Evidence Based Practice and Ethics Fa24.pptx

Evidence Based Practice and Ethics

NURS 444

Learning Outcomes

1. Define descriptive and analytic epidemiology as the basic science of public health.
2. Discuss the use of surveillance systems in public health as they apply to the control of infectious and non-infectious diseases.
3. Describe causation criteria within the epidemiological triangle
4. Describe the most common measurements of disease frequency and risk in a population.
5. Describe components of the United States’ opioid epidemic strategic plan
6. Recognize the role of registered nurses in the opioid epidemic strategic plan.

7. Discuss the three core functions of public health and their ethical tenants.

Definitions

Epidemiology: the study of the distribution and factors that determine health-related states or events in a population, and the use of this information to control health problems.

• Descriptive epidemiology
• Distribution of disease according to person, place, time
• For example: What is the disease? Who is affected? Where are they? When do events occur?
• Analytic epidemiology
• Determinants of the patterns
• For example: How does it occur? Why are some people affected more than others?

Types of Epidemiology

Descriptive

• Person (who)
• Place (where)
• Time (when)
• Secular trends
• Point epidemic
• Cyclical patterns

Analytic

• Seeks to discover the determinants of outcomes
• How? Why?
• Cohort studies
• Case-control studies
• Cross-sectional studies

History

• Ancient Greece
• Hippocrates
• Modern epidemiology emerged in the 19th century.
• John Snow, “father of epidemiology”
• Twentieth century
• Dramatic changes in life expectancy
• Increase in chronic diseases-ecologic model

Epidemiologic Triangle

Measures of Morbidity and Mortality

Proportions

• type of ratio in which the denominator includes the numerator; often expressed as a percent.
• Example: In 2006, there were 2,426, 264 deaths recorded in the US of which 631, 636 were caused by heart disease. Therefore, 631, 636/2426,264=0.260 or 26%
• The proportion may be expressed as a number per 1000 or 100,000

a measure of the frequency of a health event, how rapidly something is happening.

• The denominator serves as the # of individuals in the population during the year that change occurred
• Rates are commonly expressed as per 100, 000 or per 1,000
• Example: In 2006, the U.S. population was 299, 398, 484/100,000=2993.98484. The death rate from heart disease in 2006 would be 631, 636/2993.98484=211 per 100,000
• Covid 19 positivity rates
• Higher positivity rates = increased restrictions/policy enforcement

Rate

• Refers to the probability that an event will occur within a specified time period
• The measures of morbidity (incidence and prevalence) provide information about the risk and rates of disease presence and development

Risk

• Quantifies the rate of development of new cases in a population at risk
• Existing (prevalent) cases are excluded from the population at risk
• Example:
• Over 5-year period, 20 of 200 individuals were newly diagnosed with cancer. The incidence proportion would be 20/200 = 0.10 or 10% so over a 5-year period the risk of cancer in the population was 10%

Incidence

• Measure of existing disease in a population at a particular time (i.e., the number of existing cases divided by the current population)
• Not an estimate of the risk of developing disease!
• Example: Breast cancer screening of 8000. 35 women were previously diagnosed and additional 20 cases of breast cancer were identified through screening. 55 out of 8000 expressed as rate of 687.5 per 100,000.

Prevalence

Attack Rate and Mortality Rate

• Attack rate
• defined as the proportion of persons who are exposed to an agent and develop the disease; is often specific to an exposure.
• Form of incidence proportion
• Example: food borne illnesses
• Mortality rates
• informative only for fatal diseases
• do not provide direct information about either the level of existing disease in the population or the risk of contracting any particular disease
• Examples: Table 9-2.

Sources of Data

• Routinely collected data
• Data collected for other purposes
• Epidemiologic data
• CDC Surveys
• National Center for Health Statistics Surveys

Applications of Epidemiology in Nursing

Nurses use epidemiologic frameworks, methods, and data to better understand factors that contribute to:

• Health and disease
• Health promotion and disease prevention interventions and measures
• Identifying the presence of infectious agents in individuals and groups
• Community health programs
• Public health policies

Public Health Interventions: Surveillance

“The ongoing systematic collection, analysis, and interpretation of health data related to the occurrence of disease and the health status of a given population for the purpose of planning, implementing, and evaluating public health interventions” (Keller and Strohschein, 2001)

• Purpose of Surveillance
• The Investigation
• Defining the magnitude of a problem/event
• Endemic
• Epidemic/Outbreak
• Pandemic
• Identify Patterns of Occurrence
• When to Investigate

Collaboration Among Partners

Hospitals

Federal agencies

Health care providers

State and local public health agencies

Veterinarians

Agriculture

Medical examiners

Pharmaceutical agencies

911 systems

Emergency management

Ambulance services

Law enforcement agencies

Nurse hotlines

School

Poison control centers

Urgent care and emergency departments

Industry

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Data Sources for Surveillance

• Cases reported by clinicians, health care agencies, and laboratories to state health departments
• National Notifiable Diseases
• State Notifiable Diseases
• (Box 17.3 p 310)
• Death certificates
• Administrative data (i.e., billing)
• Sentinel surveillance system

Types of Surveillance Systems

• Passive system
• Active system
• Sentinel system

Collaborative Learning:

Syndromic surveillance: “surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response” (CDC, 2017) Use the links below to address the following questions:

• How does the EHR impact surveillance?
• Share examples of syndromic surveillance software in action

Interventions and Protection

• Response to bioterrorism or large-scale infectious disease outbreak
• Protecting health care providers from exposure
• Look to evidence-based practice guidelines!

Ethics and the Core Functions of Public Health Nursing: Assessment

Competency related to knowledge development, analysis, and dissemination

Virtue ethics or moral character/Integrity “Do good” and “Do no harm”

Beneficence and Non-maleficence

Ethics and the Core Functions of Public Health Nursing:Policy Development

Achieve the public good

•Rooted in citizenship

Service to others over self (a necessary condition)

•Serve rather than steer•Serve citizens, not customers•Value citizenship and public service above entrepreneurship

What is ethical is also good policy

Ethics and the Core Functions of Public Health Nursing: Assurance

All persons should receive essential personal health services.

Providers of public health services are competent and available.

•Healthy People 2030 objectives

•Social justice/Distributive Justice (fair allocation of resources

Note: A review from NURS 360 has been provided to you in the student powerpoint. Understand public health interventions to be evidence based with an emphasis on meta-analysis and systematic reviews. The higher the level of evidence the lower the bias; VERY important when designing and implementing interventions with large groups! Refer to your existing knowledge and resources from NURS 360 and plan to APPLY it during clinical. Some resources are already posted and available within NURS 444L clinical content tab on D2L.

Types of Evidence

• Double blind RCT generally ranks as the highest level of evidence
• Difficult to perform RCTs in public health
• Other sources are used

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Steps in the Evidence-Based Practice Process

Cultivating a spirit of inquiry

Form a PICOT question

Searching for the best evidence***

Critically appraising the evidence***

Integrating evidence with clinical expertise, client preferences, and values

Evaluating outcomes of the practice decisions or changes based on evidence

Disseminating EBP results

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Approaches to Finding Evidence

• Meta-Analysis: Method of statistical synthesis use in some systematic reviews; results from several studies are quantitatively combined
• Systematic Review: a summary of the research evidence that relates to a specific question and to the effects of an intervention.
• Example: PH Intervention Wheel
• Databases (BOX 10.2):
• Guide to Community preventive services
• Cochrane Public Health Group
• Center for Reviews and Dissemination
• Campbell Collaboration

Approaches to Evaluating Evidence

• Grading the strength of evidence
• Identify criteria used to assess level, quality, strength of evidence. There are many frameworks to use. Strength is based on 3 things:
• Quality
• Quantity
• Consistency
• Appraise evidence for: Patient Oriented Evidence that Matters (POEM)

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Collaborative Learning: Task Force on Community Preventive Services

In your learning groups, visit the Guide to Community Preventive Services website : https://www.thecommunityguide.org

• Select a topic from the top header
• Select a Task Force Finding and explore the tabs
• Summarize and share the findings
• What the task force found, rationale statements, evidence gaps, etc.

US DHHS—Public Health Conditions: Evidence-Based Perspective on Opioid Epidemic

• USDHHS Office of Disease Prevention and Health PromotionHP2030
• HP2030 objectives are federal government initiatives to guide actions to improve nation’s health
• SU 18 Reduce the proportion of persons with opioid use disorder in the past year.
• SU 19/20 Reduce the proportion of people who misused or started misusing prescription opioids in the past year

Incidence, Prevalence, Morbidity, Mortality Rate

• 500,000 died from an opioid overdose (CDC, 2021)
• 1.6 million Americans had an opioid use disorder (HHS,2021)
• 10.1 million people misused prescription opioids in the past year (HHS, 2021)

1. MORBIDITY
2. PREVALENCE
3. MORTALITY

• People who are addicted to prescription opioid painkillers are 40x more likely to be addicted to heroin (CDC 2015).
• 1.6 million people misused prescription pain relievers for the first time (HHS, 2021).
• 21-29 % of patients prescribed opioids for chronic pain misuse them (NIDA, 2021).

• PREVALENCE
• INCIDENCE
• RISK

Collaborative Learning: USDHHS Response 5 Point Strategy and Evidence Based Resources

• Visit the USDHHS Response 5 Point Strategy framework document and link in D2L
• In a group of 3-4, select one point of the strategic plan 
• Identify the roles of the registered nurse within the selected strategy
• Share your findings

United States Opioid Epidemic Strategic Plan (2017)

DATA: Better data on the epidemic

PAIN: Better pain management

ACCESS: Better prevention, treatment, and recovery services

OVERDOSES: Better targeting of overdose-reversing drugs

RESEARCH: Better research on pain and addiction

United States Opioid Epidemic Strategic Plan

Primary Prevention

Harm Reduction

Evidence based Treatment

Recovery Support

Role of the Registered Nurse in the Opioid Epidemic

Safer Care

Management of high-risk patientsEngage patients between provider visitsSBIRTNonpharmacological treatments

Patient and Family Engagement

Health literacy strategies: Teach-backMotivational Interviewing

Care Transition

Effective Communication & Coordination of Care

Medication reconciliation

Science-Driven Prevention and Treatment

(Mikosz, 2017; United States Department of Health & Human Services, 2014)

Registered Nurse Skills: Safer Care Epidemic – Inpatient Settings

Management of high—risk patients

Patient and family engagement

SBIRT-https://www.youtube.com/watch?v=KlaCo3zw1PM

Nonpharmacological treatments

CONCLUSION

References

• ATI. (2023). RN Community Health Nursing (9th ed.)
• Stanhope, M. & Lancaster, J. (2022). Foundations for population health in community/public health nursing (6th ed). ISBN: 9780323776905 (e-book); 9780323776882 (textbook)