PRACTICAL MANUAL FOR EVIDENCE BASED PRACTICE

DR. BUSHRA MEHWISH (PT)

 LIST OF LABS

S.NO LAB TOPIC PAGE T.

NUMBER SIGNATURE

DR. BUSHRA MEHWISH (PT)

 WHAT ARE THE FIVE STEPS OF EBP?

The five steps of EBP – or 5 A’s – begin and end with the

patient

1. Ask patient-centred, focused questions about the

care of individuals, communities or populations.

2. Acquire the best available evidence relevant to your

question.

3. Appraise the evidence for validity and applicability

to the problem at hand.

4. Apply the evidence by engaging in collaborative

decision-making with individual patients and/or

groups. Appropriate decision-making integrates

the context, values and preferences of the care

recipient, as well as available resources, including

Professional expertise.

5. Assess the outcomes and disseminate results.

Because the evidence-based process informs future questions

and practice, it is useful to imagine it as a continuous cycle

DR. BUSHRA MEHWISH (PT)

DR. BUSHRA MEHWISH (PT)
 LAB#1

How do I ask well-formulated, answerable questions?

Questions are often only partly formulated, which makes finding answers in the
literature a challenge. Breaking down the question into its component parts and
restructuring it so that it is easier to find answers is an important first step in EBP.

Most clinical questions can be divided into four components, abbreviated as PICO:

 Patient, Population or Problem (P): What person or group of people are

you interested in? What is the specific clinical problem that you have in
mind?

 Intervention or Indicator (I): What is the treatment strategy, exposure or

test that you want to find out about in relation to the clinical problem?
 Comparator or Control (C): an alternative control strategy, exposure or
test.
 Outcome (O): What are you or the patient most concerned about
happening, or preventing happening?

A timeframe is often implicit in the clinical question, but it is sometimes useful to

add the timeframe explicitly, giving us

PICO(T):

 Time (T): What is the timeframe of the clinical question?

DR. BUSHRA MEHWISH (PT)

ASKING RELEVANT AND WELL-FORMULATED QUESTION

1) TAKE A DETAILED HISTORY OF ANY PATIENT

2) FORM A PICO QUESTION

3) MENTION THE CATEGORY OF THE QUESTION

4) ATTACH THE FORM

DR. BUSHRA MEHWISH (PT)

 LAB#2

HOW DO I FIND THE RELEVANT STUDY DESIGN?

Different types of questions require different study designs. Once you have
identified your question type, you will be better able to target the specific studies
that best answer your clinical question.

In each case, a systematic review of all relevant studies is preferable to an

individual study.

-While looking for the evidence, one should first look for relevant Systemic
review.

-If the relevant Systemic review cannot be found, search for individual studies

-For effects of intervention, best individual studies are Randomized

controlled trials (RCTs)

-Evidence of experiences can be obtained from qualitative research that typically

involves in-depth interviews, observation of behaviors, or focus groups.

-Evidence of prognosis can be obtained from longitudinal studies.

The preferred study type is the prospective cohort study, but sometimes good
prognostic information can be obtained from retrospective cohort studies or
clinical trials

-Evidence of the accuracy of diagnostic tests comes from cross-sectional

studies that compare the findings of the test of interest with a reference standard.

DR. BUSHRA MEHWISH (PT)

FINDING RELEVANT STUDY DESIGN ACCORDING TO
QUESTION CATEGORY

Identify different categories of PICO

I. You have a patient who has difficulty exercising due to COPD and
you wonder if pursed lip breathing techniques may improve their
endurance

-What is the PICO of this case?

-What is the question category of this case?

Intervention Prognosis experience

Diagnosis Aetiology/ harm

-What type of study will best answer this question?

_________________________________________________

DR. BUSHRA MEHWISH (PT)

 II. Your patient has a history of blood clots and after they came in to
your clinic with right calf discomfort and tightness, you're
concerned about DVT. You remember reading about the
limitations of duplex ultrasound and calfveins, and are wondering
if a d-dimer assay can help you rule out DVT more accurately.

-What is the PICO of this case?

-What is the question category of this case?

Intervention Prognosis experience

Diagnosis Aetiology/ harm

-What type of study will best answer this question?

_________________________________________________

DR. BUSHRA MEHWISH (PT)

III. Your female patient is concerned about her risk of developing
breast cancer. Her friend was recently diagnosed, and mentioned
that her smoking might have been a factor. Your patient and her
wife have lived together for 10 years, and while she doesn't smoke,
her partner does. Is she at an increased risk over someone without
daily exposure to second-hand smoke?

-What is the PICO of this case?

-What is the question category of this case?

Intervention Prognosis experience

Diagnosis Aetiology/ harm

-What type of study will best answer an diagnostic question?

_________________________________________________

DR. BUSHRA MEHWISH (PT)

STEP 2

DR. BUSHRA MEHWISH (PT)

 WHAT DOES BEST QUALITY EVIDENCE MEAN?

Internet search engines - e.g. Google/ yahoo - accumulate vast quantities of results,
the majority of which will be irrelevant to your search.

Consider the intended audience of the website. Is it a commercial website (.com)

whose purpose may be to sell you something? Or alternatively an organisation
(.org) whose purpose is to disseminate quality information?

Consider the objectivity of the website. Sites sponsored by a pharmaceutical

company, for example, may give a specific bias to the information provided.

How accurate and reliable is the information provided?

Almost anyone can publish a website, and the majority of sites are not peer
reviewed or externally evaluated.

Double check important facts against other sources.

How current is the information provided? Regularly updated websites are generally
more reliable sources of information.

TOO MUCH INFORMATION?

For clinical questions, it’s best to search custom search engines or databases as
these will get you to your answer more quickly and you can be more confident of
the quality of information provided.

WHAT IS A DATA BASE?

A database is a collection of peer-reviewed, high-quality literature on a specific

subject or set of related subjects.

DR. BUSHRA MEHWISH (PT)

 LAB#3

SEARCHING PUBMED

Fill the attached worksheet below.

1. Run a search for Knee OA rehabilitation. How many hits do you get?

2. How many hits do you get for Knee OA AND rehabilitation?

3. How many hits do you get for the last ten years?

4. How can you add more Limiters/ filters to your search to get specific results?

DR. BUSHRA MEHWISH (PT)

5. What are the default settings for Sorted? Formatted? Per page? (Look on the top
right)

6. Discuss the purpose of Boolean operators.

OR

AND

NOT

7. Run your Knee OA rehabilitation search again. Click Create alert. What does
this do?

DR. BUSHRA MEHWISH (PT)

8. What is the purpose of Save, email and Send? Write in one line only.

9. On your search results page, open Advanced. What are some other examples
you can search by instead of the default All Fields?

10. Attach a screenshot or draw a table as an evidence. Also write down the
number of the filtered results you got at the end.

DR. BUSHRA MEHWISH (PT)

 LAB#4

USING MESH

1. Use your own PICO question and analyze your research question into
aspects:
E.g. IS USING MASSAGE THERAPY BETTER THAN SPLINTING IN
IMPROVING PAIN IN PATIENTS WITH CARPAL TUNNEL
SYNDROME.

2. Write the original PICO format.

PROBLEM
INTERVENTION
COMPARASION
OUTCOME

3. What is your search strategy using PUBMED

a) MeSH terms:

#1

#2

#3

DR. BUSHRA MEHWISH (PT)

 b) Tiab-terms:
Most recent articles are less likely to be searched in MeSH. Can be
found in title, abstract and author key words.
Purpose is to find variations and synonym of the aspect word.

#1

#2

#3

4. Write down an example of truncation and wild card. Does any truncation or
wild card apply to your PICO search terms? Write them down.

DR. BUSHRA MEHWISH (PT)

 5. Combine the MeSH and tiab terms together using Boolean operator OR.

#1

#2

#3

6. How are you going to use the above combined terms in Pubmed? Explain in four
steps.

6. Attach the screenshot or make a table of how many results did you get at the
end. Also paste the URL of the page.

DR. BUSHRA MEHWISH (PT)

 LAB #5

IDENTIFYING ARTICLE TYPES

Using the topic of your PICO question, find the articles for the mentioned below
categories and add references:

1) RANDOMIZED CONTROLLED TRIAL

2) CASE REPORT

3) CROSS SECTIONAL

4) SYSTEMATIC REVIEW

5) META- ANALYSIS

6) CLINICAL GUIDELINE

DR. BUSHRA MEHWISH (PT)

Fill the worksheet attached below:

Look at the first article? What is its PMID? What does PMID stand for?

Open the article citation (or multiple ones if needed) and find an example of each of the
following:

 DOI
 Similar articles
 Cited by
 Publication type
 MeSH terms
 Cite
 Favorites

Is the article available at pubmed or freely available? If so, where can you access it?

DR. BUSHRA MEHWISH (PT)

Write 4 points on how do you identify Randomized controlled trial?

Write 4 points on how do you identify Case report?

Write 4 points on how do you identify cross sectional?

Write 4 points on how do you identify systematic review?

DR. BUSHRA MEHWISH (PT)

Write 4 points on how do you identify meta analysis?

Write 4 points on how do you identify clinical guideline?

DR. BUSHRA MEHWISH (PT)

 LAB#6
USING PEDRO

Fill the attached worksheet below:

1. Run a simple search for Osteoarthritis. How many hits do you get?

2. What is the purpose of “Display selected records” and how would you use
it? Briefly define.

3. Mention the correct sequence of the “Method” Pedro show when we search
for different form of evidence.

DR. BUSHRA MEHWISH (PT)

4. Run the search for Osteoarthritis on Advanced option again. How can you
add more Limiters/ filters to your search to get specific results? One word
answer only.

5. Paste the screenshot of the filters and limiters you have applied to retrieve
the articles on Osteoarthritis.

DR. BUSHRA MEHWISH (PT)

 LAB#7
USING GOOGLE SCHOLAR

Fill the attached worksheet below:

1. Discuss the purpose of the following:

My profile

My library

Create alert

2. Think of any topic and identify it’s key words.

For e.g. Health benefits of physical activity
Key words for physical activity: Exercise, work out, movement, walking

DR. BUSHRA MEHWISH (PT)

3. Run your selected search term. How many result do you get?

4. Using Boolean operator OR and AND how many hits now you get?

5. Use the boolean operator “ ”. What does that mean?

For. E.g. “health benefits of exercise”

6. Use the Boolean operator

allintitle

What does that mean?

DR. BUSHRA MEHWISH (PT)

7. Use the Boolean operator -
why we use this hyphen?

8. How do you access the author’s profile?

9. What does h-index and i10 index mean?

DR. BUSHRA MEHWISH (PT)

DR. BUSHRA MEHWISH (PT)
 How do I critically appraise the evidence?

Now that you have acquired evidence relevant to your question, it is necessary to
assess the quality, design and applicability of that evidence. Critical appraisal is the
process of carefully and systematically examining research to judge its
trustworthiness, its value and its relevance in a particular context.

Critical appraisal of the evidence involves three components.

Ask yourself:

 What is the PICO(T) of the study and is it close enough to the PICO(T) of
your clinical question?

 How well was the study done? Is the quality of the study good enough to
produce results that can be used to inform clinical decisions?

 What are the results and are they applicable to your patients and your
clinical setting?

DR. BUSHRA MEHWISH (PT)

 LAB#8
CRITICALLY APPRAISED TOPICS

https://www.cebm.ox.ac.uk/resources/ebm-tools/critical-appraisal-tools

Follow the following link to open critical appraisal tools.

1. Using randomized controlled trial sheet of appraisal, critically

appraise any RCT of your choice.

2. Attach the article and sheet .

DR. BUSHRA MEHWISH (PT)

DR. BUSHRA MEHWISH (PT)
 Why implement Evidence Based Practice?

To achieve a measurable improvement in:

 Quality of patient care

 Consistency of patient care
 Patient outcomes
 Cost containment

EBP is the accepted standard in modern healthcare systems

and increasingly recognised as a core clinical competency.

Internationally, several regulatory agencies have emphasised

the importance of using scientific evidence to guide clinical

decisions as a means of improving patient outcomes.

To improve patient outcomes, healthcare professionals

need to do more than acquire and appraise best evidence:

implementing evidence into practice is also required.

Implementing the evidence is a complex and active process

involving individuals, teams, systems and organisations, and

requires careful planning.

DR. BUSHRA MEHWISH (PT)

DR. BUSHRA MEHWISH (PT)
After an evidence-based practice change has been

implemented, the final step in the EBP cycle involves

assessing outcomes, disseminating results and making

further changes to practice as necessary or as prompted by

new evidence.

Rengerink et al.: “Tools measuring EBP behaviour of healthcare

professionals should assess the use of EBP steps in practice,

the performance of evidence-based clinical [procedures]

and/or the effect of EBP on patient outcomes.”20 All five

steps in the EBP process should be considered as part of any

assessment

DR. BUSHRA MEHWISH (PT)

ASSESS YOUR OWN EBP PERFORMANCE

Self-assessment should be an integral part of the continuous cycle of EBP. The

checklist below sets out some of the questions you might consider:

EBP SELF ASSESSMENT CHECK LIST

EBP STEP YES NO
Step 1 Am I asking any clinical
question?
sStep 1 Am I now able to
categorize my own question
into PICO?
Step 2 Do I now try to seek
evidence using data bases?
Step 2 Am I being able to access
to best evidence quickly?
Step 2 Do I use filters and limiters
to search quickly
Step 3 Do I critically appraise the
evidence
Step 4 Do I now implement the
evidence I read?
Step 5 Do I continue to assess the
quality of patient care and
emerging knowledge
relevant to the practice
change?

DR. BUSHRA MEHWISH (PT)

REFERENCES:

1) Leen, Brendan;Bell,Miriam & McQuillan, Patricia "Evidence-based practice: a practice manual"

Kilkenny. HSE 2014.

DR. BUSHRA MEHWISH (PT)