CMS, through OASIS C, is guiding the home health industry toward evidenced-based practices. These practices require the identification of a solid literature review with established clinical integrated expertise that includes the patient’s cultural, socioeconomic, and educational background.
An organized plan with expected outcomes is being mandated in this contemporary health industry. There is a need for information directed toward diagnosis, prognosis and disease prevention. Traditional sources; such as textbooks no longer meet the fast paced knowledge accumulation of today. Time treating patients has become expensive and limited. Current up to date, tested knowledge is vital to maintain diagnostic/practitioner skills and quality outcomes.
There are specific steps recommended to achieve evidenced-based practices:
1. Select a topic or a clinical question is asked:
Problem-focused such as identified through Quality improvement, benchmarking, and recurrent data
Knowledge-focused, based on research from conferences or journals
2. Form a Team
3. Have a well defined process for evidence retrieval . A common paradigm used today is PICO; a) who is the Population, b) what is the intended Intervention, c) is there a Comparison intervention or Control group, d) what is the desired outcome.
4. Classify the literature as either conceptual (theory and clinical articles) or data driven (systemic research reviews). The data is derived from clinical trials, meta analysis, and national rated articles.
5. The information should then be interpreted and critically evaluated as to application, validity, and expected outcome. Apply the evidence.
6. The decision to change practice considers the relevance of the evidence and the consistency in research findings, looking for ways to improve or modify the application. Qualitative research is being used more frequently in this regard.
To further encourage evidence based practice in home health care, CMS is seeking standardized tools to be used in the OASIS C Integrated Assessment. These tools, such as the Braden and Norton used for skin integrity assessment are readily recognizable, not only in home health but, in other levels of care in health care. Thus, if the patient is transferred to another care level, a reliability of skin assessment can be maintained because the tool is a recognizable standardized instrument.
Evidenced-based processes are also being encouraged because the patient population is requiring more from their health care practitioners, having increased knowledge, empowerment, and access to information, and expecting predictable outcomes from care.
Evidenced – based practice is not a new concept. It is documented in Daniel 1:6 in the Bible where “controlled trials” were used in comparing dietary benefits for families. In the 1700s, James Lind used randomized trials to show that scurvy could be prevented by citrus fruit. In the 1800s, Semmelweis studied the transmittal of puerperal fever, an infection occurring in females post partum. Semmelweis was able to document that physicians and medical students would perform aurtopsies, and in the same clothing (dirty aprons and all), frequently, merely wiping their bloody hands on their aprons, then perform gynecologic examinations on the new mothers. By instituting hand washing with chloride of lime prior to examining the females, the infection rate dropped over 80%. Evidence-based practice is soundly grounded in research.
The Agency for Healthcare Research and Quality, the National Guideline Clearinghouse, and the Evidence-based Medicine Resource Center are just a few organizations involved with the practices of EBP. Discipline specific associations impacting medicine, nursing, and the rehabilitation oriented therapies are also actively involved in research.
Evidence-based practice in nursing is seen with a new model called Guided Care Nursing (GON) being researched in Maryland, to examine seven chronic care interventions, including disease management, patient self management, case management, lifestyle modification and geriatric management. The nurses involved in the program have completed a specific educational program that looked to enhance their skills in these areas. Predictive modeling software was used to identify patients for the study. The study has been so positive further clinical trials have been funded..
Researchers at the University of California San Francisco Medical Center have undertaken a prospective study to look at incongruencies in practice standards across specific disease lines.
Evidence Based Practice is now being applied in the health care education and training setting. Data has been evaluated on over 109 medical schools in the country.
Government has a strong belief that evidence based practice will positively impact both on the quality and financial outcomes in health care. It is an exciting time in health care. It is truly the time for strong data driven practice.
Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality