About 40% of adult patients are provided care that isn’t based on current evidence. Some of this care is ineffective, unnecessary and potentially even harmful (Health.vic 2021).
Evidence-based care is a key component of effective and multidimensional care provision. So, how can it be implemented?
What is Evidence-based Care?
Evidence-based care (also known as evidence-based practice) is the use of research evidence, in tandem with clinical expertise and patient values, to inform clinical decisions (Health.vic 2021).
Specifically, evidence-based care is an integration of:
Best available research evidence
Staff skills, training and experience (clinical expertise)
The patient’s values and circumstances (e.g. financial situation)
The practice context in which healthcare staff are working.
(Turner 2023)
What Are the Benefits of Evidence-based Care?
Improved patient outcomes
Improved quality of life for patients
Staff are encouraged to reflect upon whether they can perform tasks more effectively
Improved allocation of resources
Improved staff productivity
Reduced costs
Staff can stay updated about new protocols
Patients can participate in their care by voicing their concerns, values and preferences.
(Turner 2023; Health.vic 2021; ANA 2023)
Evidence-based Care in the National Safety and Quality Health Service Standards
This action aims to ensure healthcare workers use the best available evidence in their practice. Health service organisations should:
Allow staff to easily access best-practice guidelines, integrated care pathways, clinical pathways and decision support tools
Support staff to use the best available evidence in their provision of care, including clinical care standards developed by the Australian Commission on Safety and Quality in Health Care.
(ACSQHC 2022)
Evidence-based Practice Under the Strengthened Aged Care Quality Standards
The Standards outline many areas in which contemporary, evidence-based practice should be used in aged care, including:
The provision of culturally safe, trauma aware and healing informed care
The implementation of a quality system
The organisation’s policies and procedures
Timely recognition and care of older people with dementia
Infection prevention and control
Antimicrobial stewardship systems
Performing medication reviews
Comprehensive clinical assessment
The implementation of systems to promote clinical safety
Identifying changes in an older person’s health
Ensuring safe eating, drinking and swallowing
Continence care
Falls prevention
Maintaining nutrition and hydration
Optimising mental health and wellbeing
Pain management
Pressure injury prevention
Wound care
Support of older people with sensory impairment
Foods and drinks provided to older people.
(ACQSC 2024a-f)
What is Best Available Research Evidence?
The term best available research evidence refers to ‘clinically relevant research drawn from studies with the least possible bias’. In other words, it is the highest-quality research available (CIAP 2019).
In order to determine whether research is of sufficient quality to inform your clinical decision-making, you must consider:
Validity: Is the research reliable?
Impact: Are the results of the research clinically significant?
Applicability: Is the research relevant and applicable to the patient and their situation?
(Turner 2023)
Staff should have access to resources that reflect best practice-evidence. These may be in the form of:
Best-practice guidelines
Integrated care pathways
Clinical pathways
Decision support tools
Clinical care standards.
(ACSQHC 2022)
The Hierarchy of Evidence
Some types of research are considered more reliable than others.
The most suitable type of evidence depends on the kind of question you are answering. For further advice, the National Health and Medical Research Council (NHRMC) has devised a detailed table listing evidence from most to least reliable for different kinds of research questions:
Level
Intervention
Diagnosis
Prognosis
Aetiology
Screening
I
Systematic review of Level II studies
Systematic review of Level II studies
Systematic review of Level II studies
Systematic review of Level II studies
Systematic review of Level II studies
II
Randomised controlled trial
Study of test accuracy with an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation
Prospective cohort study
Prospective cohort study
Randomised controlled trial
III-1
Pseudorandomised controlled trial
Study of test accuracy with an independent, blinded comparison with a valid reference standard, among consecutive patients with a defined clinical presentation
All or none
All or none
Pseudorandomised controlled trial
III-2
Comparative study with concurrent controls:
Non-randomised, experimental trial
Cohort study
Case-control study
Interrupted time series with a control group
Comparison with reference standard that does not meet the criteria required for Level II and III-1
Analysis of prognostic factors amongst untreated control patients in a randomised controlled trial
Retrospective cohort study
Comparative study with concurrent controls:
Non-randomised, experimental trial
Cohort study
Case-control study
III-3
Comparative study without concurrent controls:
Historical control study
Two or more single arm study
Interrupted time series without a parallel control group
Diagnostic case-control study
Retrospective cohort study
Case-control study
Comparative study without concurrent controls:
Historical control study
Two or more single arm study
IV
Case studies with either post-test or pre-test/post-test
Study of diagnostic yield (no reference standard)
Case series, or cohort study of patients at different stages of disease
Crosssectional study
Case studies
(Adapted from NHMRC 2009)
The 5 Steps of Evidence-based Care
The ‘5A’s Cycle’ (ask, acquire, appraise, apply and audit) is the model used to incorporate evidence into practice.
1
Ask
Identify the need for information.
Convert this into a well-built, answerable clinical question that is:
Directly relevant to the issue you have identified
Worded in a way that can help yield a precise answer.
2
Acquire
Determine a search strategy.
Use the hierarchy of evidence to gather evidence.
3
Appraise
Assess the evidence for validity, impact and applicability using the following questions:
Why was the study performed?
What type of study is it?
What are the characteristics of the study?
How did the study address and combat bias?
What are the results?
Are the results valid?
What conclusions can you draw from the study?
4
Apply
Decide whether to incorporate the evidence into clinical decision-making. If so, how will you do it?
Integrate the evidence with the other three elements of evidence-based care (clinical expertise, patient situation and practice context).
Consider the following:
Do the results of the study apply to your patient?
Were all clinically important outcomes considered?
Are the results clinically important?
Are the likely benefits of applying this evidence worth the possible harm or cost it could incur?
What are your patient’s values and preferences?
How can you help your patient make a decision?
5
Audit
Self-evaluate your performance throughout the evidence-based care process. Consider the following:
Did you ask a well-built answerable question?
Are you becoming more efficient and gathering the best available evidence?
Did you critically appraise the evidence?
Did you integrate critical appraisals into your practice?
Is what you have learned been translated into better clinical practice?
(Turner 2023)
Supporting Evidence-based Care
In order to support staff to deliver evidence-based care, health service organisations should:
Utilise clinical care standards
Hold healthcare staff accountable for their practice
Quickly identify and manage any harmful practices that are observed
Monitor compliance with and any deviations from evidence-based practice
Designate committees or individuals responsible for approving and reviewing resources based on best available evidence
Enable peer-based feedback about compliance with and deviation from evidence-based practice
Inform staff if an unwarranted deviation from evidence-based practice has been observed
Conduct audits to determine what proportion of care is adhering to evidence-based resources.
(ACSQHC 2022)
Conclusion
By using clinical expertise, patient preferences and practice context to inform clinical decisions alongside the best, most reliable research available, you can ensure patients receive appropriate and high-quality care.
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