Apply and Assess

Guest post by Gabriel Merckx, MLIS* 

Welcome to the final article of Ascension Wisconsin Library Services’ series on Evidence Based Medicine! This is the fifth (and final) article in the series. See the whole 5-part series: The 5As of Evidence-based Practice.

You've acquired all your articles.

You’ve appraised the evidence.

Now you can finally apply them! But wait ...

Can the results can actually be applied to the patient?

You may find great articles, great solutions, but they might not truly be the best for the situation at hand. Why?

There are three things that to consider before you apply your understanding to your situation:

• Economic cost: Sometimes the solution could just be too expensive. Yes, maybe that $1,000,000 new treatment would be better than the current standard of care, but it just isn’t feasible. 

• Demographic: If the patient is an elderly man and all your papers are on treatments for young women, there’s a possibility that treatment won’t work for him.

• Patient beliefs: The patient comes first. Even if best evidence says they should get surgery, if it’s not something they want, you won’t be able to do it.

If all of those things are clear (you have enough money for the treatment, the demographics match, and patient beliefs align with this new course of action), then you can apply your findings to practice.

Assess

After that, reflect on the process. What was difficult? What would you have done differently? What would be the same? What new questions have come up because of this process?

Welcome back to Ascension Library Services’ series on Evidence Based Practice! This is the fourth article in the series. If you would like to read the series from the beginning, click [here].

Once you start to look things up, now you have to pick things out. But when you have hundreds of papers, how do you even get started?

First, look for the best evidence. In order to do that, search for

• systematic reviews
• meta-analysis
• randomized controlled trials (RCTs) / double blind studies

In PubMed, limit what is shown by using the customizing tools on the sidebar on the left. By choosing Systematic Reviews and Meta-Analyses only articles that fit systematic reviews or meta-analyses should be shown in the results list.

If you don't get any systematic reviews or meta-analyses, try the next level of best evidence: Randomized Controlled Trials (RCTs).

If using a database other than PubMed that does not have these limiters, take a look at the title and the methods. Oftentimes, the title will include “A Systematic Review," and the methods will list if it was a double-blind study or not. Either way, read through the methods to make sure. 

After reading through the paper, ask these questions:

• Were the methods clear?

• Is this backed by other studies?

• Is the conclusion actually supported by the result?

• Are the results valid?

• Is there a high risk of bias based on the method?

Worksheets such as the ones on our EBP LibGuide can help answer these questions.

If the answer to any of these questions is no, it might not be a good source.

Want more resources on appraisal? Our EBP LibGuide has several compilations of resources for your use.

If you’ve made it to this step, you’ve already formed a question using PICO. After that, it’s time to start searching for articles. Let’s look at our example question from last time.

• Does taking rizatriptan lower migraine rates in middle aged women more than over the counter remedies?

Now, plugging this question as it is into Google won’t get all the evidence you'd need to answer the question.  So, today, we’re going to talk about how to break that question down into search terms that can be used in our databases, such as PubMed or CINAHL. 

The first thing to do is decide what parts of the question are essential to the search. Not every part of the question needs to be a part of the initial search, but what does need to be included is the topic of the question and at least one other element of the question. PICO itself is an amazing way to stay on target, because PICO-formed questions break the question down into easily searched and essential parts.

The topic we’re trying to study is migraines, so that will be part of the search.

Another part could be rizatriptan, since that’s the treatment.

So where would you plug these search terms in?

In PubMed, using Boolean phrases (detailed in picture below) can be particularly helpful. In this instance, I would type in “rizatriptan” AND “migraines”.

• Putting the words in quotations makes sure the database looks for that exact word or phrase.

• Using ‘AND’ only looks for articles that contain both rizatriptan AND migraines. 

Filters or Limiters can help limit the amount of information or hits a search gets. In PubMed and CINAHL, these are found on the left-hand side. Limiters/ filters can include:

• Language

• Human Studies 

• Year Published (Try to limit the search to the last five or ten years)

• Systematic Reviews or Meta-Analysis

Another popular tool is PubMed Clinical Queries, which uses predefined filters to help you quickly refine PubMed searches on clinical or disease-specific topics to pull up clinical trials, which are considered higher quality evidence. Give it a try!

Need help with your search, but don’t have time to stop in?  Our EBP LibGuide can give you more search tips on the go.

The first step of Evidence Based Practice is to ask a question based on your clinical experience. However, it’s not just about forming the question, but forming it in the right way so that it’s easier to acquire literature in the next step. 

So, how do you do that? One method is to formulate the question using PICO.

PICO stands for:

• P: Patient OR Problem: How would you describe your patient demographically? OR what is the problem you are trying to solve?

• I: Intervention: What are you doing to the patient or problem?

• C: Comparison: What other treatment could you try? (The answer can be “nothing” or “not treating it”)

• O: Outcome: What do you want to happen?

Sometimes, we add a T: 

• T: Time: In what time period do you want this to happen in?

An example of a question formulated with PICO might be:

• Does taking rizatriptan (I) lower migraine rates (O) in middle aged women (P) more than over the counter remedies?(C)

Another example:

• Does aromatherapy (I) calm (O) patients who are agitated (P) [In comparison to not treating it] (C)? 

As you can see, they don’t have to be in the exact order, but they do need to have the PICO components.

Confused by PICO?  Our EBP LibGuide should help clear up the process.

So what is Evidence Based Practice?

Evidence Based Practice, also known as EBP for short, is a way to make informed clinical decisions, allowing for the best medical care for the patient. It is a process by which medical practice is based on evidence you find in response to a question, in addition to the patient’s wishes and clinical expertise.

This process is broken up into five sections, known as the five A’s:

• Ask
• Acquire
• Appraise
• Apply
• Assess

You are treating a patient who recently had a hip fracture, and you are wondering if physical therapy will help lower their fall risk.

• Formulate this into a question using the PICO format. (Ask)

• Using our databases, such as CINAHL, NRC Plus, Cochrane Library or PubMed, look for literature related to your question.  (Acquire)

• Looking at the sources collected using critical appraisal skills (with the help of handy worksheets), determine whether the literature found is appropriately backed by research or not. (Appraise)

• After looking at the evidence that is trustworthy, can answer question, and use that answer to make a decision related to the patient, making sure to keep their desires in mind. (Apply)

• After you see the result of your decision, reflect back on the process and think about what you would do differently, what worked well, and what you have questions about after the process. (Assess)

Sound confusing? No problem! Our EBP LibGuide and article series in the following weeks should help clear up the process.