Overview of Evidence-Based Practice

In the 1990’s and early 2000’s, healthcare in the U.S. was at a point of crisis (Institute of Medicine, 2009, p. 4). Healthcare costs were continuing to rise in an environment of limited resources. Delivery of healthcare services was characterized by inefficiency and waste. Standards of care were inconsistent or nonexistent, and these inadequacies were limiting access to and innovation in healthcare. Further, the technology supporting diagnosis and treatment of disease was, and continues to, expand rapidly, and both chronic and acute diseases are increasing in variety and prevalence. This created a complex healthcare environment where it was no longer acceptable to continue providing care in the same way “it has always been done.” In fact, continuing to provide care without incorporating the best research evidence does not benefit our patients and may result in significant harm (Dawes, et al., 2005).

For healthcare to be as efficient and effective as possible, it is important we, as healthcare providers, are ensuring that our practices are the best they possibly can be. This is the primary motivation behind evidence-based practice (Lehane, et al., 2019). The goal of medical research, in general, and translational research, in particular, is to improve health outcomes through our diagnostic and therapeutic practices. The improvements in health outcomes from these research advances are not realized if we, the healthcare providers, do not implement these findings in our provision of care (Dawes, et al., 2005).

Definition

Evidence-based medicine was first defined in 1996 by Sackett et al. for the medical community and has since been expanded and adapted to guide all areas of health care and public health professionals.  A definition of evidence-based practice that can be utilized across the health professions was developed by Howlett and Rogo (2021, pg. 5) and reads, “Evidence-based practice (EBP) is the process of combining the best available research evidence with your clinical knowledge and skill to make collaborative patient- or population-centered decisions within the context of a given health care situations.”

In this definition, you should pay close attention to the following concepts (Howlett & Rogo, 2021):

• Best available scientific evidence. This means that you should be looking for the highest quality and most recent research available whenever possible. This doesn’t necessarily mean that you will need to look for journal articles. There are other resources to help make EBP easier to implement in the clinical setting and we will learn about these in Ch. 3.
• Clinical expertise. You have obtained foundational knowledge of clinical practice during your professional program and you will continue to build upon your expertise throughout your career through professional development and continuing education opportunities. This knowledge forms the basis of every clinical decision you will make. EBP is also a collaborative process. This means that you don’t have to (and shouldn’t!) make complex care decisions on your own. It is perfectly acceptable to consult your mentors and experts outside of medical imaging for their perspectives.
• Patient’s values, perspectives and traits. Research samples provide good evidence, but may not be applicable to the needs of your patient. Patient-centered care ensures that the decision-making process is collaborative between the patient and the health professional. We must consider the patient’s traits or characteristics, such as ethnicity and gender identity, as well as their preferences in order to provide the most effective care.
• Given clinical context. Even for care of a single disease, there are many factors that can change the care decisions that are made. These factors can include the setting in which the care is being provided (inpatient/outpatient, urban/rural), the equipment that is available, the urgency of the situation and even the patient’s insurance coverage or ability to pay.

The EBP Process

As we have seen in the definitions above, evidence-based practice is a process. This means that there are certain steps that we can take to achieve EBP, and a knowledge of the steps and stages is critical to becoming competent in EBP. Like the definitions of EBP, the steps in the EBP process can vary depending on the model you are using. The Five A’s model of evidence-based practice (Goode, et al., 2010) provides a streamlined approach to EBP and is easy to remember since all of the steps start with the letter “A”. See Figure 1A.

Ask

The first step in the EBP process involves distilling the patient’s signs and symptoms, concerns and history into one or more focused clinical questions. Asking good, searchable and answerable questions is difficult. We will discuss and practice a process for asking focused clinical questions in Ch. 2.

Acquire

Once we have defined our clinical question, we need to acquire the evidence we need to answer the question. Sometimes the hard work of acquiring the evidence is already done for us. This kind of evidence is provided to healthcare providers in the form of protocols or guidelines issued either by the healthcare facility or a medical organization. A good example of protocols/guidelines issued by a medical organization is the AHA Guidelines for CPR and ECC. To compile these guidelines, the American Heart Association reviews the latest science and treatment recommendations and makes recommendations to change the clinical protocols based on this science every 5 years. This is the reason you will notice changes to the BLS training as you progress through your career. When I completed my first CPR training, we were taught to perform cycles of 5 compressions and 2 breaths. Since then, the science has shown us that the compressions are much more important to the patient’s survival than providing breaths and we have seen a shift in the protocol to cycles of 30 compressions to 2 breaths.

If you need to locate your own evidence, you will need to determine which levels of evidence are needed to answer your question and what search terms will most likely produce appropriate results. We will discuss the most useful electronic resources as well as strategies for formulating effective searches in Ch. 3.

There are also times when the research evidence does not exist or does not fully answer the focused clinical question. In these situations, you may need to review pathophysiology, the patient’s medical record, quality improvement data for the facility, international, national and local standards, infection control data, benchmarking data, or cost-effectiveness data (Goode, et al., 2010).

Appraise

Once we have located resources that seem to answer our questions, we need to evaluate those resources to determine their value and trustworthiness. When we are looking for information to apply in the clinical setting, the most reliable information will be gleaned from multiple different studies. Scientific studies that combine multiple studies on the same topic to synthesize the overall result are called meta-analyses. Meta-analyses and textbooks are peer reviewed compilations of multiple scientific studies and are therefore most useful for directing clinical decisions. However, these resources and studies do not usually contain the most up-to-date information on a topic. For more recent information, searched of journal articles are required. In Ch. 4, we will discuss strategies for appraising or evaluating the value of the source.

Apply

Once we have determined which of our resources are most reliable, it is time to get into the details of answering our clinical questions. To effectively answer our clinical questions, we will need to summarize the relevant information and apply that information to the clinical context and patient we are caring for. We will discuss strategies for organizing and summarizing your information and how to incorporate your findings into recommendations regarding the patient’s care in Ch. 4. While we are learning these skills, you will share your findings and recommendations with your care team to gain a comprehensive appreciation for the complexities involved with the patient’s care. In the clinical setting, this information would also be shared with the patient to gather their opinions and preferences regarding the course of action.

Act and Assess

In the clinical setting, we would actually implement the care plan and evaluate the patient’s health outcomes following the intervention.

Summary

Evidence-based practice involves the intentional use of the best scientific evidence and the patient’s values and characteristics, along with clinical expertise to determine the best course of action for a given clinical context. While clinical expertise and collaboration with the patient are more obvious, factoring in the best research evidence requires some specialized information literacy skills. We are using the 5 A’s Model of evidence-based practice to master these skills. The five steps for evidence-based practice are ask, acquire, appraise, apply,and act and assess. The first step involves creating a focused clinical question that guides our search for evidence. Then we determine which resources to target and compile our search queries. After we have retrieved some resources we will appraise, or evaluate them for relevance to our question and trustworthiness. If the articles are good, we summarize their findings and apply them to the clinical dilemma. These findings are shared with the patient to get their input and the action plan is implemented. Once the plan has been in effect for a bit, the outcomes are assessed to determine if the implementation is working as we had hoped.

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