02 EIDM, 6S Pyramid and Review Term 1 PDF

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Week 2study notes...

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Evidence-based Nursing: An Introduction (pp. 24-29)  

Providers and consumers of evidence-based health care can help themselves to identify current best evidence by recognizing and using the most ‘evolved’ information services for the topic areas of concern to them Information seekers should begin looking at the highest level resource avail- able for the problem that prompted their search.

Systems 

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A perfect evidence-based clinical information system would integrate and concisely summarize all relevant and important research evidence about a clinical problem and would automatically link, through an electronic medical record, a specific patient’s circumstances to the relevant information. The user would then consult the system – indeed, be reminded by the system – whenever the patient’s record was reviewed. The information contained in the system would be based on an explicit review process for finding and evaluating new evidence as it is published and then reliably updated whenever important new research evidence became available. the system would ensure that the cumulative research evidence about a patient’s problem was immediately at hand, potentially with important features related specifically to the patient highlighted Current systems don’t reach this level of perfection as yet, but production models exist for parts of such systems. Electronic medical record systems with computerized decision support rules have been shown in randomized trials to improve the process, and sometimes the outcome,[2] of care, but these cover a limited range of clinical problems, are not necessarily based on current best evidence, and are mainly ‘homebuilt’ and thus not easily disseminated to most practice settings  UpToDate & Clinical Evidence (attempting to do this)

Synopses   

When no evidence-based information system exists for a clinical problem, then synopses of individual studies and reviews are the next best source. The perfect synopsis would provide exactly enough information to support a clinical action. The declarative title for each abstract that appears in Evidence-Based Nursing, Evidence-Based Medicine, and ACP Journal Club represents an attempt at this

Syntheses  

If more detail is needed or no synopsis is at hand, then databases of systematic reviews (syntheses) are available, notably the Cochrane Library These summaries are based on a rigorous search for evidence, explicit scientific review of studies uncovered in the search, and systematic assembly of the evidence to provide as clear a signal about the effects of a health care intervention as the evidence will allow.

Studies  

If all of the preceding ‘Ss’ fail (i.e. no systems, synopses or syntheses), then it’s time to look for original studies. CINAHL, EMBASE/Excerpta Medica, PsycInfo, or MEDLINE’s PubMed  still can’t find info than use google

EBN Notebook 

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to them. A ‘‘4S’’ model for the organisation of evidence-based information services, proposed several years ago,1 begins with original studies at the foundation; syntheses (that is, systematic reviews, such as Cochrane Reviews) at the next level up; then synopses (very brief descriptions of original articles and reviews, such as those that appear in the evidence-based journals); and the most evolved services, systems (such as computerised decision support systems that link individual patient characteristics to pertinent evidence) at the top. summaries of evidence about all pertinent management options for a health condition, such as those included in Clinical Evidence and PIER.

The 5S Model 

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summaries resides between synopses (succinct descriptions of an individual study or a systematic review) and systems (decision support services that match information from individual patients with the best evidence from research that applies). Summaries integrate best available evidence from the lower layers (drawing on syntheses [ie, systematic reviews] as much as possible) to provide a full range of evidence concerning management options for a given health problem (eg, acute coronary syndromes [ACS]). The lower layers—synopses, syntheses, and original studies—most often examine only 1 aspect of management leaving decision makers to do their own integration and, for original studies, their own critical appraisal of the evidence. topic summary exists, it would summarise the relevant synopses, syntheses, or studies about several aspects of a health condition The only more compiled source would be a system, such as an electronic medical record, in which the individual patient’s characteristics were automatically linked to the current best evidence that matched their specific circumstances, with caregivers being reminded or notified of key aspects of management

Caveat Emptor 

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systems based on guidelines for patient care should be explicit about the source of the guidelines, and the guidelines should be based on systematic reviews of the pertinent evidence to date. Summaries should include details of the retrieval process used to find best evidence, the appraisal process for rating the quality of evidence should be explicit and auditable, key references should be provided for all care recommendations, the date of most recent updating should be stated, and updating should be done frequently enough to assure that important new evidence has not been neglected. Services that provide synopses should have defined procedures for retrieving and appraising original and review articles and should report evidence quantitatively

Accessing pre-appraised evidence: Fine tuning the 5S model into a 6S mode

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over the past decade, many practical resources have been created to facilitate ready access to high-quality research.  Pre-appraised In the hierarchy of evidence, a systematic review bests a single study, so we are adding a layer to the model to distinguish the 2 types of synopses. The 6S Model When using this model to guide clinical decision making, begin your search at the highest possible layer in the 6S model. In an ideal situation, this would be the systems layer. An evidence-based clinical information system integrates and concisely summarises all relevant and important research evidence about a clinical problem, is updated as new research evidence becomes available, and automatically links (through an electronic medical record) a specific patient’s circumstances to the relevant information

In these computerised decision support systems (CDSSs), detailed individual patient data are entered into a computer program and matched to programs or algorithms in a computerised knowledge base, resulting in the generation of patient-specific assessments or recommendations for clinicians. If a CDSS does not exist, the next best step is to look for summaries. These include clinical pathways or textbook summaries that integrate evidence-based information about specific clinical problems and provide regular updating.  Clinical Evidence, Dynamed, Physicians’ Information and Education Resource (PIER) When a summary does not exist for a clinical problem, then synopses of syntheses are the next best source. A synthesis or systematic review is a comprehensive summary of all the research evidence related to a focused clinical question. Given that many busy clinicians do not have the time to review detailed systematic reviews, a synopsis that summarises the findings of a high-quality systematic review can often provide sufficient information to support clinical action.  Journal Club, Evidence-Based Medicine, Evidence-based Mental Health, Evidence-based Nursing If more detail is needed or no synopsis exists, then databases of syntheses (systematic reviews) are available, notably ACPJC PLUS, EvidenceUpdates and Nursing+ which contain systematic reviews from .160 journals and the Cochrane Library. If there are no systems, summaries, synopses of syntheses, or syntheses related to the clinical problem, the next stop is synopses of single studies.  These synopses are also found in the evidencebased abstraction journals and are accompanied by commentaries that address the clinical applicability of the study findings.

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The final stop for pre-appraised evidence, if there are no synopses of single studies, is the single original study. Studies that have met critical appraisal criteria appear in ACPJC PLUS, EvidenceUpdates, and Nursing+....