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Integrating evidence into practice
Whether we are looking for evidence to support clinical decision making in an individual case or wanting to develop evidence-based guidelines for your practice, it can be helpful to structure the process.
One model that can provide a framework to structure the process is the 5As model. This identifies five steps to follow when integrating evidence into practice.
There are five key steps to follow when integrating evidence into practice:
- ASK - The first step in searching for literature is to define your question, phrasing it in such a way that it will help you find all relevant articles and reduce the chance of you leaving anything important out. One way to do this is to use the PICO method. Learn more...
- ACQUIRE – The next step is to use the key concepts from the PICO to identify search terms and use these to build a search strategy. Learn more...
- APPRAISE – Before using the checklists to critically appraise an article, you need to determine the study design presented in the article. EBVM Toolkit 3 explains how different types of study design can affect the "levels of evidence" a study provides; and EBVM Toolkit 4 offers advice on how to identify what type of study it is. EBVM Toolkits 6-15 provide critical appraisal checklists for different types of studies. Learn more...
- APPLY – We need to apply the evidence to our clinical practice. Learn more...
- ASSESS - We need to evaluate the impact of the evidence on our practice. Learn more...
Ask is about understanding your information needs and structuring your question in a way that gives you the best chance of finding the evidence you need.
It is helpful to start by thinking about why you are searching for evidence and being realistic about the time that you have, these questions will guide both where you search and how you search.
There are many reasons you may be looking for information in the literature, these include
- to obtain general information about a particular subject or condition
- to answer a specific clinical question that has arisen from a particular case or a question from an owner
- to find the full text of a particular paper that you know exists
- to identify appropriate secondary sources of evidence such as an existing knowledge summary, systematic review or guideline relevant to a particular subject or condition
Taking time to structure your question can help you to identify search terms for the search process and thereby improve the likelihood that you will find the relevant evidence and reduce the risk of missing anything important.
RCVS Knowledge has a range of tools and resources to help you to refine your questions.
- Asking an answerable question Formulating an answerable (PICO) question increases your chances of finding the information you need, we have a tool to help.
- Submit a clinical query to Veterinary Evidence. If you think that there is a question that needs answering, submit a clinical query that could form the basis of a future knowledge summary.
Acquire is about finding the evidence that you need, it is also about understanding the most appropriate types of evidence to answer your question and how and where to look for them to find them quickly.
Published evidence can be divided into two broad categories: primary research and secondary sources such as knowledge summaries and systematic reviews, where at least some of the work of searching and appraising the evidence has been done for you.
Whatever type of evidence you are looking for a systematic search strategy is most likely to enable you to find the information you need. This may be a structured PICO question (Patient, Intervention, Comparator, Outcome) if you want to find evidence about the “best” treatment for a particular condition, or a broad-based search based on species, patient/condition and intervention (SPI) if you are looking for a broader range of evidence.
RCVS Knowledge has a range of tools and resources to help you find the published evidence you need.
- Finding the best available evidence The EBVM toolkit can help you construct a search strategy to find the best evidence
- RCVS Knowledge Library - The Library has a range of electronic and print materials in all disciplines of veterinary medicine and library membership allows you access to a wide range of full text electronic journals via Discovery and OpenAthens. If you are short of time or having difficulty finding information the Library and Information Service staff can help you locate the evidence you need.
- Veterinary Evidence - is an online, open access, peer-reviewed journal owned and published by RCVS Knowledge. It publishes Knowledge summaries of critically appraised evidence, and other content relating to evidence-based veterinary medicine.
- InFocus - is a veterinary journal watch that keeps practitioners up-to-date with the latest published papers that have the potential to positively impact patient care
- In The Spotlight- 'In The Spotlight' features bring together collections of papers on a subject of interest to help you locate the most relevant evidence.
Appraising a published paper is about ensuring that it is a reliable and relevant source of evidence to support your clinical decision making.
When appraising primary research, it is important to consider whether the type of study is appropriate to the question and likely to provide reliable evidence, for example using a hierarchy of evidence. But it is equally important to consider other factors such as
- How well the study was conducted?
- How recently the study was conducted?
- How relevant the study is to your patients?
When appraising secondary sources such as knowledge summaries, systematic reviews and published guidelines, it is also important to consider how reliable the evidence is, by looking for a clear description of how the evidence has been gathered and evaluated. With secondary sources of evidence, it is particularly important to consider whether any important or relevant evidence has been left out, such as newly published primary research.
RCVS Knowledge has a range of tools and resources to help you appraise different types of published evidence.
- Critically appraising the evidence for validity – The EBVM Toolkit has a range of resources and checklists to help you critically appraise different types of study.
- Journal club resources – we have developed a range of resources to help you set up and run a journal club along with checklists and suggestions for papers to discuss.
Applying published evidence in practice is about how to use the evidence to support your clinical decision making and improve the quality of care you provide. This may be in terms of the treatment of an individual patient or through the development of practice guidelines or checklists.
When applying the evidence to the treatment of an individual patient it is important to integrate the most relevant published evidence with clinical experience and consider patient circumstances and client preferences, as part of evidence-based practice.
When developing practice guidelines or checklists it is important that the published evidence is interpreted in the light of local regulations and policies and clearly communicated to all staff so that any changes can be fully discussed before implementation.
Assessing the evidence applied in practice enables you to evaluate the impact of the evidence on your practice and can help determine if further changes are needed.
In the case of treatment of an individual animal, assessment can simply take the form of following up and recording whether the intervention had the desired effect and whether there were any unexpected side-effects. You may also consider contributing to a group or national audit or registry.
Assessment of broader changes to practice or the implementation of a guideline or checklist could be assessed through a more formal clinical audit.
RCVS Knowledge has a range of tools and resources to help you assess your practice