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Evidence based practice – need, classification, steps

Need of Evidence Based Practice

  • Increasing choices in healthcare and treatments .
  • Clients’ expectations of healthcare is increasing
  • Vast quantity of research literature of varied quality
  • Large number of sources of information
  • Much is out of date
  • Scientific quality varied
  • Limited time available for reading
  • Continuing education programs are helpful but not sufficient sources of information
  • Evidence based practice helps clinicians stay current

Evidence Based Health Care Includes

  • Evidence based medicine: is the process of systematically reviewing, appraising and using clinical research findings to aid the delivery of optimum clinical care to patients.
  • Evidence based practice: is one useful approach to improving the impact of practice in medicine, psychology, social work, nursing and allied fields.
  • Evidence based policy: is public policy informed by rigorously established objective evidence. It is an extension of the idea of evidence-based medicine to all areas of public policy. An important aspect of evidence-based policy is the use of scientifically rigorous studies such as randomized controlled trials to identify programs and practices capable of improving policy relevant outcomes.
  • Evidence based purchasing: Evidence-Based Purchasing attempts to minimize misuse and overuse and decrease costs, by applying rigorous scientific evidence of effectiveness to coverage policy in a more comprehensive manner than has been traditional practice.
  • Evidence based management: Evidence-based management entails managerial decisions and organizational practices informed by the best available scientific evidence.

Classification of Evidence Based Practice

Evidence-based guidelines: Evidence-based guidelines (EBG) is the practice of evidence-based medicine at the organizational or institutional level. This includes the production of guidelines, policy, and regulations. This approach has also been called evidence based healthcare.

Evidence-based individual decision making

Evidence-based individual decision (EBID) making is evidence-based medicine as practiced by the individual health care provider. There is concern that current evidence-based medicine focuses excessively on EBID.

Key steps of Evidence based practice

Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings. The practice of Evidence-Based Practice includes five fundamental steps.

Step 1: Asking the burning clinical question in the format that will yield the most relevant and best evidence (i.e. PICO Format)

Step 2: collecting the most relevant and best evidence to answer the clinical question including searching for systematic reviews/ meta-analysis or clinical practice guidelines

Step 3: Critically appraising the evidence that has been collected for its validity, relevance and applicability.

Step 4: integrating the evidence with ones clinical expertise, assessment of patients condition and available health care resources along with the patients preferences and values to implement a clinical decision

Step 5: Evaluating the change resulting from implementing the evidence in practice.

Steps of evidence based practice

  1. Asking a searchable, answerable question

The first step to accomplish this goal is to formulate the clinical issues to a searchable answerable question. There are two type of questions- Background questions and foreground questions.

Background questions are those that need to be answered as a foundation of asking the searchable answerable foreground questions.

Sackett and collegues(2000) describe background questions as that ask for general information about a clinical issue. It has two components: the starting place of questions(e.g. what, where,why, how) and outcome of questions (clinical diagnosis) e.g. How does drug Acetaminophen work to affect fever? The answer to this question can be found in a drug pharmacokinetic text.

Foreground questions are those that can be answered from scientific evidence about diagnosing, treating, and assisting patients with understanding their prognosis. These questions form on specific knowledge e.g. which is more effective in reducing fever in children Acitaminophen or Ibuprofen? Or which position is more effective in patients with ARDS – Prone or supine positiong?

The first question is based on the knowledge of how acetaminophen works but can be answered only by a study that compare the two listed medications.

The second question requires knowledge of how positioning changes hemodynamic but the two types of positioning must be compared in specific population of patients in order to answer it.

Posing the question using PICOT

Patient population of interest

Intervention of interest

Comparison of interventions

Outcome of interest



P The patients population or disease of interest e.g. age, gender, ethnicity, and certain disorders (e.g. Hepatitis)
I Intervention or range of intervention of interest e.g. exposure to diseases, risk behavior
C What you want to compare the intervention against e.g. no disease, placebo or no intervention/ therapy, absence of risk factors
O  Outcome of interest e.g. risk of disease, accuracy of diagnosis,rate of occurrence of adverse outcomes (death)
T  Select the time frame during which the impact of the intervention on the population is observed. The period could be brief — the first 24 hours after surgery — or extended — three months on a new medication. This step is optional because it may not apply in all clinical settings, but using a specific time frame makes it easier for to analyze the results. 


As for example, for patients of 65 years old (P) does the use of an influenza vaccine (I) reduces the future risk of Pneumonia (O) compared with patients who have not received the vaccine (C).