Evidence Based Practice and
the Development of AORNs
Recommended Practices
Lisa Spruce, DNP, RN, CNOR, ACNS, ACNP
Director, Evidence-Based Perioperative Practice
It starts with research
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Why EBP?
• It takes an average of 17 years to move research to
practice
• EBP provides point of care clinicians tools needed to
improve care
• EBP transforms health care based on one clinician, one
encounter at a time
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Why EBP?
4
EBP
5
EBP
• By individual clinical expertise we mean the proficiency
and judgment that individual clinicians acquire through
clinical experience and clinical practice. Increased
expertise is reflected in many ways, but especially in
more effective and efficient diagnosis and in the more
thoughtful identification and compassionate use of
individual patient’s predicaments, rights, and preferences
in making clinical decisions about their care.³
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Why Clinical Practice Guidelines?
• “Rather than dictating a one-size-fits-all approach to patient care, clinical practice
guidelines offer an evaluation of the quality of the relevant scientific literature and
an assessment of the likely benefits and harms of a particular treatment¹.”
~Institute of Medicine
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Where do we start?
• Formulate the clinical question
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IM Injections: Aspirate or not?
Question:
Among adult patients,
does aspirating while
giving an IM injection
cause injury compared
to no aspiration?
Search the literature
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Conducting a Search
Databases
Databases
~ Cochrane
~ AHRQ - NGC
~ Pubmed
~ CINAHL®
~ ANA - Medline
~ AORN Journal
~ Medical Library
~ Google Scholar
~ Joanna Briggs
~ Virginia Henderson
International Nursing
Library
~ Embase
Types of evidence
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Appraise the evidence
AORN’s tools
Research
Non-Research
Evidence appraisal
The strength of the research evidence is indicated by I, II,
or III for research and IV or V for non-research
The quality of the
research evidence is
indicated by A, B, or C
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Appraisal Score
Quality is subjective
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Quality is the challenge
• Was there a clear explanation of the purpose of the study and,
if so, what was it?
• Were there enough people in the study to establish that the
findings did not occur by chance?
• How were variables defined?
• Were the instruments designed to measure a concept valid
(did they measure what the researchers said they measured)?
• Were they reliable (did they measure a concept the same way
every time they were used)?
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Quality
• What statistics were used to determine if the purpose of
the study was achieved?
• Did people leave the study and, if so, was there
something special about them?
• Did the researchers base their work on a thorough
literature review?
• Is the study purpose an important clinical issue?²
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AORN Evidence Rating Model
Appraisal Score
Research
Non-Research
IA
IVA
Regulatory
Evidence Rating
Evidence Requirements
1: Strong Evidence
1: Regulatory requirement
Interventions or activities for which effectiveness has been demonstrated by
strong evidence from rigorously-designed studies, meta-analyses, or
systematic reviews, rigorously-developed clinical practice guidelines, or
regulatory requirements.
•Evidence from a meta-analysis or systematic review of research studies that
incorporated evidence appraisal and synthesis of the evidence in the analysis.
•Supportive evidence from a single well-conducted randomized controlled trial.
•Guidelines that are developed by a panel of experts, that derive from an
explicit literature search methodology, and include evidence appraisal and
synthesis of the evidence.
2: Moderate Evidence
Interventions or activities for which the evidence is less well established than
for those listed under “1: Strong Evidence.”
•Supportive evidence from a well-conducted research study.
•Guidelines developed by a panel of experts which are primarily based on the
evidence but not supported by evidence appraisal and synthesis of the
evidence.
•Non-research evidence with consistent results and fairly definitive
conclusions.
3: Limited Evidence
Interventions or activities for which there are currently insufficient evidence or
evidence of inadequate quality.
•Supportive evidence from a poorly conducted research study.
•Evidence from non-experimental studies with high potential for bias.
•Guidelines developed largely by consensus or expert opinion.
•Non-research evidence with insufficient evidence or inconsistent results.
•Conflicting evidence, but where the preponderance of the evidence supports
the recommendation.
Selected interventions or activities for which the AORN Recommended
Practices Advisory Board (RPAB) is of the opinion that the desirable effects of
following this recommendation outweigh the harms.
IB
IIA, IIB
IIIA, IIIB
IVB
VA, VB
IC
IIC
IIIC
IVC
VC
No requirement
No requirement
4: Benefits Balanced With Harms
No requirement
No requirement
5: No Evidence
Interventions or activities for which no supportive evidence was found during
the literature search completed for the recommendation.
•Consensus opinion.
AORN Evidence Rating Model
1:
1:
IA
Strong Evidence
Regulatory requirement
IVA
Regulatory
1: Strong Evidence
1: Regulatory requirement
Interventions or activities for which effectiveness has been
demonstrated by strong evidence from rigorously-designed studies,
meta-analyses, or systematic reviews, rigorously-developed clinical
practice guidelines, or regulatory requirements.
•Evidence from a meta-analysis or systematic review of research
studies that incorporated evidence appraisal and synthesis of the
evidence in the analysis.
•Supportive evidence from a single well-conducted randomized
controlled trial.
•Guidelines that are developed by a panel of experts, that derive from an
explicit literature search methodology, and include evidence appraisal
and synthesis of the evidence.
AORN Evidence Rating Model
2:
IB
IIA, IIB
IIIA, IIIB
3:
IC
IIC
IIIC
Moderate Evidence
IVB
VA, VB
2: Moderate Evidence
Interventions or activities for which the evidence is less well
established than for those listed under “1: Strong Evidence.”
•Supportive evidence from a well-conducted research study.
•Guidelines developed by a panel of experts which are primarily based
on the evidence but not supported by evidence appraisal and
synthesis of the evidence.
•Non-research evidence with consistent results and fairly definitive
conclusions.
Limited Evidence
IVC
VC
3: Limited Evidence
Interventions or activities for which there are currently insufficient
evidence or evidence of inadequate quality.
•Supportive evidence from a poorly conducted research study.
•Evidence from non-experimental studies with high potential for bias.
•Guidelines developed largely by consensus or expert opinion.
•Non-research evidence with insufficient evidence or inconsistent
results.
•Conflicting evidence, but where the preponderance of the evidence
supports the recommendation.
AORN Evidence Rating Model
4:
No requirement
5:
No requirement
Benefits Balanced with Harms
No requirement
4: Benefits Balanced With Harms
Selected interventions or activities for which the AORN Recommended
Practices Advisory Board (RPAB) is of the opinion that the desirable
effects of following this recommendation outweigh the harms.
No Evidence
No requirement
5: No Evidence
Interventions or activities for which no supportive evidence was found
during the literature search completed for the recommendation.
•Consensus opinion.
Evidence synthesis
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Evidence Rating
[3: Limited Evidence]
Public comment
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AORN Evidence Rated RP
AORN Evidence Rated RP
AORN Evidence
Rated RP
National Guideline Clearinghouse
National Guideline Clearinghouse™
The National Guideline Clearinghouse™ (NGC), an AHRQ initiative, is a publicly available database of evidencebased clinical practice guidelines and related documents. Updated weekly with new content, the NGC provides
physicians and other health professionals, health care providers, health plans, integrated delivery systems,
purchasers, and others an accessible mechanism for obtaining objective, detailed information on clinical practice
guidelines and to further their dissemination, implementation, and use.
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Meeting NGC Criteria
• Documentation will need to be provided showing that the
guideline is based upon a systematic review of the
evidence.
• Documentation must contain an assessment of the
benefits and harms of the recommended care and
alternative care options.
Compassion
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Questions
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References
1.
2.
3.
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Institute of Medicine. National Academy of Sciences, (2011). Clinical
practice guidelines we can trust. Retrieved from IOM website:
http://citationmachine.net/index2.php?reqstyleid=2&mode=form&reqsrcid=
APAGovernmentReport&srcCode=9&more=yes&nameCnt=1
Fineout-Overholt, E., Melnyk, B., Stillwell, S., & Williamson, K. (2010).
Evidence-based practice, step by step: Critical appraisal of the evidence
part i. American Journal of Nursing, 110(7), 47-52.
Drisko, J. (2012, 0924). Social work resources: Evidence-based practice.
Retrieved from
http://sophia.smith.edu/~jdrisko/evidence_based_practice.htm