Master the basics of EBP
Get to the root of your questions
By Janice Petrella Lynch, MSN, RN
EDITOR'S NOTE: Janice Petrella Lynch, MSN, RN, is a nurse consultant for
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.
How do ICU patients (P) experience delirium (I)?
How do adult patients (P) experience pressure ulcers (I)?
How do parents (P) experience SIDS (I)?
Create a searchable PICO question
Sources of evidence
External: Research, clinical practice guidelines, subject matter experts
Internal: Quality, safety, satisfaction
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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