- Evidence-based practice uses systematically reviewed scientific evidence to make nutrition practice decisions by integrating best available evidence, professional expertise, and client values. - Implementing evidence-based practice provides benefits like improved quality of care, increased patient safety, and enhanced professional status and confidence. - The evidence-based practice process involves defining questions, reviewing literature, analyzing evidence, developing conclusions and recommendations, and disseminating results.

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. Presentation Objectives Define Evidence-Based Dietetics Practice Discuss the benefits of using EBP Outline the EBP process Discuss areas for EBP implementation

4. Why is EBP important? Evidence-based practice will position the profession for improved reimbursement, recognition, and quality services.

5. What is Evidence-Based Practice?

6. The use of systematically reviewed scientific evidence in making food and nutrition practice decisions Achieved by integrating best available evidence with professional expertise and client values to improve outcomes Source: ADA Scope of Dietetics Framework Definition of Terms 2007 ADA Definition

7. Key Considerations EBP is based on the best available evidence including research, national guidelines, policies, consensus statements, expert opinion and quality improvement data. EBP involves continuing evaluation of outcomes . EBP involves complex and conscientious decision-making based not only on the available evidence but also on client/customer/community characteristics, situations, and preferences .

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

9. Code of Ethics Supports EBP Principle 12: The dietetics practitioner practices dietetics based on evidence-based principles and current information. Principle 13: The dietetics practitioner presents reliable and substantiated information and interprets controversial information without personal bias……

10. Nutrition Care Process supports EBP March 2003

11. The Nutrition Care Process Middle Ring: Characteristics of the RD & DTR: Evidence-based Practice Code of Ethics – Principles 12 & 13 Critical Thinking Skills/Competencies Critical thinking

12. The Nutrition Care Process Relationship is based on: Understanding the client’s values and incorporating them into the intervention plan Client’s trust in our competence & our recommendations The NCP Core : Relationship between the RD-DTR & the client

13. Why use Evidence-Based Practice?

14. Explosion of Literature Over 10,000 new research articles added to MedLine annually Estimated that clinicians must read ~20 articles a day to keep up!

15. Unmet Information Needs Questions from clients and other stakeholders are continuously being generated.

16. Implementation Delays Research findings are often delayed in implementation. It can take 10 to 20 years for original research to be put into clinical practice http://www. ahrq .gov/RESEARCH/trip2fac. htm

17. Need for Data on MNT Effectiveness There is limited data on MNT effectiveness beyond diabetes and lipid disorders. Relatively speaking, there is limited nutrition research; especially that targets the RD.

18. Importance of collecting outcomes/data Ensure progress of profession Reimbursement No data no research No research no evidence No evidence no basis for practice standards Align our profession with other medical fields basing their practice on evidence There is limited nutrition research

19. Standardization of Practice There is a significant gap between best research evidence and application of evidence to practice. Nutrition support is not always applied effectively or consistently, despite available scientific evidence that could be used to enhance a given treatment protocol.

20. Benefits of EBP Provides RDs and DTRs with an overarching foundation for patient care and customer service – a disciplined approach for how we practice Supports the relationship we have with our clients – they trust us & expect us to provide the “best care” Facilitates use of the rapidly expanding body of nutrition knowledge Reduces the gap between research and day-to day practice

21. Personal Benefits of EBP Enhances our status on the health care team Enhances our confidence – the EAL is a great resource to support our recommendations to team members & payers Provides a sense of satisfaction – Measuring outcomes allows us to see that we make a difference Promotes effective time management Promotes compliance with regulations for MNT, e.g. Medicare part B Limits the basis for litigation

22. Bottom Line Benefits EBP leads to: Improved quality of care Increased patient safety Decreased variation in practice Efficient use of resources Increased likelihood of achieving desired patient outcomes Improved client, provider & payer satisfaction Increased likelihood of coverage for MNT

23. The Development of EBP includes…. Five Fundamental Steps.

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 Develop conclusion statement & assign grade 7. Publish to online EAL

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.”

26. Expert Workgroup Experts in field Appointed by Evidence-based Practice Committee (oversight group) Balance of researchers and practitioners Assists in question development Review work of analysts and provide final approval

27. Evidence Analysts Experts in critically analyzing articles Must have at least Master’s degree; many have PhD’s Trained at ADA’s EA workshop Mentored by ADA Staff and Lead Analysts Read and analyze articles

28. Step 4--Critical Appraisal of Each Article Completes worksheet Completes quality criteria checklist Completes overview tables Completes evidence summaries. Most detailed information on EAL Responsibility of analyst Reviewed by lead analyst Approved by workgroup

29. Step 5--Evidence Summary Summarize articles into Overview Table Information synthesized from articles in to narrative evidence summary Responsibility of Evidence Analyst Reviewed by Lead Evidence Analyst Reviewed and Approved by Work Group

30. Evidence Summary : narrative summary Evidence Table

31. Step 6--Conclusion and Grade Drafted by Analyst Reviewed, Approved and Graded by Work Group Bottom Line – Answer to question based on the science Determined after research analyzed Graded based on quality of supporting evidence

32. 12/28/10 Conclusion Statement Grading Table

33. Guideline Development

34. Step 9--Recommendations Drafted by Lead Analyst Reviewed, Approved and Rated by Work Group Translation of the evidence into a course of action for the RD State “what to do” and “why” for the RD Links to supporting analyzed evidence Provides “transparency” Conditional rating=for a specific population Imperative rating=for a broad range

35. Recommendation Examples 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. Rating: Strong Imperative 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 Rating: Strong Conditional Strong, Imperative

36. Recommendation on the EAL

37. Toolkit Development

38. Features of Evidence-Based Toolkits Set of companion documents for application of the practice guideline Disease/condition specific Include: documentation forms outcomes monitoring sheets client education resources case studies MNT protocol for treatment of disease/condition Incorporate Nutrition Care Process/SL as the standard for care Electronic downloadable purchase item

39. Client Education Materials: 5-6 th grade reading level

40. How do I implement Evidence-Based Practice?

41. Access EBP Resources ADA’s Evidence Analysis Library www.adaevidencelibrary.com A compilation of systematic reviews on a variety of topics Evidence-based Nutrition Practice Guidelines Free ADA member benefit ! (Cost to non-members-- $400)

42. Access Other EBP Resources Society for Critical Care Medicine Clinical Guidelines Canadian Clinical Guidelines UpToDate.com Clinical Reference Cochrane.org Database of Systematic Reviews Zynxhealth.com Evidence NHLBI Clinical Guidelines

43. How do I practice when there’s no evidence? -- Lack of evidence is NOT the same as lack of effectiveness

44. Action Steps-Client Care Settings Use critical thinking skills & clinical expertise Make data-driven decisions Use existing data Collect data when none exist Evaluate programs and services to make improvements Contribute to the body of evidence through outcomes research Publish and/or present results of outcomes research

45. Is Evidence-Based Dietetics Practice for all ADA members?

46. A Role for All Members ADA Code of Ethics – Principles 12 & 13 Understand the importance of EBP to the profession Foundation for our Future Respect from policy makers, payers and other providers Support other members in implementing & using EBP Role as Delegates - Affiliates and DPGs Mentor Students and Dietetic Interns (CADE standards) Students mentor your preceptor

47. A Role for All Members Practice based on up-to-date research Use evidence-based methods Use evidence-based resources: ADA Position Papers JADA articles – look for the EAL icon On-line JADA – link to articles with EAL content Promote ADA’s use of EBP to others

48. Incorporate Research into EBP Develop research policy Create job responsibility requirement Insert research in evaluation process Schedule time to work on research Provide Collaborative Institutional Review Board (IRB) Training Initiative (CITI) training, CITI training program log-on to www. citiprogram .org Provide Institutional Review Board support

49. Incorporate Research into EBP Train a manager in research skills Create project accomplishment reporting system Praise research accomplishments Become a DBPRN member Volunteer to be an ADA Evidence Analyst Develop a research culture

50. Examples of Practice Areas for Research Food service Community Research Clinical inpatient care Private practice Long term care Nutrition support 12/28/10

51. EAL Tutorial Check out the EAL TUTORIAL Complete the four 10-12 minute modules and receive 1 FREE CPE. www. eatright . org/ealtutorial

52. Evidence Analysis Training Workshops VOLUNTEERS NEEDED! If you know someone who is interested in becoming an evidence analyst, please ask them to submit an application. If you have questions, contact Toni Acosta at [email_address] .org Benefits: Professional Development Professional Exposure Continuing Education Hours

53. Decide to Make a Difference!

54. Questions? 12/28/10