agree.  I’m not sure I entirely agree with her, but I definitely think it’s a good point to take into consideration with meta-analysis studies.

She had 2 main research objectives: to determine the highest level of evidence used in answering questions, and also to determine the number of times guidelines are used.  To answer them, she looked at 2 primary care answering services in the UK: ATTRACT and the NLH Primar Care Answering Service.  Their answers are publicly posted online, so it was simply a matter of tallying everything up.

Some results:

  • On average (for both services), only 11% of the answers used top-level evidence.
  • The two services had very different numbers of questions not answered…the sidenote being that there will always be questions for which there is no evidence.  Yet.
  • 42% of the answers referred to guidelines.
  • Very few of the questions were answered using level 2 evidence (clinical trials)

As of now, the NLH service has closed.  Which perhaps underscores Karen’s conclusion that since guidelines are so important, doctors need to know where to find them!

An audience member wanted to know whether there is a difference between UK and US guidelines; Karen’s answer was that she believe the UK is a bit stricter about having obvious “expiration” dates on their guidelines, but she noted that the answering services used US guidelines in many of their replies.

I found this to be a fascinating presentation, and I was very pleased to see that Karen’s slides are posted (.pptx).  Check them out for more results and pretty graphs!

Using Patient-Oriented Evidence to Reduce Health Disparities

David Slawson, MD, one of the founders of InfoPOEMs®, gave a provocative talk during the concurrent sessions on Sunday, October 19, 2008 at the 2008 Midwest Chapter/MLA and MHSLA joint meeting.

David Slawson, MD, one of the founders of InfoPOEMs®, gave a provocative talk during the concurrent sessions on Sunday, October 19, 2008 at the 2008 Midwest Chapter/MLA and MHSLA joint meeting. He pointed out that according to WHO rankings, the U.S. is 12th out of 13 countries in regard to quality, but first in regard to health care costs. Because of inequities in access to health care in the U.S., and our reluctance to ration care, he stated, “We don’t ration services, we ration people.” He discussed fallacies regarding rationing.
In the U.S., overuse and misuse of treatments and screening tools has led to large increases in costs while decreasing value. Value (value is equal to quality divided by cost) will not increase until doctors use evidence to make rational treatment decisions, thus decreasing costs. Because doctors are the ones who decide what treatments to use, they are the key to the control of costs and value. They must use the evidence when providing care and deciding on what treatments to use. He stated that we can “safely eliminate at least 20% of what we currently do” in the U.S. He added, “We must limit unnecessary services (or deny care to more people).”
For example, he believes that based on the evidence, women who have had hysterectomies for benign reasons and women who have had consecutively normal Pap smears do not need to have yearly Pap smears. In another example, he points out that doctors frequently ignore recommendations about treatment for hypertension, using the newest drug or samples that they have on hand, rather than prescribing the cheaper beta blockers and diuretics that are recommended as the first step in treatment. He quoted David Eddy (Clinical Decision Making: From Theory to Practice, Jones and Bartlett, 1996) who said, “In a field filled with uncertainty and doubt, the difference between ‘when in doubt, do it’ and ‘When in doubt, stop’ could easily swing $100 billion a year.”
Dr. Slawson and his co-author, Allen F. Shaughnessy, have several prescriptions:

  • “Analyze practices at the level of specific indications, e.g. mammography, other cancer screening, BMD, others.”
  • “Accept that resources are limited.”
  • “Change our way of thinking from qualitative to quantitative reasoning.”
  • “Focus on populations rather than on individuals.”
  • “Help patients understand consequences.”
  • “Ensure that measures used to judge value of services lead to an increase in quality while decreasing costs.”
  • “For the individual practitioner: ‘When in doubt, don’t.’”

The slides for Dr. Slawson’s presentation (titled “The True Mission of Information Mastery: Using “Medical Poetry” to Remove the Inequities in Health Care Delivery”) are available at http://snipurl.com/4ts8y or from the University of Virginia Health System’s Information Master Practicum and Course page at
http://snipurl.com/4tscd.
Mary K. Taylor, Natural Sciences Librarian
Morris Library, Southern Illinois University Carbondale
mtaylor AT lib.siu.edu