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Evidence Based Practice
What is Evidence-Based Practice (EBP)?

EBP is the explicit linking of evidence from clinical research to decision making, (Sackett DL Richardson WS Rosenberg W Haynes RB).

Evidence-based medicine: how to practice and teach EBM,  (London Churchill Livingstone 1997).

EBP means using best available, relevant evidence to make decisions about patient care.

Centre for Evidence-Based Medicine provides more information to the background of EBP discusses what isn’t. http://www.cebm.net

Why do we need EBP?

We need EBP because we want to give our patients the best possible treatments. We need EBP because we don’t want to guess. We need EBP because personal experiences and expertise can be misleading. We need EBP because science is important.

How do I do EBP?

The following points briefly outline how to ‘do’ evidence-based practice. This summary is designed as a brief overview, and not as a comprehensive guide! There are several web-sites which provide more comprehensive information, and which can act as a teaching tool to help you do EBP. For those of you who want more than our simple overview we provide some links to other web-sites.

1. Ask a question
In order to do EBP you must ask a clearly focused and structured clinical question. To do this effectively you should use the PICO structure, where your question should contain 4 key elements: P – Patient or Problem I – Intervention C – Comparison intervention O – Outcome For example, a physiotherapist may be interested in the effectiveness of giving walking sticks to patients with hemiplegia. Using the PICO structure, she can form a very clear and specific question (or questions): · Is walking with a walking stick more effective than walking without a walking aid at increasing walking speed in patients with hemiplegia following stroke? · Is the provision of a walking stick more effective than no walking aid at prevention of falls in patients with stroke living at home? If you have formed a clearly thought out and structured appropriate and clinically relevant question then the subsequent stages of searching and appraisals become relatively straightforward. Read more about forming clinical questions: http://www.cebm.net/focus_quest.asp What type of question am I asking? You might want to ask a question about clinical examination, aetiology, diagnosis, prognosis, treatment or prevention. The type of question that you ask will affect the type of research evidence that you want to search for. Read more about types of question: http://www.cebm.net/question_types.asp

2. Search for the evidence
Once you have formed a clear clinical question you need to find the best evidence to answer your question. Type of evidence The type of evidence that you want to search for will depend on the focus of your question. Questions about treatment or prevention are best answered by a prospective randomised controlled trial. Read more about types of research by types of evidence: http://www.cebm.net/question_types.asp and the advantages and disadvantages of different research study designs: http://www.cebm.net/study_designs.asp Hierarchy of evidence The randomised controlled trial and the systematic review of several randomised controlled trials are methods which are likely to tell us the effectiveness of a therapy or preventive intervention. These have become the ‘gold standard’ for judging whether a treatment is beneficial or harmful (Sackett DL. Evidence-based medicine: what it is and what it isn’t. http://www.cebm.net/ebm_is_isnt.asp). Where systematic reviews or randomised controlled trials have not been carried out, evidence from less robust research studies become the source of evidence (cohort studies / case-controlled studies / case studies / anecdotal evidence). It is important to remember that lack of evidence is not evidence of no effect. Read more about searching for the evidence: http://www.cebm.net/searching.asp

3. Critically appraise the evidence
Once you have found evidence related to your question, you need to decide whether the research is valid and reliable, important and clinically relevant to your patient. You have to ask different questions about the research depending on the type of research. There are a number of different guides and worksheets available to assist you in critically appraising different types of research (www.cebm.net/using_ebm.asp, www.phru.nhs.uk/casp/casp.htm). Critically Appraised Topics (CATs) It is likely that your search will generate more than one piece of research evidence. You therefore need to read and critically appraise each relevant research study that you find. Once you have appraised the individual studies it is important that you consider the combined evidence from all the research that you have found. In doing this you have to systematically identify where the research evidence is conclusive and where it differs, and determine the clinical significance of the evidence. The process of pulling together a number of pieces of research evidence which all address the same question can be called a CAT. Read more about CATs – http://www.cebm.net/cat_about.asp

4. Implement evidence-based treatment
Once you have the answer to your clinical question you can implement your evidence-based treatment. In cases of individual patient treatment decisions this may be a relatively simple process of prescribing and applying the appropriate treatment. However in other cases the implementation of evidence-based treatment may require change at policy and managerial levels, as well as by the clinician. There are a number of useful websites providing help and advice in the implementation of change. Links – If there are relevant evidence-based guidelines, these can be a useful tool in implementing evidence-based treatment (www.sign.ac.uk, www.rcp.ac.uk).

Barriers to EBP

It is logical and sensible that we should give our patients treatments based on the best available evidence. Patients and their carers would be appalled if they felt that we were not. So why don’t we? Barriers to EBP are:

  1. TIME. We don’t have enough time to do the things necessary for EBP.
  2. ABILITY / CONFIDENCE. We often lack the ability or confidence in our ability to search, find, appraise, understand and implement the relevant research.
  3. IMPLEMENTATION. Even if we find the time to search, find and appraise relevant research, we still find it difficult to transfer these research findings into practice. Ref: Pollock AS, Legg L, Langhorne P, Sellars C. Barriers to achieving evidence-based stroke rehabilitation. (Clin Rehabil 2000; 14: 611-617)

STEP has developed effectiveelderlycare.org to break down the barriers to EBP. effectiveelderlycare.org is your one-stop shop to EBP, where experts have asked the questions, performed the searching, critically appraised the evidence, and produced simple statements of effect of treatments with links to relevant guidelines. How can effectiveelderlycare.org help me with EBP? effectiveelderlycare.org has asked the questions, done the searching, critically appraised the evidence, produced simple statements of the benefits or harms of an intervention, and provided links to relevant guidelines. effectiveelderlycare.org provides an explicit route to a clear statement of evidence. effectiveelderlycare.org has done the hard work for you. If you, as a clinician, have a question about the effectiveness of a treatment / intervention for stroke, you can match your question to our EBP questions and will instantly get a clear statement of the evidence associated with that treatment / intervention.

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