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Building Evidence-Based Practice into All Areas of Dietetics Linda Farr RD/LD TDA Delegate 2007-2012  Owner Nutrition Asso...
Presentation Objectives <ul><li>Define Evidence-Based Dietetics Practice  </li></ul><ul><li>Discuss the benefits of using ...
 
Why is EBP important? <ul><li>Evidence-based practice will position the profession for improved reimbursement, recognition...
What is Evidence-Based Practice?
<ul><li>The use of  systematically reviewed scientific evidence  in making food and nutrition practice decisions  </li></u...
Key Considerations <ul><li>EBP is based on the  best available evidence  including research, national guidelines, policies...
Clinical Expertise Client values Clinical State Evidence  Adapted from: IOM Model for Evidence-Based Clinical Decisions AC...
Code of Ethics Supports EBP <ul><li>Principle 12: The dietetics practitioner practices dietetics based on evidence-based p...
Nutrition Care Process supports EBP March 2003
The Nutrition Care Process <ul><li>Middle Ring: </li></ul><ul><li>Characteristics of the RD & DTR: </li></ul><ul><li>Evide...
The Nutrition Care Process <ul><li>Relationship is based on: </li></ul><ul><li>Understanding the client’s values and incor...
Why use Evidence-Based Practice?
Explosion of Literature <ul><li>Over 10,000 new research articles added to MedLine annually </li></ul><ul><li>Estimated th...
Unmet Information Needs <ul><li>Questions from clients and other stakeholders are continuously being generated.  </li></ul>
Implementation Delays <ul><li>Research findings are often delayed in implementation. It can take 10 to 20 years for origin...
Need for Data on MNT Effectiveness <ul><li>There is limited data on MNT effectiveness beyond diabetes and lipid disorders....
Importance of collecting outcomes/data   <ul><li>Ensure progress of profession </li></ul><ul><li>Reimbursement </li></ul><...
Standardization of Practice <ul><li>There is a significant gap between best research evidence and application of evidence ...
Benefits of EBP <ul><li>Provides RDs and DTRs with an overarching foundation for patient care and customer service – a dis...
Personal Benefits of EBP <ul><li>Enhances our status on the health care team </li></ul><ul><li>Enhances our confidence – t...
Bottom Line Benefits <ul><li>EBP leads to: </li></ul><ul><li>Improved quality of care  </li></ul><ul><li>Increased patient...
The Development of EBP includes…. Five Fundamental Steps.
Evidence-Analysis Process Steps 1. Select topic & appoint  expert work group 2. Define questions and determine inclusion/ ...
Guidelines Methodologies Used http://www.cebm.net/ http://www.nhlbi.nih.gov / http://www.icsi.org/ Whenever possible we do...
Expert Workgroup <ul><li>Experts in field </li></ul><ul><li>Appointed by Evidence-based Practice Committee (oversight grou...
Evidence Analysts <ul><li>Experts in critically analyzing articles </li></ul><ul><li>Must have at least Master’s degree; m...
Step 4--Critical Appraisal of Each Article <ul><li>Completes worksheet </li></ul><ul><li>Completes quality criteria checkl...
Step 5--Evidence Summary <ul><li>Summarize articles into Overview Table </li></ul><ul><li>Information synthesized from art...
Evidence Summary : narrative summary Evidence Table
Step 6--Conclusion and Grade <ul><li>Drafted by Analyst </li></ul><ul><li>Reviewed, Approved and Graded by Work Group </li...
12/28/10 Conclusion Statement Grading Table
Guideline   Development
Step 9--Recommendations <ul><li>Drafted by Lead Analyst </li></ul><ul><li>Reviewed, Approved and Rated by Work Group </li>...
Recommendation   Examples <ul><li>Dietary sodium intake  should be limited to no more than 2300 mg sodium  (100 mmol) per ...
Recommendation on the EAL
Toolkit   Development
Features of Evidence-Based Toolkits   <ul><li>Set of companion documents for application of the practice guideline </li></...
Client Education Materials:  5-6 th  grade reading level
How do I implement  Evidence-Based Practice?
Access EBP Resources <ul><li>ADA’s Evidence Analysis Library   </li></ul><ul><li>www.adaevidencelibrary.com </li></ul><ul>...
Access Other EBP Resources <ul><li>Society for Critical Care Medicine Clinical Guidelines </li></ul><ul><li>Canadian Clini...
How do I practice when there’s no evidence? -- Lack of evidence is NOT the  same as lack of effectiveness
Action Steps-Client Care Settings <ul><li>Use critical thinking skills & clinical expertise </li></ul><ul><li>Make data-dr...
Is Evidence-Based Dietetics Practice for all ADA members?
A Role for All Members <ul><li>ADA Code of Ethics – Principles 12 & 13 </li></ul><ul><li>Understand the importance of EBP ...
A Role for All Members <ul><li>Practice based on up-to-date research </li></ul><ul><li>Use evidence-based methods </li></u...
Incorporate Research into EBP <ul><li>Develop research policy </li></ul><ul><li>Create job responsibility requirement </li...
Incorporate Research into EBP <ul><li>Train a manager in research skills </li></ul><ul><li>Create project accomplishment r...
Examples of Practice Areas for Research <ul><li>Food service </li></ul><ul><li>Community </li></ul><ul><li>Research  </li>...
EAL Tutorial   <ul><li>Check out the  EAL TUTORIAL   Complete the four 10-12 minute modules and receive 1 FREE CPE. www. e...
Evidence Analysis Training Workshops    <ul><li>VOLUNTEERS NEEDED!  If you know someone who is interested in becoming an e...
Decide to Make a Difference!
<ul><li>Questions? </li></ul>12/28/10
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Evidence Based Practice in All

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  • Thank you (to whoever did the introduction. Acknowledgements as needed.) Today, I would like to update you on just some of the many, many things that are going on at the American Dietetic Association to expand the leadership role of registered dietitians, DTRs and all ADA members in the wide and growing world of food and nutrition. Under the leadership of the House and the Board and with the hard work of ADA’s Headquarters Team, we have found solutions, taken advantage of opportunities and made progress that is nothing short of amazing by any measure.
  • EBP is an approach to health care where health practitioners use the best evidence possible to make decisions for individual patients. It involves complex and conscientious decision-making based not only on the available evidence but also on client characteristics, situations, and preferences. Emphasis is on systematically reviewed scientific evidence. But note that it must be applied when using professional expertise and knowledge of client values.
  • The Nutrition Care Process developed and published was intended to establish a routine thinking and action process that all RDs used as they provided nutrition services/care regardless of setting and type of patient. It is intended to be applicable to acute care setting, long term care setting, ambulatory setting, community and public health and nutrition education.
  • The Nutrition Care Process developed and published was intended to establish a routine thinking and action process that all RDs used as they provided nutrition services/care regardless of setting and type of patient. It is intended to be applicable to acute care setting, long term care setting, ambulatory setting, community and public health and nutrition education.
  • The Nutrition Care Process developed and published was intended to establish a routine thinking and action process that all RDs used as they provided nutrition services/care regardless of setting and type of patient. It is intended to be applicable to acute care setting, long term care setting, ambulatory setting, community and public health and nutrition education.
  • Explosion of literature--published at a rate individual clinicians can’t keep up with. EBP can be made in a focused and time efficient manner.
  • Quality improved through promoting practices that support the best outcomes
  • Quality improved through promoting practices that support the best outcomes
  • Topics and questions come from a variety of sources inlcuding member requests, practice group suggestions, ADA strategy, etc
  • The evidence summary includes of all the evidence supporting the conclusion statement and recommendation. Each evidence summary has the information presented in a narrative summary and an overview table (see overview table on next slide).
  • After analysis is complete and a set of conclusion statements developed to summarize the research on a topic, then a series of recommendations are formed to help the practitioner understand how to use this information. The series of recommendations, introduction and treatment algorithms make up a “Evidence-Based Nutrition Practice Guideline.” You can see from the rigor of the process that the evidence-based guidelines are more than just “guidelines based on evidence”.
  • This is an example of a recommendation- the structure is “what” the RD should do and “why” to do it. The recommendation is also given a rating, in this case Strong. The next slide shows the rating scale definitions and implications for practice.
  • Transcript of "Evidence Based Practice in All"

    1. 1. Building Evidence-Based Practice into All Areas of Dietetics Linda Farr RD/LD TDA Delegate 2007-2012 Owner Nutrition Associates of San Antonio 210-735-2402 [email_address]
    2. 2. Presentation Objectives <ul><li>Define Evidence-Based Dietetics Practice </li></ul><ul><li>Discuss the benefits of using EBP </li></ul><ul><li>Outline the EBP process </li></ul><ul><li>Discuss areas for EBP implementation </li></ul>
    3. 4. Why is EBP important? <ul><li>Evidence-based practice will position the profession for improved reimbursement, recognition, and quality services. </li></ul>
    4. 5. What is Evidence-Based Practice?
    5. 6. <ul><li>The use of systematically reviewed scientific evidence in making food and nutrition practice decisions </li></ul><ul><li>Achieved by integrating best available evidence with professional expertise and client values to improve outcomes </li></ul>Source: ADA Scope of Dietetics Framework Definition of Terms 2007 ADA Definition
    6. 7. Key Considerations <ul><li>EBP is based on the best available evidence including research, national guidelines, policies, consensus statements, expert opinion and quality improvement data. </li></ul><ul><li>EBP involves continuing evaluation of outcomes . </li></ul><ul><li>EBP involves complex and conscientious decision-making based not only on the available evidence but also on client/customer/community characteristics, situations, and preferences . </li></ul>
    7. 8. Clinical Expertise Client values Clinical State Evidence Adapted from: IOM Model for Evidence-Based Clinical Decisions ACP Journal Club, March/April 2002 Clinical Setting
    8. 9. Code of Ethics Supports EBP <ul><li>Principle 12: The dietetics practitioner practices dietetics based on evidence-based principles and current information. </li></ul><ul><li>Principle 13: The dietetics practitioner presents reliable and substantiated information and interprets controversial information without personal bias…… </li></ul>
    9. 10. Nutrition Care Process supports EBP March 2003
    10. 11. The Nutrition Care Process <ul><li>Middle Ring: </li></ul><ul><li>Characteristics of the RD & DTR: </li></ul><ul><li>Evidence-based Practice </li></ul><ul><li>Code of Ethics – Principles 12 & 13 </li></ul><ul><li>Critical Thinking </li></ul><ul><li>Skills/Competencies </li></ul><ul><li>Critical thinking </li></ul>
    11. 12. The Nutrition Care Process <ul><li>Relationship is based on: </li></ul><ul><li>Understanding the client’s values and incorporating them into the intervention plan </li></ul><ul><li>Client’s trust in our competence & our recommendations </li></ul>The NCP Core : Relationship between the RD-DTR & the client
    12. 13. Why use Evidence-Based Practice?
    13. 14. Explosion of Literature <ul><li>Over 10,000 new research articles added to MedLine annually </li></ul><ul><li>Estimated that clinicians must read ~20 articles a day to keep up! </li></ul>
    14. 15. Unmet Information Needs <ul><li>Questions from clients and other stakeholders are continuously being generated. </li></ul>
    15. 16. Implementation Delays <ul><li>Research findings are often delayed in implementation. It can take 10 to 20 years for original research to be put into clinical practice </li></ul><ul><ul><li>http://www. ahrq .gov/RESEARCH/trip2fac. htm </li></ul></ul>
    16. 17. Need for Data on MNT Effectiveness <ul><li>There is limited data on MNT effectiveness beyond diabetes and lipid disorders. </li></ul><ul><li>Relatively speaking, there is limited nutrition research; especially that targets the RD. </li></ul>
    17. 18. Importance of collecting outcomes/data <ul><li>Ensure progress of profession </li></ul><ul><li>Reimbursement </li></ul><ul><li>No data no research </li></ul><ul><li>No research no evidence </li></ul><ul><li>No evidence no basis for practice standards </li></ul><ul><li>Align our profession with other medical fields basing their practice on evidence </li></ul><ul><li>There is limited nutrition research </li></ul>
    18. 19. Standardization of Practice <ul><li>There is a significant gap between best research evidence and application of evidence to practice. Nutrition support is not always applied effectively or consistently, </li></ul><ul><li>despite available scientific evidence </li></ul><ul><li>that could be used to enhance </li></ul><ul><li>a given treatment protocol. </li></ul>
    19. 20. Benefits of EBP <ul><li>Provides RDs and DTRs with an overarching foundation for patient care and customer service – a disciplined approach for how we practice </li></ul><ul><li>Supports the relationship we have with our clients – they trust us & expect us to provide the “best care” </li></ul><ul><li>Facilitates use of the rapidly expanding body of nutrition knowledge </li></ul><ul><li>Reduces the gap between research and day-to day practice </li></ul>
    20. 21. Personal Benefits of EBP <ul><li>Enhances our status on the health care team </li></ul><ul><li>Enhances our confidence – the EAL is a great resource to support our recommendations to team members & payers </li></ul><ul><li>Provides a sense of satisfaction – Measuring outcomes allows us to see that we make a difference </li></ul><ul><li>Promotes effective time management </li></ul><ul><li>Promotes compliance with regulations for MNT, e.g. Medicare part B </li></ul><ul><li>Limits the basis for litigation </li></ul>
    21. 22. Bottom Line Benefits <ul><li>EBP leads to: </li></ul><ul><li>Improved quality of care </li></ul><ul><li>Increased patient safety </li></ul><ul><li>Decreased variation in practice </li></ul><ul><li>Efficient use of resources </li></ul><ul><li>Increased likelihood of achieving desired patient outcomes </li></ul><ul><li>Improved client, provider & payer satisfaction </li></ul><ul><li>Increased likelihood of coverage for MNT </li></ul>
    22. 23. The Development of EBP includes…. Five Fundamental Steps.
    23. 24. Evidence-Analysis Process Steps 1. Select topic & appoint expert work group 2. Define questions and determine inclusion/ exclusion criteria 3. Conduct literature review for each question 4. Analyze Articles/ Critical Appraisal 5. Overview Table & Evidence summary <ul><li>Develop conclusion </li></ul><ul><li>statement & assign grade </li></ul>7. Publish to online EAL
    24. 25. Guidelines Methodologies Used http://www.cebm.net/ http://www.nhlbi.nih.gov / http://www.icsi.org/ Whenever possible we don’t “reinvent the wheel.”
    25. 26. Expert Workgroup <ul><li>Experts in field </li></ul><ul><li>Appointed by Evidence-based Practice Committee (oversight group) </li></ul><ul><li>Balance of researchers and practitioners </li></ul><ul><li>Assists in question development </li></ul><ul><li>Review work of analysts and provide final approval </li></ul>
    26. 27. Evidence Analysts <ul><li>Experts in critically analyzing articles </li></ul><ul><li>Must have at least Master’s degree; many have PhD’s </li></ul><ul><li>Trained at ADA’s EA workshop </li></ul><ul><li>Mentored by ADA Staff and Lead Analysts </li></ul><ul><li>Read and analyze articles </li></ul>
    27. 28. Step 4--Critical Appraisal of Each Article <ul><li>Completes worksheet </li></ul><ul><li>Completes quality criteria checklist </li></ul><ul><li>Completes overview tables </li></ul><ul><li>Completes evidence summaries. </li></ul><ul><li>Most detailed information on EAL </li></ul><ul><li>Responsibility of analyst </li></ul><ul><li>Reviewed by lead analyst </li></ul><ul><li>Approved by workgroup </li></ul>
    28. 29. Step 5--Evidence Summary <ul><li>Summarize articles into Overview Table </li></ul><ul><li>Information synthesized from articles in to narrative evidence summary </li></ul><ul><li>Responsibility of Evidence Analyst </li></ul><ul><li>Reviewed by Lead Evidence Analyst </li></ul><ul><li>Reviewed and Approved by Work Group </li></ul>
    29. 30. Evidence Summary : narrative summary Evidence Table
    30. 31. Step 6--Conclusion and Grade <ul><li>Drafted by Analyst </li></ul><ul><li>Reviewed, Approved and Graded by Work Group </li></ul><ul><li>Bottom Line – Answer to question based on the science </li></ul><ul><li>Determined after research analyzed </li></ul><ul><li>Graded based on quality of supporting evidence </li></ul>
    31. 32. 12/28/10 Conclusion Statement Grading Table
    32. 33. Guideline Development
    33. 34. Step 9--Recommendations <ul><li>Drafted by Lead Analyst </li></ul><ul><li>Reviewed, Approved and Rated by Work Group </li></ul><ul><li>Translation of the evidence into a course of action for the RD </li></ul><ul><li>State “what to do” and “why” for the RD </li></ul><ul><li>Links to supporting analyzed evidence </li></ul><ul><li>Provides “transparency” </li></ul><ul><li>Conditional rating=for a specific population </li></ul><ul><li>Imperative rating=for a broad range </li></ul>
    34. 35. Recommendation Examples <ul><li>Dietary sodium intake should be limited to no more than 2300 mg sodium (100 mmol) per day. Reduction of dietary sodium to recommended levels lowers systolic blood pressure by approximately 2 - 8 mmHg. </li></ul><ul><li>Rating: Strong Imperative </li></ul><ul><li>If the critically ill ICU patient is hemodynamically stable with a functional GI tract, then EN is recommended over PN . Patients who received EN experienced less septic morbidity and fewer infectious complications than patients who received PN. In the critically ill patient, EN is associated with significant cost savings when compared to PN </li></ul><ul><li>Rating: Strong </li></ul><ul><li>Conditional </li></ul><ul><li>Strong, Imperative </li></ul>
    35. 36. Recommendation on the EAL
    36. 37. Toolkit Development
    37. 38. Features of Evidence-Based Toolkits <ul><li>Set of companion documents for application of the practice guideline </li></ul><ul><li>Disease/condition specific </li></ul><ul><li>Include: </li></ul><ul><ul><li>documentation forms </li></ul></ul><ul><ul><li>outcomes monitoring sheets </li></ul></ul><ul><ul><li>client education resources </li></ul></ul><ul><ul><li>case studies </li></ul></ul><ul><ul><li>MNT protocol for treatment of disease/condition </li></ul></ul><ul><li>Incorporate Nutrition Care Process/SL as the standard for care </li></ul><ul><li>Electronic downloadable purchase item </li></ul>
    38. 39. Client Education Materials: 5-6 th grade reading level
    39. 40. How do I implement Evidence-Based Practice?
    40. 41. Access EBP Resources <ul><li>ADA’s Evidence Analysis Library </li></ul><ul><li>www.adaevidencelibrary.com </li></ul><ul><ul><li>A compilation of systematic reviews on a variety of topics </li></ul></ul><ul><ul><li>Evidence-based Nutrition Practice Guidelines </li></ul></ul><ul><ul><li>Free ADA member benefit ! </li></ul></ul><ul><ul><li>(Cost to non-members-- $400) </li></ul></ul>
    41. 42. Access Other EBP Resources <ul><li>Society for Critical Care Medicine Clinical Guidelines </li></ul><ul><li>Canadian Clinical Guidelines </li></ul><ul><li>UpToDate.com Clinical Reference </li></ul><ul><li>Cochrane.org Database of Systematic Reviews </li></ul><ul><li>Zynxhealth.com Evidence </li></ul><ul><li>NHLBI Clinical Guidelines </li></ul>
    42. 43. How do I practice when there’s no evidence? -- Lack of evidence is NOT the same as lack of effectiveness
    43. 44. Action Steps-Client Care Settings <ul><li>Use critical thinking skills & clinical expertise </li></ul><ul><li>Make data-driven decisions </li></ul><ul><ul><li>Use existing data </li></ul></ul><ul><ul><li>Collect data when none exist </li></ul></ul><ul><ul><li>Evaluate programs and services to make improvements </li></ul></ul><ul><li>Contribute to the body of evidence through outcomes research </li></ul><ul><ul><li>Publish and/or present results of outcomes research </li></ul></ul>
    44. 45. Is Evidence-Based Dietetics Practice for all ADA members?
    45. 46. A Role for All Members <ul><li>ADA Code of Ethics – Principles 12 & 13 </li></ul><ul><li>Understand the importance of EBP to the profession </li></ul><ul><ul><li>Foundation for our Future </li></ul></ul><ul><ul><li>Respect from policy makers, payers and other providers </li></ul></ul><ul><li>Support other members in implementing & using EBP </li></ul><ul><ul><li>Role as Delegates - Affiliates and DPGs </li></ul></ul><ul><ul><li>Mentor Students and Dietetic Interns (CADE standards) </li></ul></ul><ul><ul><li>Students mentor your preceptor </li></ul></ul>
    46. 47. A Role for All Members <ul><li>Practice based on up-to-date research </li></ul><ul><li>Use evidence-based methods </li></ul><ul><li>Use evidence-based resources: </li></ul><ul><ul><li>ADA Position Papers </li></ul></ul><ul><ul><li>JADA articles – look for the EAL icon </li></ul></ul><ul><ul><li>On-line JADA – link to articles with EAL content </li></ul></ul><ul><li>Promote ADA’s use of EBP to others </li></ul>
    47. 48. Incorporate Research into EBP <ul><li>Develop research policy </li></ul><ul><li>Create job responsibility requirement </li></ul><ul><li>Insert research in evaluation process </li></ul><ul><li>Schedule time to work on research </li></ul><ul><li>Provide Collaborative Institutional Review Board (IRB) Training Initiative (CITI) training, CITI training program log-on to www. citiprogram .org </li></ul><ul><li>Provide Institutional Review Board support </li></ul>
    48. 49. Incorporate Research into EBP <ul><li>Train a manager in research skills </li></ul><ul><li>Create project accomplishment reporting system </li></ul><ul><li>Praise research accomplishments </li></ul><ul><li>Become a DBPRN member </li></ul><ul><li>Volunteer to be an ADA Evidence </li></ul><ul><li>Analyst </li></ul><ul><li>Develop a research culture </li></ul>
    49. 50. Examples of Practice Areas for Research <ul><li>Food service </li></ul><ul><li>Community </li></ul><ul><li>Research </li></ul><ul><li>Clinical inpatient care </li></ul><ul><li>Private practice </li></ul><ul><li>Long term care </li></ul><ul><li>Nutrition support </li></ul>12/28/10
    50. 51. EAL Tutorial <ul><li>Check out the EAL TUTORIAL   Complete the four 10-12 minute modules and receive 1 FREE CPE. www. eatright . org/ealtutorial </li></ul>
    51. 52. Evidence Analysis Training Workshops   <ul><li>VOLUNTEERS NEEDED!  If you know someone who is interested in becoming an evidence analyst, please ask them to submit an application.  </li></ul><ul><li>  </li></ul><ul><li>If you have questions, contact Toni Acosta at [email_address] .org </li></ul><ul><li>Benefits: </li></ul><ul><li>Professional Development </li></ul><ul><li>Professional Exposure </li></ul><ul><li>Continuing Education Hours </li></ul>
    52. 53. Decide to Make a Difference!
    53. 54. <ul><li>Questions? </li></ul>12/28/10
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