Get to the root of it
Master the basics of EBP
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By Janice Petrella Lynch, MSN, RN
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EDITOR'S NOTE: Janice Petrella Lynch, MSN, RN, is nurse editor/nurse executive. Also a nursing educator, she has held faculty positions at Wagner College, Skidmore College, Molloy College and Adelphi University. Jan is a member of the New York Organization of Nurse Leaders and the Greater New York Nassau-Suffolk Organization of Nurse Executives.
Nurses know their practice should be guided by evidence, and many now want to learn more about ways to implement EBP on their units. The process starts with the ability to form a relevant and searchable clinical question, said Mary Burkett, DNP, RN, CNS, NEA-BC.
“First, we need to understand that evidence-based practice should not be confused with research, but rather, research is the fuel for EBP,” said Burkett, assistant professor, Capital University, Columbus, Ohio, who presented on the topic at the 2016 American Nurses Association convention in Florida. “EBP projects should not require sophisticated statistical analysis and they should not be intimidating.” Most simply explained EBP is the use of best available evidence to guide clinical practice, Burkett said. Sources of evidence can include external evidence from research, clinical practice guidelines and subject matter experts; internal evidence on quality, safety and satisfaction; and individual evidence such as content and clinical experts that are part of the organization, as well as published expert opinion and patients' preferences. Passionate about helping nurses learn more about EBP, Burkett teaches research and EBP to traditional undergraduates, associate-degree students who are earning BSNs, accelerated degree students and graduate students. Burkett gives examples of EBP in clinical practice and explains what a PICO question is and how to form a relevant clinical question.
“EBP is an organized and structured process, which requires finding, appraising and synthesizing the body of evidence related to the topic, so a practice decision can be made,” said Burkett. In her practice, Burkett and her colleagues used EBP to reduce central line-associated blood stream infections. The CLABSI rate was under the established CDC benchmark, and they knew the problem was a significant risk for their chronic, critically ill patient population. They looked at their internal evidence and found the weak link in the CLABSI prevention was "scrubbing the hub," she said, which requires a standard method of disinfecting ports prior to accessing a central line. “The evidence allowed us to find antimicrobial impregnated caps as a prevention strategy.” These caps provide a reservoir of antimicrobial solution that the needle penetrates as the line is accessed. The team implemented the intervention in 2012, and there was an immediate and sustained decrease in CLABSI. “This, no doubt, saved lives,” Burkett said. Burkett and colleagues also routinely received patients with new tracheostomies who were ventilator dependent. An analysis of their internal quality data showed patients were at risk for dislodgement in the first few days after transfer.

During a search of external evidence, they found predictors of dislodgement, which was most prominently associated with short, thick necks, and an analysis of their internal data substantiated this factor as a risk. “We developed a dislodgement tool, which created a structured method to assess new admissions with recent tracheostomies for their risk and provided education to our RN and respiratory therapy staff,” Burkett said. Along with other recommended precautions, the pulmonologist was consulted about the use of a longer trach in high-risk cases, because the longer ones are less likely to dislodge. Once all of the precautions were implemented, Burkett said there was an immediate and sustained decrease in dislodgement episodes.
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… we need to understand that evidence-based practice should not be confused with research, but rather, research is the fuel for EBP.”
— Mary Burkett, RN
EBP for reducing the CLABSI rate or to develop the dislodgement tool came to fruition because the team first honed in on an accurate PICO question.

A PICO question is a tool to guide the efficient and effective search for relevant evidence, Burkett said. Components of a PICO question can include: P – patient, problem or population; I – intervention; C – comparison or control; O – outcome. According to Burkett, the comparison is not always needed, and although a time frame (or T) can be added to the question, it often is not needed. Most people err in forming PICO questions that are not rooted in a background search; instead they seem to be pulled from thin air and are too complicated, Burkett said. “I tell students the PICO is not a literary endeavor, and the format needs to include only what you need.” She recommended using the P-I-O format for most nursing intervention PICO questions. For example, "In ICU patients (P) how does sedation vacation (I) affect delirium (O)?" she said. Meaning PICOs are those that examine an experience or the perception of an area of interest. When searching a meaning question, nurses can confine the question to just the P and I, Burkett said. For example:
Examples of EBP
Follow the PICO format
Burkett suggested nurses interested in pursuing an EBP project should become an expert on the topic and formulate a searchable PICO. Scanning through library electronic databases to find searchable terms for interventions or interests and outcomes is the best means to formulating the PICO. “For example, if I want to write an intervention PICO for delirium, I would search ‘delirium and interventions’ in the database and scan for interventions that have been researched,” Burkett said. “I also would look for alternative ways my intervention or interest is identified in the databases. Once I have determined the intervention I want to examine and any alternative terms, I can develop the PICO." Burkett said in healthcare conditions, interventions and outcomes are often called by different terms. For example, decubitus ulcers also are called hospital-acquired pressure ulcers, or HAPUs, and pressure ulcers. Knowing this information, nurses would search the various ways an issue is named in the literature to ensure they are capturing all relevant information. In the final analysis, Burkett said, PICO questions originate from a spirit of inquiry with nurses examining practices under the lens of evidence from the literature. “When you scan the literature, you are seeking interventions that exist in the research, and then, you are ready to form your question,” she said.
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How do ICU patients (P) experience delirium (I)?
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How do adult patients (P) experience pressure ulcers (I)?
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How do parents (P) experience SIDS (I)?
Create a searchable PICO question
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Sources of evidence
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External: Research, clinical practice guidelines, subject matter experts
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Internal: Quality, safety, satisfaction
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Individual: Content and clinical experts who are part of the organization, as well as published expert opinion and patients' preferences, when applicable
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Current Opportunities:
• Critical Care (PICU, CICU, NICU) • Emergency Medicine • Operating Room • Acute Care – Medical Surgical • Dialysis • Primary Care • Specialty Ambulatory Care • Case Management • Clinical Documentation Improvement

Be there for our kids
There's nothing like being there for our kids

Join us at Children's National Health System, the premier provider of pediatric care in the
Washington, DC region
Opportunities are available in:
• Critical Care (PICU, CICU, NICU) • Emergency Medicine • Operating Room • Acute Care – Medical Surgical • Dialysis • Primary Care • Specialty Ambulatory Care • Case Management • Clinical Documentation Improvement
• Children’s School Services - Community Health Nurse - At least 3 years of Registered Nurse experience in community health, ambulatory care, school health or other related fields

- LPN – At least 3 years of supervised nursing experience in community health or child health prior to entry into school nursing practice. Experience in the care of school-aged children
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Contents
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Get to the root of it
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Master the basics of EBP and learn how to start your own project.
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Research seeds practice
Turn a patient care idea into evidence-based practice by starting with solid research.
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Fuel career satisfaction
Rejuvenate your career with new evidence that transforms old practices.
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EBP blasts make an impact
A nurse who manages six clinics successfully expands healthcare access and relieve congestion.
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CE Catalog
Boost your knowledge of evidence-based practice processes in various settings with these education offerings.
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Self-care is a safety issue
Nurses who work nights or rotating shifts can suffer from sleep deprivation, which negatively impact their health and puts patients at risk.
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Create a dream team
Interprofessional collaboration and care has the potential improve outcomes and processes.
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Follow the evidence
You know EBP is important; now grasp the strategies and thought processes behind it by taking this CE module.
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Pregame practice for students
Nursing students are being taught the importance of providing high-quality care that’s supported by evidence.
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TeamSTEPPS improves communication
TeamSTEPPS was created as a nursing strategy to improve patient safety. Learn how the model took shape.
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Elevate your care
Learn why evidence-based practice is a must when it comes to quality patient care.
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Hold the power for change
Bedside nurses have the ability to make significant practice changes in the workplace.
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Making the grade
Use your critical thinking skills to continue to reevaluate evidence and adjust EBP, if necessary.
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Protect them from pain
Age-appropriate EBP helped nurses reduce pain levels in their young patients.
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The journey continues
Nurse leaders have the difficult task of increasing participationin EBP, but they know it’s worth the effort.
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An unacceptable risk
Perioperative nurses are striving to decrease the risk of hospital-acquired pressure ulcers.
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Training days
Managing the healthcare of specific patient populations using EBP to drive clinical decision making has become a necessity.
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Patient care gets revamped
Cancer center uses evidence-based studies and patient input to make changes to bedside reporting, elevate patient safety and improve care.
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