Ask the Experts Candida

Ask the Experts
Candida
HöferArchivo
di Stato
Napoli I
Goals of Presentation
v  Provide an overview of the levels of evidence used
in clinical practice as standards for APRN practice
v  Apply concepts to a framework of expertise
v  Discuss resources for evidence based references to
assist investigators
v  Select and apply evidence to clinical cases without
initial expert input
v  Guide exemplar cases using evidence based
resources to assist further expert consultation for
resolution
Definition of Evidence Based
Practice
Evidence-Based Medicine is the integration
of best research evidence with clinical
expertise and patient values.
[Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: how to
practice and teach EBM. 2d ed. Edinburgh: Churchill Livingstone, 2000.]
Levels of Evidence
Categories of Evidence
v 
Category I: Evidence from at least one properly randomized controlled trial.
v 
Category II-1: Evidence from well-designed controlled trials without
randomization.
v 
Category II-2: Evidence from well-designed cohort or case-control analytic
studies, preferably from more than one center or research group.
v 
Category II-3: Evidence from multiple times series with or without
intervention or dramatic results in uncontrolled experiments such as the
results of the introduction of penicillin treatment in the 1940s.
v 
Category III: Opinions of respected authorities, based on clinical experience,
descriptive studies and case reports, or reports of expert committees.
Harris, R.P. et al. (2001). Current methods of the U.S. Preventive Services Task Force: a
review of the process. American Journal of Preventive Medicine. April 20 (3 Supplement):
21-35
Another Rating System for
Evidence
v  Level I: Evidence from a systematic review of all
relevant randomized controlled trials (RCT's), or
evidence-based clinical practice guidelines based on
systematic reviews of RCT's
v  Level II: Evidence obtained from at least one well-
designed Randomized Controlled Trial (RCT)
v  Level III: Evidence obtained from well-designed
controlled trials without randomization, quasiexperimental
Another Rating System for
Evidence
v  Level IV: Evidence from well-designed case-control and
cohort studies
v  Level V: Evidence from systematic reviews of descriptive
and qualitative studies
v  Level VII: Evidence from the opinion of authorities and/
or reports of expert committees
"Evidence-based practice in nursing & healthcare: a guide to best practice" by
Bernadette M. Melnyk and Ellen Fineout-Overholt 2005.
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unknown)
(Author
Background sources of
information
Clinical Summaries, Textbooks
The best place for clinicians to get up to speed on
unfamiliar topics and filling holes in their knowledge base.
Several of these resources are (or act as) clinical textbooks
with either brief or detailed entries on conditions and
interventions.
Primary Literature
In the health field this is usually journal articles outlining
methodology, data, results, and conclusions.
These sources contain the original data and analysis from
research studies. No outside evaluation or interpretation is
provided. An example of a primary literature source is a
peer-reviewed research article. Other primary sources
include preprints, dissertations, technical reports and
conference proceedings.
Secondary Literature
Meta-analyses, Systematic Reviews, Evidence-based Guidelines
These sources summarize the medical literature by finding (via
explicit, thorough literature search) and appraising relevant
individual studies to answer a particular clinical question.
These sources provide analysis, synthesis, interpretation and
evaluation of primary works. A narrative review article is an
example of a secondary source.
Filtered resources: Select evidence based synthesis to answer
clinical questions.
Examples of Filtered Resources for
Clinical Guidelines
v  Cochrane Library
www.thecochranelibrary.com (free)
v  TRIP
www.tripdatabase.com (free, requires
registration)
v  National Guideline Clearinghouse (NGC)
http://www.guideline.gov (free)
v  Up to Date (subscription) www.uptodate.com
http://www.ebbp.org/
course_outlines/
searching_for_evidence/
Type of information needed:
Sample question:
Selected EBBP resources:
General summary or overview of a
condition
Where can I find a quick review of the
etiology, symptoms and recommended
treatment strategies for major
depressive disorder?
E-textbooks, such as ACP Pier,
Clinical Evidence, MD Consult,
DynaMed
Synthesis of evidence on populationbased intervention programs
What programs have been proven
effective to increase the level of
physical activity in teenagers?
The Community Guide (CDC)
Current guidelines outlining state-ofthe-art treatment
What is the recommended treatment
protocol for insomnia?
National Guideline Clearinghouse
Empirically-supported treatments on
psychological disorders
What evidence is available to support
the use of DBT for treating Borderline
Personality Disorder?
APA list of ESTs
Cochrane Library
Health Technology Assessment
Randomized controlled trials for a
"PICO" therapy question
Is treatment of ADHD with stimulants
alone as effective as combined
medication and psychosocial
intervention?
PubMed
Primary research articles on the use of
alternative modalities
What is the role of clinical hypnosis in
the treatment of eating disorders?
PsycInfo
Steps in Evidence Based
Practice
v  Step 1: Formulating a well-built question
v  Step 2: Identifying articles and other evidence-based
resources that answer the question
v  Step 3: Critically appraising the evidence to assess its
validity
v  Step 4: Applying the evidence
v  Step 5: Re-evaluating the application of evidence and
areas for improvement
Case Exemplar
v  George Box, 42 year old ANP working in a pain
clinic. A complaint was initiated by an emergency
room MD caring for an individual that was Mr. Box’s
patient. The patient was brought to the ER for a
opiate overdose.
1)  Question
2)  Articles or Evidence to answer question
3)  Assessment of validity of evidence
4)  Apply the evidence
5)  Reevaluate the application of evidence and need for
improvement
May require an expert
Question: What mechanisms should a prescriber employ to decrease the risk
of narcotic abuse for patients with chronic pain?
Source
APS-AAPM Clinical Guidelines for the Use of Chronic Opioid
Therapy in Chronic Noncancer Pain 2009
http://www.americanpainsociety.org/uploads/pdfs/
Opioid_Final_Evidence_Report.pdf
Abstract The American Pain Society and the American Academy of
Pain Medicine commissioned a systematic review of the evidence on
chronic opioid therapy for chronic noncancer pain and convened a
multidisciplinary expert panel to review the evidence and formulate
recommendations.
Recommendations
v  5.2.In patients on COT who are at high risk or who have
engaged in aberrant drug-related behaviors, clinicians
should periodically obtain urine drug screens or other
information to confirm adherence to the COT plan of care
(strong recommendation, low-quality evidence). v  5.3.In patients on COT not at high risk and not known to
have engaged in aberrant drug-related behaviors, clinicians
should consider periodically obtaining urine drug screens or
other information to confirm adherence to the COT plan of
care (weak recommendation, low-quality evidence).
Level VII Evidence from the opinion of authorities and/or
reports of expert committees
Investigatory Process
Problem Statement
v  Investigators for Boards of Nursing may or may not be
nurses. Those who are nurses may not be licensed or
experienced in APRN practice.
v  Investigators are asked to investigate cases related to
standard of practice and clinical actions which may
require outside expertise.
v  Hiring experts can be costly, unpredictable, and can
create a situation of “dueling experts” at hearing.
v  Multiple laws and standards apply to APRN practice
Prescriptive Authority
Employers
Board of
Pharmacy
Insurers
APRN
Board of
Medicine
(in some
states)
Board of
Nursing
DEA
Investigatory Process
v  Focus on factual information in investigation rather than
opinion related to clinical practice and standards
§ 
Determine whether or not a violation has occurred
§ 
Link the violation to applicable law
§ 
Nurse Practice Act
§ 
Board of Medical Examiners/APRN Regulatory Board
§ 
Department of Health
§ 
State Pharmacy Law
§ 
CFR—DEA regulations, Medicare law
§ 
State Insurance codes, regulations regarding consent/minors
§ 
Who, what, when, where, how
§ 
Why?
Use of Evidence in
Investigatory Process
v  Document factual evidence in report using
standardized format
v  Use evidence based guidelines as needed which help
support investigatory authority, factual findings, and
identified violation
v  Provide multiple methods and access to “expertise”
for investigatory staff, including examples discussed in
this presentation (ie Up to Date)
v  Use experts as needed to confirm rather than establish
standard of practice
Recommendations
Provide resources and education for staff to evaluate
evidence resources for application to the complaint
Sources for Level of Evidence CE
Training Modules for Evidence Based Process
v  University of Minnesota
http://hsl.lib.umn.edu/learn/ebp/mod01/
index.html (free online module)
v  Duke/UNC
http://www.hsl.unc.edu/services/tutorials/
ebm/Resourc.htm (free online module)
v  US Cochrane Center
http://us.cochrane.org/understandingevidence-based-healthcare-foundation-action
What if there is no “evidence”?
v  If clinical standards and guidelines are not available or in
conflict with each other:
v  Note that there is a lack of evidence
v  Identify community standard: local norms bounding
acceptable conduct (examples local practice survey, facility
policies, state or community based professional associations)
v  Identify national standards: national guidelines and
recommendations regarding conduct or competency
(examples ANA Code of Ethics, NONPF national
competencies for Nurse Practitioners, ACNM Core
Competencies)
v  Consult with legal counsel regarding which one or both are
applicable to the case being investigated
Case Exemplar
v  Kathleen Jones CNM is reported to the Board for use
of a vacuum extractor which resulted in a poor birth
outcome.
1)  Question
2)  Articles or Evidence to answer question
3)  Assessment of validity of evidence
4)  Apply the evidence
5)  Reevaluate the application of evidence and need for
improvement
May require an expert
Question: Do midwives use vacuum extractors in their practice?
http://www.ncbi.nlm.nih.gov/pubmed/16260366
J Midwifery Womens Health. 2005 Nov-Dec;50(6):517-24.
Clark PA.
Source
Department of Global Outreach, American College of NurseMidwives, USA. [email protected]
Abstract This article provides an update on use of vacuum extraction
by certified nurse-midwives (CNMs) and certified midwives (CMs).
Research findings from the last decade relevant to the training and use
of vacuum extractors are reviewed along with professional guidelines
and legal implications. PMID: 16260366 [PubMed - indexed for
MEDLINE]
Likely Level II-I or Level II-II evidence combined with Level III
Case Exemplar
v  Question: Did Ms. Jones have clinical training,
competency, or credentialing/privileging to use a
vacuum extractor? (addressed by investigatory fact
finding and documentation)
v  Question: Did Ms. Jones follow clinical guidelines,
recommendations, or standards when using the
vacuum extractor?
http://www.midwife.org/ACNM/files/
ccLibraryFiles/Filename/000000000551/LSS
%20Mod%209_10_final%20print2_11.pdf (Level III
Evidence)
May require
an expert
Summary Comments
v  Is lower level evidence invalid?
v  NO.
v  But it is important to know the evidence which does or does
not exist to support your preliminary assessment of a clinical
complaint in order to identify when and where an expert is
needed for further consultation.
v  Use evidence based guidelines when possible and
appropriate.
v  Will we see more issues which have no or little evidence?
v  YES.
v  This is where expert opinion related to community and
national standards is most helpful.
Questions