The document discusses evidence-based practice (EBP) and outlines the key steps in the EBP process. It defines EBP as integrating the best available research evidence, clinical expertise, and patient values. The 6 essential steps are: 1) ask, 2) acquire, 3) appraise, 4) apply, 5) audit, and 6) disseminate results. Higher levels of evidence like systematic reviews and randomized controlled trials provide stronger evidence than expert opinion. The document also reviews study designs and databases for finding evidence.

1. Sreeraj S R
Evidence Based Practice
Dr Sreeraj S R

2. Sreeraj S R
Definitions
 Evidence is basis for belief or disbelief; knowledge on which to
base belief
 Evidence-based practice (EBP) is 'the integration of best
research evidence with clinical expertise and patient values.
 As defined by the EBM Working Group “evidence-based medicine
de-emphasises intuition, unsystematic clinical experience and
pathophysiologic rationale as sufficient grounds for clinical
decision making and stresses the examination of evidence from
clinical research.”
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The EBP Process
 The essential steps of EBP are as follows:
• Step 1: Ask
• Step 2: Acquire
• Step 3: Appraise
• Step 4: Apply
• Step 5: Audit
 Later Added;
• Step 0: Cultivate a spirit of inquiry
• Step 6: Disseminate EBP results
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Cultivate a spirit of inquiry
 Spirit of inquiry is a persistent sense of curiosity that informs both
learning and practice.
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Ask
 Formulate a question that encompasses the clinical scenario, and
for which evidence can be found by searching the literature.
 To facilitate the search process, the question should include terms
that can be used in the literature search.
 The PICO strategy;
• Patient, Population or Problem.
• Intervention.
• Comparison.
• Outcome.
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ACQUIRE
 Search the peer-
reviewed literature for
research evidence
relevant to the clinical
question.
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Appraise
 Once articles are selected for review, they must be rapidly
appraised to determine which are most relevant, valid, reliable, and
applicable to the clinical question.
 Rapid critical appraisal uses three important questions to evaluate
a study’s worth;
1. What are the results and are they important?
2. Are the results of the study valid?
3. Will the results help me care for my patients?
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Apply
 Integrate the highest quality research evidence in combination
with clinical expertise and the patient’s preferences, within the
context of the practice environment, to make a clinical decision
(e.g. a strategy for treatment, diagnosis or management).
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Audit
 A regular assessment of the extent to which clinical decisions in the
practice were based on the best available research evidence.
 Just because an intervention was effective in a rigorously
controlled trial doesn’t mean it will work the same way in the
clinical setting.
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Disseminate EBP results
 Share EBP results/experiences with colleagues and other health
care organizations.
 This leads to needless duplication of effort, and perpetuates clinical
approaches that are not evidence based.
 Among ways to disseminate successful initiatives are EBP rounds in
your institution, presentations at local, regional, and national
conferences, and reports in peer-reviewed journals, professional
newsletters, and publications for general audiences.
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Levels of Evidence
 Levels of evidence (sometimes called hierarchy of evidence) are
assigned to studies based on the methodological quality of their
design, validity, and applicability to patient care.
 These decisions gives the "grade (or strength) of
recommendation."
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Levels of Evidence
LOE Description
I
Evidence from a systematic review or meta-analysis of all relevant RCTs
(randomized controlled trial) or evidence-based clinical practice guidelines based
on systematic reviews of RCTs or three or more RCTs of good quality that have
similar results.
II Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT).
III
Evidence obtained from well-designed controlled trials without randomization (i.e.
quasi-experimental).
IV Evidence from well-designed case-control or cohort studies.
V
Evidence from systematic reviews of descriptive and qualitative studies (meta-
synthesis).
VI Evidence from a single descriptive or qualitative study.
VII Evidence from the opinion of authorities and/or reports of expert committees.
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Evidence Pyramid
Meta-Analysis
Systematic Review
Critically Appraised Topic
Critically Appraised Articles
Randomized Controlled Trial
Cohort Study
Case-Control Study
Background Information/Expert
Opinion
Animal Research/Lab Studies
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Filtered resources
Unfiltered resources

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Types of Study Designs
• Meta-Analysis: A systematic review that uses quantitative methods to summarize the results.
• Systematic Review: Authors have systematically searched for, appraised, and summarised all of the medical literature
for a specific topic.
• Critically Appraised Topic: Authors evaluate and synthesize multiple research studies.
• Critically Appraised Articles: Authors evaluate and synopsize individual research studies.
• Randomized Controlled Trials: Include a randomized group of patients in an experimental group and a control
group.
• Cohort Study: following the research subjects forward for the outcome of interest.
• Case-Control Study: Identifies patients who have the outcome of interest (cases) and control patients without the
same outcome, and looks for exposure of interest.
• Background Information/Expert Opinion: A belief or conclusion held with confidence but not substantiated by
positive knowledge or proof.
• Animal Research/Lab Studies: Ideas turn into therapies and diagnostic tools, which then are tested with lab models
and animals.
• In Vitro Research: In the laboratory (outside the body). The opposite of in vivo (in the body). (NCI Dictionary of
Cancer Terms)
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Filtered Resources
 Cochrane Database of Systematic Reviews: Cochrane systematic
reviews are considered the gold standard for systematic reviews.
 Joanna Briggs Institute EBP Database: This database includes
systematic reviews, evidence summaries, and best practice
information sheets.
 Database of Abstracts of Reviews of Effects (DARE): DARE contains
reviews and details about systematic reviews on topics for which a
Cochrane review may not exist. Note: it only has abstracts.
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Unfiltered resources
 CINAHL Plus with Full Text: The CINAHL Plus with full text database is a
great place to search for different study types. To find systematic
reviews in CINAHL, select Systematic Review in the Publication Type box.
 MEDLINE with Full Text: The MEDLINE with Full Text database has a
more medical focus than CINAHL.
 TRIP Database:TRIP (Turning Research into Practice) is a freely-
accessible database that includes evidence-based synopses, clinical
answers, systematic reviews, guidelines, and tools.
 Google Scholar to find full text.
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Unfiltered resources
 PEDro: Physiotherapy Evidence Database (PEDro) of physical
therapy.
 PubMEd: U.S. National Library of Medicine (NLM): search service to
Medline and Pre-Medline (database of medical and biomedical
research).
 RehabDATA: Database of disability and rehabilitation research.
 Ovid: Database of health and life science research
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References
1. Evidence Based Practice(EBP) in Physiotherapy [Internet]. Physiopedia. 2012 [cited 2020 Aug
23]. Available from: https://www.physio-
pedia.com/Evidence_Based_Practice(EBP)_in_Physiotherapy
2. DOIG G. Evidence-based veterinary medicine: what it is, what it isn’t and how to do it.
Australian Veterinary Journal. 2003 Jul;81(7):412–5.
3. O’sullivan, Susan B. “Clinical Decision Making.” Physical Rehabilitation, by Susan B O’sullivan
et al., Philadelphia, F.A. Davis Co, 2014, pp. 17–19.
4. EBP Process | Evidence Based Practice in Optometry EBP Australia UNSW [Internet].
Eboptometry.com. 2012 [cited 2020 Aug 23]. Available from: https://tinyurl.com/y4p7ynpr
5. Melnyk, Bernadette Mazurek, et al. “Evidence-Based Practice: Step by Step: The Seven Steps
of Evidence-Based Practice.” AJN, American Journal of Nursing, vol. 110, no. 1, Jan. 2010, pp.
51–53. doi: 10.1097/01.naj.0000366056.06605.d2.
6. Research Hub: Evidence Based Practice Toolkit: Levels of Evidence [Internet]. Winona.edu.
2014 [cited 2020 Aug 23]. Available from: https://tinyurl.com/y2fgb6o6
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