Evidence Based Practice (EBP)

Importance of Evidence Based Practice in nursing

Discuss about the Evidence Based Practice.

Evidence based practice is the type of nursing practice in which the current evidence are used in making decisions about patient care (Hall & Roussel, 2016).  It is a type of problem solving approach for the clinical learning. It is a systematic search and a type of critical appraisal of the evidences to find the answer to a clinical problem.

The EBP is a method which allows the medical practitioner to study journals, clinical guidelines and other resources based on the information, and then apply the findings to clinical practice. The evidence does not make the decision but it helps to support the process of patient care. It includes three important components which is needed to the practice, these are:

• Best research evidence
• Clinical expertise
• Patient values and preferences

These three components enhance the clinical outcomes and the quality of life. EBP generally requires new skills of clinical learning, which includes literature searching and the application of the evidence for the evaluation of the problem. The EBP is usually needed to generate the questions for the therapy, the diagnosis, and the prognosis of the diseases.

Key Steps in the EBP Process

• Framing the Clinical Question
• Finding the Evidence
• Assessing the Evidence
• Making the Clinical Decision

• Systemic Review: basic appraisal and assessment of research that endeavors to address an engaged inquiry utilizing the techniques proposed to lessen the probability of predisposition. The procedure of organizing a systemic review incorporates a search of the writing, also including unpublished examinations.
• Meta-Analysis: outline that joins a quantitative system for consolidating the results of various examinations into summary.
• Risk Assessment: It is a type of approach to deal with the threat to people and populations by natural contaminations.
• Decision Analysis: precise way to deal with basic leadership under vulnerability; includes recognition of every single accessible option and assessing the probabilities of potential results related with every option, esteeming every result, and, on that basis of the probabilities and qualities, a quantitative study is estimated.
• Economic Evaluation: relative analysis of the alternatives in terms of their expenses and results.
• Expert Panels and Consensus Conferences: examination of research contemplates and their importance to being healthy conditions, remedial and therapeutic strategies, arranging health policies, and group interventions. Ordinarily the boards of specialists are assembled by government offices or particular wellbeing associations.
• Practice Guidelines: methodically created to help expert and patients decisions about health care for particular clinical conditions; might be created by government offices, establishments, or by the gathering of master boards.

The structures and culture of the associations are the main barriers of evidence based practice. Components which are external to the individuals are of most important. Existing hierarchical structures is the proof of the existence of a generally respectful culture which stresses the routine in basic leadership are clearly mentioned in NHS.  Given this reality, associations should receive various methodologies to encourage and advance the utilization of proof by and by basic leadership.

Barriers to the utilization of research in clinical practice have been cited as often as possible. Studies have researched imaginable barriers to the selection of EBP by medical nurses. These examinations have distinguished regular obstructions over various nations. Truly, the essential boundaries to the utilization of research have been connected to the support given by the association in which medical attendants work, the medical attendants’ examination esteems and aptitudes, the nature of research, and how the exploration is imparted or displayed.

The key facilitating factors for EBP include support, encouragement, and recognition by the management and administration. Numerous facilitators of research utilization have been recognized in the articles. These facilitators incorporate administrative and associate help, accessibility of time to audit and execute examine discoveries, accessibility of significant research, partners’ help, strong arrangements, and preparing openings. Barriers and facilitators to inquire about usage were classified into authoritative variables, singular components, communicational elements, and nature of research (Harvey & Kitson, 2015). 

Components and key steps in the EBP process

PICO – The PICO is a technique to study evidence based practice and makes a framework to find the answer of a health care question. The PICO stands for

• P – Patient, problem or population
• I – Intervention
• C – Comparison or control
• O – Outcome

PICO – Does the platelet transfusion indications in pediatric cancer patients works or not?

P: population (pediatric cancer patients) (aged less than 18)

I: Intervention strategy: blood components transfusion (platelets, red blood cells, cryoprecipitate) irradiated products, leukocyte-depleted products, platelet aphaeresis.

Comparison: Platelet transfusion is suitable or not

Outcomes: indications for transfusions in the specified population.

Transfusion therapy is the mostly used now-a-days for the treatment of pediatric cancer. In this paper the age group which was taken into consideration for addressing is under 18. Despite the knowledge of the principles of immunology which maintains the transplants of a tissue by minimizing the transfusion therapy risks.  Additional evidence is needed to determine the most appropriate instance for using transfusion therapy in pediatric cancer patients.

The first step was searching for evidence-based clinical practice guidelines in Pub Med, CINAHL, MEDLINE, WHO – World Health Organization, Google scholar, National Cancer Institute Journal and many more.

Keywords that were used for the search are:

“Infant” OR “Child, “Adolescent” OR “childhood” OR “Pediatrics” OR “Minor”

AND

“Blood Component Transfusions” OR “Erythrocyte Transfusions” OR “Red Blood Cell Transfusion” OR “Platelet Transfusions” OR “Blood Component Transfusion” OR “Aphaeresis”

AND

“Tumors” OR “Neoplasm” OR “Tumor” OR “Cancer” OR “Neoplasm” OR “Neoplasm”

AND

“Random research design” OR “Evaluation Studies” OR follow-up studies OR prospective studies OR cross-over studies OR control OR prospective OR volunteer AND “evidence-based medicine”

A key rule in transfusion treatment expresses that the reason for anaemia might be recognized before RBC transfusion. Moreover, the choice to transfusion of RBC must depend on the symptoms instead of by the hemoglobin levels and remember that RBC transfusion is just suggested in the patients who are suffering from leukemia and unable to manage normal range of hemoglobin. There are two basic therapies for this disease. The prohibitive methodology that demonstrates transfusion is based on two principles: haemoglobin level below 8g/dL and proof of hemodynamic degeneration. The second approach is liberal and sets up more elevated amounts of hemoglobin ignoring the hemodynamic effect.

The result of this survey suggests the prohibitive methodology, to diminish the extent of transfused patients and the measure of RBC transfused, with no effect on morbidity or term of staying at hospital. The conclusion is thus stated that the advantages of reducing transfusions are more than the threat of RBC transfusion. Platelet transfusion support is resolved on the principle of two methodologies: a prophylactic technique described by recording platelet count to keep the threat of haemorrhage; and the therapeutic methodology that suggests platelet transfusion when bleeding causes.

Barriers of evidence based practice

In the case of platelet transfusions, allo-immunization might be avoided, A with respect to ABO platelets. Un-identical ABO platelet organization is a satisfactory transfusion when platelet count deficiencies are an issue, or when the patient requires HLA platelets that are not ABO coordinated. In RH D negative patients, concentration is to be negative, especially in ladies. The platelet prescribed volume is 10-20 ml/kg for kids under 15 kg and one unit for aphaeresis for patients more than 15 kg, 11 at an implantation rate of 20-30 cc/kg/h.

Kaufman et al., 2015, told that Platelet prophylaxis, as compared with a therapeutic platelet transfusion strategy, reduces but does not eliminate the risk for bleeding in hospitalized patients with therapy-induced hypo-proliferative thrombocytopenia. However, low-dose platelets must be transfused more often because they provide a lower platelet increment.

New et al., 2014, studied and reported that pediatric RBC transfusion practice has demonstrated significant variation in pre-transfusion Hb, frequent prescribing in units rather than milliliters, and a high proportion of single transfusions during admissions. Future education and research should target transfusion triggers and prescription volumes for children in all clinical areas.

Ruccione et al., 2014, examine 75 patients up to age 14, who are receiving PRBC transfusions and conclude that excessive iron content may occur in children and also in the adolescent during the treatment of PRBC transfusion.

Kumar et al., 2015, had done 17 RCTs and 55 observational studies, and concluded that prophylactic transfusion results in bleeding as compared to therapeutic transfusion is not so different. Results observed do not show a much difference in bleeding in patients.

Sloan & Parker, 2016, stated that Prophylactic platelet transfusions for children undergoing cancer treatment are not well characterized and require further investigation. The effect of routine platelet transfusion in pediatric cardiac surgery on postoperative outcome is unknown. The determination of platelet count threshold before various invasive procedures and clinical settings should be studied.

Pardo-González, Linares & Torres, 2016, studied 56 journals concluded that Red blood cells transfusion is done by restrictive strategy in which prophylactic platelet transfusion is done. Cryoprecipitate is recommended when fibrinogen levels fall below 100 mg / dL, and indications on irradiated blood products were established. It resulted that transfusion of cryoprecipitate is very limited.

Havens et al., 2015, queried at 2 tertiary academic hospitals about the EGS, and got the results that despite of similar blood loss; EGS patients received higher rates of intra-operative blood product transfusion, which was independently associated with major complication.

Facilitators of evidence based practice

Solh et al., 2016, done a retrospective cohort study at two different hospitals and evaluated two groups: study group, patients with oncology receiving chemotherapy and control group, patients without cancer. They found that alloimmunization frequency was low and it is not possible to determine an association between chemotherapy and alloimmunization due to the low event rate.

Werner & Ramirez, 2017, discuss five topics, handoff communication, identification and early treatment of sepsis and three approaches to disease prevention or mitigation-influenza vaccination, time to antibiotics in immune compromised patients, and iron chelation therapy for patients receiving erythrocyte transfusion. Each of these is relevant to pediatric hematology/oncology patients and providers and demonstrates how quality improvement methods lead to a higher delivery rate for evidence-based care.

Fielding, Grigg, & Booth, 2016, although a number of stem cell transplantation (HSCT) patients need intensive care to treat life threatening complications, many of them are hard to be improved. It might be caused by complicated conditions consist of multiple organ failure or immunodeficiency.

Conclusion

Thus it can be conclude that the platelet transfusion is very risky in pediatric cancer patients, as it leads to heavy bleeding which cause anaemia.

References

Hall, H. R., & Roussel, L. A. (2016). Evidence-based practice. nursing Jones & Bartlett Publishers.

Harvey, G., & Kitson, A. (2015). Implementing evidence-based practice in healthcare: a facilitation guide. Routledge.

Kaufman, R. M., Djulbegovic, B., Gernsheimer, T., Kleinman, S., Tinmouth, A. T., Capocelli, K. E., … & Mintz, P. D. (2015). Platelet transfusion: a Clinical Practice Guideline From the AABB Platelet transfusion: a clinical practice guideline from the AABB. Annals of internal medicine, 162(3), 205-213.

New, H. V., Grant?Casey, J., Lowe, D., Kelleher, A., Hennem, S., & Stanworth, S. J. (2014). Red blood cell transfusion practice in children: current status and areas for improvement? A study of the use of red blood cell transfusions in children and infants. Transfusion, 54(1), 119-127.

Ruccione, K. S., Wood, J. C., Sposto, R., Malvar, J., Chen, C., & Freyer, D. R. (2014). Characterization of transfusion-derived iron deposition in childhood cancer survivors. Cancer Epidemiology and Prevention Biomarkers, cebp-0292.

Kumar, A., Mhaskar, R., Grossman, B. J., Kaufman, R. M., Tobian, A. A., Kleinman, S., … & Djulbegovic, B. (2015). Platelet transfusion: a systematic review of the clinical evidence. Transfusion, 55(5), 1116-1127.

Sloan, S. R., & Parker, R. I. (2016). Current status of platelet transfusion in pediatric patients. Transfusion medicine reviews, 30(4), 230-234.

Pardo-González, C. A., Linares, A., & Torres, M. (2016). Transfusion therapy evidence-based recommendations for the pediatric cancer patient. Colombian Journal of Anesthesiology, 44(2), 151-160.

Havens, J. M., Do, W. S., Kaafarani, H., Mesar, T., Reznor, G., Cooper, Z., … & Haider, A. H. (2016). Explaining the excess morbidity of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassively transfused patients. The American Journal of Surgery, 211(4), 656-663.

Solh, Z., Athale, U., Arnold, D. M., Cook, R. J., Foley, R., & Heddle, N. M. (2016). Transfusion?related alloimmunization in children: epidemiology and effects of chemotherapy. Vox sanguinis, 111(3), 299-307.

Werner, E. J., & Ramirez, D. E. (2017). Implementation of Evidence-Based Care in Pediatric Hematology/Oncology Practice. In Patient Safety and Quality in Pediatric Hematology/Oncology and Stem Cell Transplantation (pp. 253-275). Springer International Publishing.

Fielding, K., Grigg, A., & Booth, D. (2016). Analysis of Prognostic Factors of Hematopoietic Stem Cell Transplantation Patients Admitted to ICU. Abstracts/Biol Blood Marrow Transplant, 22(S19eS481), S19eS481.

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