Health Services in a Bid to Enhance Patient Outcomes - Essay Example

………………………………………………………………………….xxxxxx …………………………………………………………………….xxxxxx …………………………………………………………………………xxxxx ………………………………………………………………………..xxxxx @2012 Summative Assessment – EBP Introduction `My name is Lilia, married with three teenage children. I have been working for more than ten years in a residential care home which caters thirty elderly service users both male and female. The service users suffer from different kinds of medical conditions from Parkinson disease, Alzheimer’s disease, through after care of stroke victims, heart problems and other general disabilities like with learning difficulties and wheelchair bound service users. The service users are unique individuals with different care needs. Evidence based practice refers to the organised use of empirical information in decision making about the health care of individual patients. Evidence-based practice entails the use of research evidence in delivering health services in a bid to enhance patient outcomes. Evidence-based practice (EBP) began in the medical field with researchers conducting numerous randomized clinical trials to improve healthcare. The challenge arises in the incorporation of research findings in clinical practice. It involves the integration of clinical expertise and clinical evidence from systematic research and using the information in decision making for patient care. EBP main objectives are integration of variables contributing to treatment of the patient. These variables are clinical expert opinion, external empirical evidence from research work and patient’s value and perspectives all towards the provision of high quality health care services based on the needs and choices of the patient. This can be summarised as shown in “ASHA’s trilateral figure”. Decision making that is evidence based is influenced by the practitioner’s skills as well as experiences. Clinician skills draw from expertise and multiple observations on patients especially on their response to different interventions. Clinical expertise is instrumental in averting the mechanical application of guidelines, decision rules and care maps. Moreover clinical expertise greatly influences the following parameters: quality of initial assessment (the clinical state of the client and prevailing circumstances), problem formulation, decision about evidence in light of availability of healthcare resources, exploring patient preferences, clinical intervention delivery, and evaluation of patient outcome (Melynk and Overholt, 2012). The main role played by the clinician is the interpretation of best current research evidence in relation to the clients preferences, environment, cultural believe and value in regard to health and personal well being. For instance, in the case of stroke survivors, the clinician identifies the secondary condition that the patient is suffering from as part of their recovery. These conditions include incontinence, spastic movement, and lack of mobility among others. The evidence based practice would be aimed at managing this condition along with the medical needs and preferences of the patient and the caregiver (Fitzpatrick 2007). In order to develop EBP skills the following steps are followed 1. Assess the patient condition and record the facts about their specific case 2. Formulate relevant clinical questions derived from the case that the EBP program seeks to respond to. 3. Identify appropriate resources and conduct a research to acquire evidence related to the case 4. Determine the evidence validity and applicability depending on the resources at your disposal as a care giver and the patients need. 5. Communicate the information to the patient to air their preferences before implementing research findings. 6. Evaluate the effectiveness of the EBP on the managing the patients condition. This is measured in relation to the patient’s progress after applying the EBP methods on them (Del Mar 2007). The nurse is also expected to be competent in their professional field and have adequate knowledge that they can apply in decision-making. An observant care-giver is in a position to identify their client’s needs especially for those recovering from stroke that have an array of complications (Salisbury et.al, 2010). Fluency and communication skills are necessary in establishing a basis for information sharing with the patient and other professionals. Nurses should have a questioning approach in their practice and be receptive and open-minded to receive questions from others. Effective implementation of EBP requires that the nurse develops skills in sourcing for evidence and their efficiency in practice context. Search for evidence: application of PICO technique There exists a lot of information on different subjects and in most cases the scientific information is contradictory. With the advent of ICT, it is important to access information from various studies. Physicians and nurses need to find answers quickly and a search should take less than ten minutes to find a solution to a clinical question. Accessibility to knowledge produced on any given subject is instrumental in the design of research as well as adequate and correct clinical action. Despite the availability of vast information on many subjects, there is need to filter information in order to select relevant information from the immense information available. The PICO model presents a means to define the search topic. In addition, it directs the construction of a research question and bibliographic search. It also promotes professionalism in research and clinical practice incase doubt arises. The researcher is well guided to accurately retrieve the best scientific information (Da Costa et al., 2007). The process of searching for evidence for specific cases can be hectic requiring to be managed appropriately. Patients recovering from stroke have diverse medical needs. Searching for the information to integrate in evidence management of the condition may be time consuming if the search is not guided. Since the information is the web-based location, the identification of relevant information requires specific search and PICO is used in doing so. This is tool used by health care-givers in conducting research based on the specific patient details. The PICO question is “Do stroke patients, their families and carers have better healthcare experiences when stroke management follows national guidelines?” The PICO question is comprises of the following four elements that are utilized in formulating a good clinical research question. P-patient or problem. This can be one patient or patient group with a given health condition. The problem can be a disease, unique behaviour and symptoms I- intervention being considered appropriate for the condition; these are the treatment and drugs, procedures, diagnostic test and exposure history. The intervention of interest can be preventive (e.g. vaccination), therapeutic, preventive, prognostic, or administrative. C – Comparison or control. Comparison between the intervention and any other alternative that the care giver would consider. The control is the standard intervention, no intervention or commonly used intervention. O -result expected on the implementation of the intervention procedure. Treatment and patient outcomes are considered. The PICO model is used to construct research questions originating from a search of symptom assessment instruments and clinical practice. An adequate and well constructed research question guides the search of relevant evidence that will be useful in solving the clinical research question. Moreover it maximizes the chances of recovering relevant evidence in a database. The search for information conforms to the research scope and unnecessary searching is avoided ((Da Costa et al., 2007). After formulation of the PICO question, the relevant domain such as prognosis, diagnosis, prevention/therapy is established. The type of research to answer the research question is also defined. The exclusion or inclusion criteria are also formulated in order to precisely select the patient or problem specific factors. In order to conduct a search on credible literature, the PICO question needs to be converted to key words. All articles and retrieved information from scholarly sources should be evaluated in light of scientific quality and relevance to the question at hand. After compliance to the protocol, an evidence based answer can be generated to the initially posed question (Loveren and Aartman, 2007). The category of question should be specified as therapy/prevention, diagnostic, etiology or prognosis. This enables the clinician to limit the research results to fit the specific patient case. Current trend of migration to evidence based medicine the application of PICO in clinical health care lead to the formulation of management plans that include the patient’s needs and not based on the theoretical knowledge. A different PICO question is formulated to suit each unique condition that stroke patient. This ensures that the evidence is gathered in small comprehensive bits. Its utilisation would be manageable since it is stated objectively in clear terms. It is also possible to predict the treatment and patient outcome based on the scientific empirical information. It improves the specification and contextual clarity of clinical problems. The care giver is therefore in positions to clearly state what they are searching for when dealing with the unique health care needs of a patient. It elicits more information during the pre-search stage since there are different types of stroke with each case of a survivor having a unique set of characteristics at various level of the recovery process (Salisbury, 2010). Semantic classification of information into age, gender, treatment status, physical condition and medical history specify the evidence based practice to each case (Straus, 2005). PICO technique makes the rest of the process of finding and evaluating evidence much more straight forward. Information is appraised by systematically assessing and interpreting its validity and relevance. It would be risky for a caregiver to apply randomly the information gathered from their evidence research without analysing its applicability and the feasibility of evidence based practice (Straus, 2005). Critical appraisal uses intrinsic research designs factors in evaluating web-based information. This method considers quality of information selected randomly to avoid obvious bias, validity with outcomes that make sense and similar to clinical practice or with evidence of having of being used in clinical practice, reliability in the trial credible ability to give consistent results and repeatability. The evidence gathered is organised in order of priority starting with the measures that address urgent medical needs progressing to the secondary needs chronologically. However, there few studies on the applicability of the PICO frame work especially in diagnostic and prognostic research question. The method is preferred for therapy questions, but an increasing number of people are using this technique to research for diagnosis and prognosis EBP. Structural completeness of the PICO question is sometimes neglected hence interfering with the quality of evidence gathered. This would in turn make the medical decision taken incomplete and unreliable. The use hypothesised diseases and symptoms may not give accurate diagnostic responds to the question. The question should be formulated based on real patient condition and not assumptions if the evidence is to be applied in making a medical decision for the patient. The research question is “Do stroke patients, their families and carers have better healthcare experiences when stroke management follows national guidelines?” Post stroke recovery process based on EBP should state its research question with the following PICO. P- Stroke patients and their carers I- stroke management following national guidelines C-stroke management not following national guidelines O-healthcare experiences Prioritization is necessary, and the patient and carer should be proactively involved in the evidence gathering process. This is in line with EBP medicine since this is a method that attempts to ensure that clients receive the most effective intervention possible. The following five steps are engaged Formulating an answerable question regarding the practice need for the specific case. Intervention possible. The following five steps are engaged Formulating an answerable question regarding the practice need for the specific case. Evidence can be structured to fit different levels of a hierarchy. The quantitative pyramid shows the relative importance attached to different types of evidence to answer cause and effect question of the EBP technique. Qualitative pyramid rates evidence on the ability to respond to meaning and experience questions. Levels in quantitative pyramid 1. Systematic analysis of relevant randomised controlled trials-RCTs(meta-analysis) (Chris 2007) 2. Evidence from at least one well-designed RCT(randomised controlled trials with definitive results) 3. Evidence from a well designed controlled trial without randomisation(randomised control trial with non-definitive results) 4. Evidence from well-designed case control and control and cohort studies(cohort studies) 5. Evidence from systematic reviews of descriptive and qualitative study(case control studies) 6. Evidence from a single descriptive or qualitative study(cross-sectional studies) 7. Evidence from expert opinion (case report) (Fitzpatrick 2007 ) The reduction of bias and increasing validity through aspects like blinding, control and randomisation gives rise to the quantitative pyramid. The most rigorous evidence based research for practice is generated via double blind randomised control trial. From the various levels of evidence search, the consumer narrows down from the initial broad results to one specific option that demonstrates validity and reliability if applied to the specific case. Some of the flaws in this method include level of transparency and accountability on clinical decisions make by caregivers and being open to scrutiny by peers and public. Practice guidelines and supporting evidence The National Institute for Health and Clinical excellence (NICE) has developed guidelines that address the initial management of acute stroke and transient ischemic attack (TIA). NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales (NICE, 2008). Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions up to 2 weeks are covered. Clinicians and concerned with adult care must appreciate the needs of secondary and rehabilitation care in stroke patients in order to boost healthcare across all stages and phases. Due diligence must be taken in the application of recommendations as some may be inappropriate for patients with severe comorbidities as well as the dying patients (NICE, 2008). Practical guidelines and supporting evidence are clinical guidelines used by health care professionals and help the health care professionals to use specific examples analyzing a medical condition. Home care is crucial especially for patients with chronic ailments such as stroke, cancer, neurodegenerative disease etc. Most stroke survivors have comorbidities like diabetes and heart disease. Thus the residential workers must be in a position to address all these health complications. Moreover, they should have information on reducing risk factors to prevent future complications. They need to encourage patients to embrace healthy lifestyles via wholesome diets, stress management and exercise. Knowledge of home care practice is crucial for residential workers in order to enhance patient comfort and outcome. Most important, health and safety practice guides residential workers on activities such as lifting and moving patients, lone working and protection upon exposure to infections, abuse, general hazards (slips and trips) and violence. Home care enables patients to lead independent lives in their homes close to family, loved ones and the community. The demand has increased due to technological and medical advances that allow patients to receive health care from the comfort of their homes. In addition, high health care costs and few hospital beds have encouraged earlier patient discharge. Due to shifting economic realities stroke patients are being discharged from hospitalisation earlier as compared to previous practice. Among chronic diseases, stroke has been confirmed to be third leading cause of death and a major cause of long-term disability among adults in Scotland. As a result, research has shown that there in an increasing demand for home care among patients (Straus, 2005). These are usually family members taking care of the patient voluntarily from home after they have received professional medical help. This form of service is relevant to health care provision because care home practice in making a hospital to home transition. Currently the economic depression has left the majority of families struggling on an alternative that reduce their spending. The situation needs assistance to manage some tasks such as bathing, dressing and taking medication. They also need to be informed on professional tasks such as tube feeding to reduce the risk of complication and ventilation care. Due to the short hospitalisation time, family members and home care givers have a short time to absorb information they would need on going home. Extensive educational need is required to expose the people involved to necessary information and management of the same (Fitzpatrick 2007). The guidelines on home care of after-stroke patients are categorised in 7 groups which evolve from analysis of specific examples from healthcare practice: I. Stroke recovery: includes measures to prevent recurrence of stroke and medical follow-up of the current condition II. Stress management: both the care givers and patient are likely to experience stress associated with management of chronic conditions III. Promotion of a healthy lifestyle: guides physical fitness, leisure activities, nutritional management and sleep-patterns that the care gives should recommend on the patient for a healthier way of life. IV. Special accompanying problems: patience recovering from stroke suffers other conditions like aphasia, bowel/bladder incontinence, emotional liability and spasticity. The caregiver should incorporate evidence based practice in management of these conditions V. Therapeutic skill training: care give would need to work closely with a professional nurse to learn the skills required for comprehensive rehabilitation of the patients. VI. Coping with the after effects of stoke and its management relaxation techniques and problem solving skills should be integrated in the care giving program. VII. Community networks: meeting with other stroke survivors and caregivers builds psychological comfort since experiences are shared and evidence information on the recovery program can be enhanced (Trinder, 2000). The guidelines can be summarised in four levels based on their role in guiding EBP by the caregiver: Public and professional individuals to recognize quickly and to act on stroke symptoms immediate access to specialized stroke units, Advisory for discharge planning, and information about community-based services Access to review, by a specialist stroke team as required (Salisbury, 2010). Guidelines on the care of stroke patients are developed by a collaborative network of healthcare professionals, clinicians, and patient organizations. These parties form SIGN (Scottish Intercollegiate Guidelines Network) which is a body of NHS Quality Improvement Scotland. The SIGN guidelines are developed by various multidisciplinary groups of practising clinicians (SIGN, 2010). They use a standard methodology that is based on a systematic review of existing credible evidence. Caregivers are usually experiencing stress and burden of care. Clear guidelines are therefore needed to manage this feeling. Though they operate with care, love and deep feelings of pride, sometimes they get angry and unappreciated and frustration when they patient shows no improvement and helplessness start to set in. Recognising and accepting these emotional concerns is a major step in resolving problems and preventing emotional imbalances that are work related (Salisbury 2010). Manipulating the evidence- Challenges facing producers and consumers of evidence in EBP The credibility of information available in scholarly sources is also under question in light of recently revealed ghost writers who submit false manuscripts to medical journals (Fugh, 2010). This was revealed in a litigation case where 1500 documents provided insight into the crafty dealings of pharmaceutical companies to give falsified information in a bid to promote drugs. The ghost written commentaries and reviews were published in journals and they promoted unproven benefits of hormone therapy (HT) while downplaying the harm of this therapy. Moreover, raloxifine and other alternative therapies were cast in a negative light (Fugh, 2010). This troubling information casts doubt on peer reviewed scholarly journals as sources of information. Wyeth, a pharmaceutical company is behind the submission of ghost written articles that downplayed the potential risks of HT in predisposing women to breast cancer. Moreover, the ghost writers presented false evidence of HT in yielding cardiovascular benefits and promoted the therapy for unproven uses such as prevention of dementia, wrinkles, vision problems and Parkinson's disease. In another case study, false clinical trial results were presented in a ghost writing scam where data is manipulated to favor the medication under study. A study on the pediatric use of paroxetine showed negative efficacy and the drug was also harmful. However, a ghost written publication presented evidence of paroxetine efficacy as well as safety (McHenry and Jureidini, 2008).There is need for strict monitoring of researchers submitting articles to peer reviewed journals. Reviewers must be vigilant in the publishing of research articles. In addition prescribers and pharmaceutical companies must renounce ghost writing and strict penalties and fines should be imposed on violators. Unscrupulous relationships that exist between academia and industry should be abhorred (Fugh, 2010). Limited insight and access to the broad body of medical information limits the areas covered in the available empirical data on evidence based practice in care giving. Majority of the evidence consumers are handicapped by their low literacy on health literature which impairs their comprehension of the same (Fitzpatrick 2007). This further affects their ability to identify relevant and credible evidence in relation to their case and medical needs. Currently persons with low heath issue awareness and hence literacy do not benefit from advances in consumer health information and cyber medicine since they lack access and understanding of the technology. Limited mechanisms have been put in place for quality assurance of the information. The lack of a standard quality assurance checklist on which consumers and developers of evidence can compare their empirical data has made the information available to be either incomplete or substandard. Important details are omitted, fail to give a balanced view of effectiveness of different treatments and ignore uncertainties while still only a few promote a participative approach to decision making and this is an indication of evidence can be manipulated (Fitzpatrick 2007). EBP Toolbox This refers to a collection of links to research databases which contain information on medical management of patients. The resources includes Search engines which are a collection of powerful databases Databases Guidelines Nursing and medical websites Performance measures EBM tutorial (Medical toolbox 2011) Evidence based practice can be utilized to improve home care to recovering stroke patients. In a study on stroke patients receiving home care by Salisbury et al, (2010), complications were encountered in the recognition of stroke symptoms by professionals and study participants, hospital admission to the stroke unit, consultation during discharge, and accessibility to follow up services. Despite clinical guidelines to direct stroke management, the experience of carers and patients with stroke does not conform to guideline recommendations. There is a discrepancy as the recommendations do not translate into clinical practice. These considerations should be made by residential workers in the delivery of home care to recovering stroke patients. Conclusion/Opportunities EBP has been embraced by the increasing number of medical practitioners and administrator in improving the quality of health care while reducing cost. Majority of patients with long term conditions are turning to these techniques since they get to access reliable care at a cheaper cost. Beyond the quality of the guidelines and evidence base itself require critical factors for its success like the involvement of local clinician, unified medical staff, procedures that minimise use of clinical judgement and call for the involvement o f clinical service extenders who offer to develop the base at reduced financial incentives. EBP solely is not the solution to the problem of increasing cost of health care and public expectations. It serves as an important source of information related to the value of service, medical technology and public priorities (Chris 2007). The information resources are dynamic and continue to challenge the information developers and consumers. Flexibility and adaptability are qualities required in the skill of utilising the evidence based practice. Working towards seamless integration of relevant evidence based clinical information in individual patient electronic medical records. This would make it easier even for patient recovering from stroke and their care givers to access relevant information on medication and medical history (Straus 2005). EBP is not just about finding an answer to the patient current condition, it gives an opportunity to be informed on the current trend in the medical field and the best option out of the several existing based on peer reviewed medical evidence. However, the utilization of EBP in clinical management unique patient conditions requires competence in information mastery. This is the ability to locate, appraise and assimilate evidence from scientific studies (Chris 2007). References Alaska Medical Library Evidence Based Practice www.consortiumlibrary.org/aml. Accessed on 4th April 2013 Da Costa, S. C.M., De Mattos, P.C.A. and Nobre, M.R. (2007). The PICO strategy for the research question construction and evidence search. Rev. Latino-Am. Enfermagem. 15(3):508-511. Fitzpatrick, J., 2007. Finding the Research for Evidence-based Practice-part one: The Development of EBP. University of West England. www.nursingtimes.net. Accessed on 4th April 2013 Fugh-Berman, A.J. (2010). The Haunting of Medical Journals: How Ghostwriting Sold “HRT”. PLoS Med. 7(9): 1-30. Hachinski V. & Hachinski .L. (2002). A Comprehensive Guide. University of Western Ontario Loveren, C. and Aartman, I.H.(2007). The PICO (Patient-Intervention-Comparison- Outcome) question. Ned Tijdschr Tandheelkd. 114(4):172-178. Melynk, B.M. and Overholt, E.F. (2012). Evidence-based Practice in Nursing and Healthcare. New York: Lippincott Williams & Wilkins.  McHenry, L.B. and Jureidini, J.N.(2008). Industry-Sponsored Ghostwriting in Clinical Trial Reporting: A Case Study. Accountability in Research: Policies and Quality Assurance. 15(3): 152-167. NICE. (2008). Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). NICE clinical guideline 68. Salisbury, L. (2010). After the Stroke: Patient’s and Carer Experience of Healthcare after stroke in Scotland. Queen Margret University. Straus , S.E. (2005). Evidence Based Medicine How to Practice and Teach EBM. Edinburgh. Churchill Livingstone SIGN.(2010). Management of patients with stroke: Rehabilitation, prevention, and management of complications, and discharge planning. [online]. Assessed http://www.sign.ac.uk/pdf/sign118.pdf Trinder, L. and Reynolds. S. (2000). Evidence Based Practice: A critical Appraisal. Oxford: Blackwell science Evidence Based Practice Toolbox user Guide Chris Del Mar, 2007. Evidence Based Practice. Medicine Workbook BMJ Books Appendixes – EBP toolbox for medical practitioners Search Engines: Up ToDate Clinical Reference- is a database of clinical topic reviews that synthesize clinical evidence and practice expertise. The site offers practice recommendations supported by high-quality evidence. DynaMed is a clinical reference tool created for use primarily at the “point of care”. With clinically organized summaries for more than 3,000 topics. The tool is updated daily and monitors over 500 medical journals and systematic evidence review databases directly. OVID to link to Cochran Database of Systematic review- – This database comprises full text systematic reviews of the medical literature. Cochran conducts rigorous appraisals and synthesis of the literature to answer focused clinical questions of interest to clinicians. Cochran Library SumSearch – UT Health Science Center (easy to use search engine) TRIP Database- Click on the Pyramid to link to different grades of evidence sources MD Consult – The database is tailored for common clinical topics BMJ Evidence Center - Clinical Evidence systematic reviews summarize the current state of knowledge and uncertainty about the prevention and treatment of clinical conditions, based on thorough searches and appraisal of the literature. Research Databases PubMed University of Washington (one stop shopping) Duke Library Google Scholar Google Other Sites: Pathway /Order Set Literature Locator - EBL librarians answer questions that support pathways and order sets. Eskind Digital Library Informatics resources and professional support through Eskind Library Guidelines Scottish Intercollegiate Guidelines National Clearinghouse Guidelines National Institute of Clinical Excellence Institute for Clinical Systems Improvement Center for Disease Control Cancer Management Guidelines New Zealand Guidelines Group Nursing Websites Mosby’s Nursing Consult - via EBL Log-in with VUNET ID Medscape Nursing: requires account to be created EBP at VU - Nursing Research Resource You can submit literature search questions to the EBP team CINAHL (access through EDL) the database covers appr. 2,700 nursing, allied health, biomedical, and consumer health journals, and ANA and NLN form 1982 to present Nursing Digital Library: Evidence Based Nursing Journal online: access through Eskind Nursing Guidelines Royal College of Nursing RN association of Ontario AHRQ Patient Safety & Quality Handbook for Nurses Nursing Digital Books Mosby’s Nursing Skills - available via Mosby's Nursing Consult Ulrich & Canale: Nursing Care Planning Guides Urden: Thelan's Critical Care Nursing: Diagnosis and Management Evidence Base Medicine Tutorials University of Minnesota: EBM Tutorial Duke & UNC-Chapel Hill: Evidence-Based Medicine Tutorial University of Rochester Medical Center: Evidence Based Clinical Practice Tutorial UIUC Library of the Health Sciences: EBM: Finding the Best Clinical Literature UNC Tutorial of EBM Center for Evidenced Based Mental Health Searching the Evidence 1 Searching the Evidence 2 CEBM Netting the Evidence: Patient Information Web Sites – Mosby’s Nursing Consult- click on Patient Education Link from Mosby’s homepage MD Consult Up-To-Date- Medline Plus UNC Preparing Pt Ed Handouts Books on line Lexi Comp Online (Medications) PDR Online ICD-9 Look up CPD codes The Merck Manual Lippincott: Mosby’s e-Book List Helpful Cheat Sheets/Tutorials PubMed 10 tips PubMed on line training Internet Tutorials EBSCO Tutorials (includes CINAHL) DynaMed Tutorial Ovid Tutorials Google Scholar Tips Read More