General objective:

 At the end of this class students will be acquainted with evidence based practice in
cardiovascular & thoracic nursing.

Specific objective:

 Define evidence based practice.

 Explain the steps of evidence based practice.

 Discuss about recent evidence based practice in in cardiovascular & thoracic nursing.

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INTRODUCTION

Evidence-based practice (EBP) attempts to cover gaps in patient care for better outcomes and
a healthier population by blending clinical experience and evidence. Further, it takes into
account patient values to promote better patient experiences. Evidence-based research offers
nurses a unique opportunity to expand their roles and transform patient care. This practice
requires nurses to utilize critical thinking-, appraisal- and decision-making skills. Nurses
must learn to efficiently analyze research to determine its relevance to a particular patient.

EVIDENCE BASED PRACTICE:

 Ervin (2002) proposed this definition of EBP for

nursing: “Evidence-based nursing practice is practice
in which nurses make clinical decisions using the
best available research and other evidence that is
reflected in approved policies, procedures, and
clinical guidelines in a particular healthcare agency”
 The EBP process is collaborative and involves all
members of the health care team.
 Steps of the Evidence-Based Practice Process
 The process of EBP is systematic and includes several steps as presented by Sackett et al.
(2000) in the context of practicing and teaching medicine.

1. Asking “burning” clinical questions

2. Finding the very best evidence to try to answer those questions

3. Critically appraising and synthesizing the relevant evidence

4. Making recommendations for practice improvement

5. Implementing accepted recommendations

6. Evaluating outcomes

1. Asking “burning” clinical questions

 Clinical questions are derived when clinicians do not have all the information they
need to make the best possible decisions about patient care.
 A “burning” clinical question is one that usually arises in daily practice or when
attending a class or reading a professional journal.

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  PICO (alternately known as PICOT) is a mnemonic used to describe the four
elements of a good clinical question.
 It stands for:
P--Patient/Problem
I--Intervention
C--Comparison
O--Outcome

 Often we start with a vague question such as, "How effective is CPR, really?" But,
what do we mean by CPR? And how do we define effective? PICO is a technique to
help us - or force us - to answer these questions. Note that you may not end up with a
description for each element of PICO.
 P - our question above doesn't address a specific problem other than the assumption of
a person who is not breathing. So, ask yourself questions such as, am I interested in a
specific age cohort? (Adults, children, aged); a specific population (hospitalized,
community dwelling); health cohort (healthy, diabetic, etc.)
 I - our question above doesn't have a stated intervention, but we might have one in
mind such as 'hands-only'
 C - Is there another method of CPR that we want to compare the hands-only to? Many
research studies do not go head to head with a comparison. In this example we might
want to compare to the standard, hands plus breathing
 O - Again, we need to ask, what do we mean by 'effective'? Mortality is one option
with the benefit that it's easily measured.
 Our PICO statement would look like:

P - community dwelling adults

I - hands only CPR

C - hands plus breathing CPR

O - mortality

2. Finding the Best Evidence

 Finding the best available evidence to answer a focused clinical question has been a
challenge for clinicians and health care agencies.

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3. Critically appraising and synthesizing the relevant evidence

 The key to this step is a collaborative team effort. One effective strategy is to have each
member of an EBP team take responsibility for summarizing and critically appraising a
select number of articles number of relevant articles your search revealed) and then
presenting the review to all team members.
 This helps clarify, extend, and come to consensus on what the best evidence is to answer
the clinical question.

4. Making recommendations for practice improvement

 Once you have reviewed and critically appraised all the relevant evidence, you are
ready to make practice recommendations in a written report to whoever needs to review
them for potential approval. The clinical application at the end of the chapter illustrates
this process.

5. Implementing accepted recommendations

 This step is perhaps the most exciting and energizing component of an EBP project.
After all the hard work of focusing the practice problem, critically appraising the
evidence, and getting practice recommendations approved, the protocol and
implementation plan can be developed.

6. Evaluating outcomes

 Evaluating outcomes requires valid and reliable measurement tools. For example, if the
clinical question is evaluating the effect of music therapy on reducing postoperative
abdominal pain, then a tool to measure pain intensity and quality would be used.

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 RECENT EVIDENCE BASED NURSING IN CARDIOVASCULAR &
THORACIC NURSING

 Health literacy and coronary artery disease: a systematic review.

 Acute chest pain evaluation using coronary computed tomography angiography
compared with standard of care: A meta-analysis of randomised clinical trial
 Childhood obesity and adult cardiovascular disease risk factors: A systematic review
with meta-analysis
 Meta-analysis comparing ≥10-year mortality of off-pump versus on-pump coronary
artery bypass grafting
 Health benefits of physical activity: A systematic review of current systematic
reviews
 Effectiveness of Self-Instructional Module on Knowledge of Digitalis Therapy
Among the Nurses Working in Coronary Care Unit of Selected Tertiary Care
Hospital, Belagavi, Karnataka, India
 Slow walking pace is ‘good predictor’ of heart-related deaths

1. Health literacy and coronary artery disease: a systematic review.

Abstract
Objective
Identify health literacy (HL) screening instruments available to CAD patients; describe
the prevalence of low HL; explore the predictors of low HL; and, identify the association
between HL, health behaviors, and outcomes among these patients.

Methods
 A literature search of electronic databases was conducted for published articles from
database inception to February 2017.
 Eligible articles included the assessment of HL in CAD patients. Health behaviors and
outcomes included diet, exercise, smoking, medication use, hospital readmission,
knowledge, health-related quality of life (HRQoL), and psychosocial indicators.

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 Results
 Overall, ten articles were included, of which two were RCTs, and seven were considered
“good” quality.
 The most used screening instruments were REALM and TOFHLA. The average
prevalence of low HL was 30.5%.
 Low HL participants were more likely to be older, male, from a non-white ethnic group,
have many CVD co morbidities, lower educational level, disadvantaged socioeconomic
position, and less likely to be employed.
 Low HL was consistently associated with hospital readmissions, low HRQoL, higher
anxiety and lower social support.

2. Acute chest pain evaluation using coronary computed tomography angiography

compared with standard of care: A meta-analysis of randomised clinical trial

Abstract
Objective

 Coronary CT angiography (CCTA) has certain advantages compared with stress testing
including greater accuracy in identifying obstructive coronary disease.

 The aim of the study was to perform a systematical review and meta-analysis comparing
CCTA with other standard-of-care (SOC) approaches in evaluation of patients with acute
chest pain.

Methods

 Electronic databases were systematically searched to identify randomised clinical trials of

patients with acute chest pain comparing CCTA with SOC approaches.

 We examined the following end points: mortality, major adverse cardiac events (MACE),
myocardial infarction (MI), invasive coronary angiography (ICA) and revascularisation.
Pooled risk ratios (RR) and their 95% CIs were calculated using random-effects models.

Results

 Ten trials with 6285 patients were included. The trials used different definitions and
implementation for SOC but all used physiologic testing.

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 The clinical follow-up ranged from 1 to 19 months. There were no significant differences
in all-cause mortality (RR 0.48, 95% CI 0.17 to 1.36, p=0.17), MI (RR 0.82, 95% CI 0.49
to 1.39, p=0.47) or MACE (RR 0.98, 95% CI 0.67 to 1.43, p=0.92) between the groups.

 However, significantly higher rates of ICA (RR 1.32, 95% CI 1.07 to 1.63, p=0.01) and
revascularisation (RR 1.77, 95% CI 1.35 to 2.31, p<0.0001) were observed in the CCTA
arm.

Conclusions

 Compared with other SOC approaches use of CCTA is associated with similar major
adverse cardiac events but higher rates of revascularisation in patients with acute chest
pain.

3. Childhood obesity and adult cardiovascular disease risk factors: A systematic review
with meta-analysis

Abstract
Background
 Overweight and obesity is a major public health concern that includes associations
with the development of cardiovascular disease (CVD) risk factors during childhood
and adolescence as well as premature mortality in adults.
 Despite the high prevalence of childhood and adolescent obesity as well as adult
CVD, individual studies as well as previous systematic reviews examining the
relationship between childhood obesity and adult CVD have yielded conflicting
results.
 The purpose of this study was to use the aggregate data meta-analytic approach to
address this gap.

Methods
 Studies were included if they met the following criteria:
 (1) longitudinal and cohort studies (including case-cohort),

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  (2) childhood exposure and adult outcomes collected on the same individual over
time, (3) childhood obesity, as defined by the original study authors,
 (4) English-language articles,
 (5) studies published up to June, 2015,
 (6) one or more of the following CVD risk factors [systolic blood pressure (SBP),
diastolic blood pressure (DBP), total cholesterol (TC), high-density lipoprotein
cholesterol (HDL), low-density lipoprotein cholesterol (LDL), non-high-density
lipoprotein cholesterol (non-HDL), and triglycerides (TG)],
 (7) outcome(s) not self-reported, and
 (8) exposure measurements (child’s adiposity) assessed by health professionals,
trained investigators, or self-reported.
 Studies were retrieved by searching three electronic databases as well as citation
tracking.

Results
 Of the 4840 citations reviewed, a total of 23 studies were included in the systematic
review and 21 in the meta-analysis.
 The findings suggested that childhood obesity is significantly and positively associated
with adult SBP (Zr = 0.11; 95% CI: 0.07, 0.14), DBP (Zr = 0.11; 95% CI: 0.07, 0.14),
and TG (Zr =0.08; 95% CI: 0.03, 0.13), and significantly and inversely associated with
adult HDL (Zr = −0.06; 95% CI: -0.10, −0.02).
 For those studies that adjusted for adult body mass index (BMI), associations were
reversed, suggesting that adult BMI may be a potential mediator. Nine studies had more
than 33% of items that placed them at an increased risk for bias.

Conclusions
 The results of this study suggest that childhood obesity may be a risk factor for
selected adult CVD risk factors.
 However, a need exists for additional, higher-quality studies that include, but are not
limited to, both unadjusted and adjusted measures such as BMI before any definitive
conclusions can be reached.

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4. Meta-analysis comparing ≥10-year mortality of off-pump versus on-pump coronary
artery bypass grafting

Abstract
 Off-pump coronary artery bypass grafting (CABG) is suggested to be associated with
an increase in long-term (≥5-year) all-cause mortality.

 To determine whether off-pump CABG is associated with an increase in very long-

term (≥10-year) all-cause mortality, we performed a meta-analysis of propensity-score
matched observational comparative studies of off-pump versus on-pump CABG.
MEDLINE and EMBASE were searched through May 2017.

 A hazard ratio of follow-up (including early) all-cause mortality for off-pump versus
on-pump CABG was extracted from each individual study.

 Study-specific estimates were combined using inverse variance-weighted averages of

logarithmic hazard ratios in the random-effects model. Of 164 potentially relevant
studies, our search identified 16 propensity-score matched observational comparative
studies of off-pump versus on-pump CABG with ≥10-year follow-up enrolling a total
of 82,316 patients.

 A pooled analysis of all the 16 studies demonstrated that off-pump CABG was
significantly associated with an increase in all-cause mortality (hazard ratio, 1.07;
95% confidence interval, 1.03 to 1.12; p for effect = 0.0008; p for heterogeneity =
0.30; I2 = 12%) In a sensitivity analysis, exclusion of any single hazard ratio from the
analysis (leave-one-out meta-analysis) did not substantively alter the overall result

 There was no evidence of a significant publication bias In conclusion, off-pump

CABG is associated with an increase in very long-term (≥10 years) all-cause mortality
compared with on-pump CABG.

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5. Health benefits of physical activity: A systematic review of current systematic
reviews

 The health benefits of physical activity and exercise are clear; virtually everyone can
benefit from becoming more physically active.
 Most international guidelines recommend a goal of 150 min/week of moderate-to-
vigorous intensity physical activity.
 Many agencies have translated these recommendations to indicate that this volume of
activity is the minimum required for health benefits. However, recent evidence has
challenged this threshold-centered messaging as it may not be evidence-based and
may create an unnecessary barrier to those who might benefit greatly from simply
becoming more active.
 This systematic review evaluates recent systematic reviews that have examined the
relationship between physical activity and health status.
 Recent findings: Systematic reviews and/or meta-analyses (based largely on
epidemiological studies consisting of large cohorts) have demonstrated a dose–
response relationship between physical activity and premature mortality and the
primary and secondary prevention of several chronic medical conditions.
 The relationships between physical activity and health outcomes are generally
curvilinear such that marked health benefits are observed with relatively minor
volumes of physical activity.
 Summary: These findings challenge current threshold-based messaging related to
physical activity and health. They emphasize that clinically relevant health benefits
can be accrued by simply becoming more physically active.

6. Effectiveness of Self-Instructional Module on Knowledge of Digitalis Therapy

Among the Nurses Working in Coronary Care Unit of Selected Tertiary Care
Hospital, Belagavi, Karnataka, India

 A pre-experimental, evaluative research approach was used with one group pre-test
post-test design was undertaken in KLES Dr. Prabhakar Kore Hospital and Medical
Research Centre, Belagavi.
 The aim of the study to assess the knowledge on digitals therapy among coronary
care nurses before and after introduction of self-instructional module and to find
association between the pre-test posttest knowledge scores with selected
demographic variables.

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  The sample composed of 70 nurses working in coronary care unit (CCU) through
non-probability Purposive sampling technique using structured knowledge
questionnaire. Data was analyzed by using descriptive and inferential statistics.
 The study revealed that highest number 35 (50%) of the nurses were 20-25 years of
age group where higher percentage 42 (60%) were female. Majority 43 (61.4%) of
them were having diploma holder. Maximum number 53 (75.7%) nurses were from
ITU. Maximum number 36 (51.4%) nurses had total years of clinical experience of
0-2 years where as majority 31 (58.6%) of nurses were having 0-2 years of
experience in coronary care unit and did not attended training program (100%).
 The pretest posttest finding showed that, nurses had average level of knowledge
regarding digitalis therapy whereas post test score was significantly higher than the
pre-test score.
 Therefore, the self-instructional module was found to be effective teaching strategy
in increasing the knowledge of the nurses on digitalis therapy.

7. Slow walking pace is ‘good predictor’ of heart-related deaths

 They suggested that walking pace could be a “simple” indicator of a patient’s risk of
developing cardiovascular disease and ultimately dying from it.

 “Slow walkers were around twice as likely to have a heart-related death”

 The researchers analysed data on 420,727 people who were free from cancer and heart
disease at the time of the collecting their information during 2006-10.
 In the following 6.3 years after the data was collected, there were 8,598 deaths within
the sample population, of which 1,654 were from cardiovascular disease and 4,850
from cancer.

 The study, published in the European Heart Journal, found that slower walkers – both
men and women – were around twice as likely to die from cardiovascular causes than
faster walkers.

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 “A simple self-reported measure of slow walking pace could aid risk stratification for
all-cause and cardiovascular mortality within the general population,” concluded the
researchers.
 “Self-reported walking pace could be used to identify individuals who have low
physical fitness and high mortality risk”
 Lead study author Professor Tom Yates, from the University of Leicester, said: “Our
study was interested in the links between whether someone said they walked at a
slow, steady or brisk pace and whether that could predict their risk of dying from
heart disease or cancer in the future.

 “Slow walkers were around twice as likely to have a heart-related death compared to
brisk walkers,” he said, adding that it was not affected by related risk factors such as
smoking or body mass index.

 “This suggests habitual walking pace is an independent predictor of heart-related

death,” said Professor Yates.

 He added: “Self-reported walking pace could be used to identify individuals who have
low physical fitness and high mortality risk that would benefit from targeted physical
exercise interventions.”
 The research team also analysed actual handgrip strength as measured by a
dynamometer to see if it was a good predictor of cancer or heart-related deaths.

 Handgrip strength appeared to be only a weak predictor of heart-related deaths in men

and could not be generalised across the population as a whole, they concluded.

 They added that associations between self-reported walking pace and handgrip
strength and cancer-related deaths were not consistent.

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 The study was carried out by a team of researchers at the Leicester Biomedical
Research Centre – a partnership between University Hospitals of Leicester NHS
Trust, the University of Leicester and Loughborough University.

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BIBLIOGRAPHY:
1. https://www.mdlinx.com/cardiology/evidence-based-medicine.cfm/evidence-based-

medicine-articles/

2. Farrell, M. and Dempsey, J.2011 Smeltzer & Bare’s Textbook of Medical Surgical

Nursing. 2nd ed. 530 Walnut Street, Philadelphia Lippincott Williams & Wilkins

3. Berman, Audrey. Kozier, Barbara.(Eds) 2008 Kozier & Erb’s fundamentals of nursing:

concepts, process, and practice upper Saddle River,N.J.:Pearson Prentice Hall,

4. Http://ebn.bmj.com/cardiology/ evidence-based-nursing articles.

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