Steps in Evidence Based Practice

The goal of this section is to provide a guideline on how to implement Evidence Based Practice (EBP).

Key Steps in Evidence Based Practice

There are five essential steps of evidence-based medicine:[1]

Step 1: Ask- Converting the need for information into an answerable question.

Step 2: Acquire-Gathering the best information/evidence available in the medical and scientific literature to answer that question.

Step 3: Appraise- Critically appraising the information or evidence for it is validity (closeness to facts), impact (size of the effect) and applicability (how useful it is in our clinical practice).

Step 4: Apply Integrating the critical appraisal with our clinical expertise and patient’s unique values, circumstances and preferences.

Step 5: Assess: Evaluating our effectiveness and efficiency in executing steps 1-4 and considering ways to improve then for next time.

Asking Structured and Focused Clinical Questions

The first step in the Evidence-Based Practice (EBP) process is to determine the need for information or need for the answers pertaining to your inquiry or subject of interest, and then translating this need for information into answerable clinical questions. To develop this ability of formulating a precise, structured and answerable clinical questions is one of the most important tasks in the process of using EBP in answering research and clinical questions.

• The questions chosen should be relevant to the problem selected.

• The question should be formulated in a way that facilitates searching for the answers with ease, allows you to locate best evident quickly and efficiently. [2] [3] [4]

EBP experts recommend using a PICO Framework or PICO Model in formulating a clinical question.

Finding the Evidence: Using PICO model

What is a PICO model? The PICO Model is a format to help define your information need into a clinical question. By organizing a clinical question using PICO, the searcher can use the specific terms to aid in finding clinically relevant evidence in the literature.[5]

When using EBM, always start with a question that can be modeled using the PICO method.

PICO is a format for developing a good clinical research question prior to starting one’s research. It is a mnemonic used to describe the four elements of a sound clinical foreground question. The question needs to identify the patient or population we intend to study, the intervention or treatment we plan to use, the comparison of one intervention to another (if applicable) and the outcome we anticipate.

These make up the four elements of the PICO model:

P: Problem, Population, or Patient: This identifies who is the patient, or what population is being studied? What are the characteristics of patient or population? What is the problem or what is the condition or disease you are interested in?

I: Intervention or Issue: This refers to the issue that the researcher is interested in. It can refer to the disease that a researcher is interested in studying. It can refer to an intervention (drug or treatment) that the researcher is interested in to see if it is appropriate for the disease of medical condition of interest. It can also refer to diagnostic test or assessment test that a researcher is interested in potentially using to evaluate the patient. This is the basis of the questions(s) that a researcher seeks to resolve in a research study.

C: Comparison: In Clinical research, subjects are usually divided into two groups. One group is subjected to intervention (medication or treatment). The other group is a control or baseline group, receiving either a placebo or sham treatment or the treatment that is the standard of care or otherwise no treatment at all. These two groups are then compared to see if the group receiving the intervention show a significant change or improvement over the control group.

O: Outcome: What was the outcome of the study in related to the patient of subject of interest? Did the intervention improve the patient outcomes or did the outcome remain same or worse when compared to the control group?

[1] Guyatt, G.H., Haynes, R.B., Jaeschke, R.Z., & Cook, D.J. (2000). Users' guides to the medical literature: XXV. evidence-based medicine: principles for applying the users' guides to patient care. JAMA, 284, 1290-1296. doi: http://dx.doi.org/10.1001/jama.284.10.1290

[2] Module 1: Ask - Evidence-Based Practice in Health - UC Library Guides at University of Canberra (libguides.com)

[3] Geddes, J. (1999). Asking structured and focused clinical questions: essential first step of evidence-based practice. Evidence Based Mental Health, 2, 35-36 doi: doi: http://dx.doi.org/10.1136/ebmh.2.2.35

[4] Richardson, W. (1998). Ask, and ye shall retrieve [EBM note]. Evidence-Based Medicine, 3:100−1.

[5] Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making, 7, 16. doi: http://dx.doi.org/10.1186/1472-6947-7-1