Evidence-based veterinary medicine (EBVM) is defined by Holmes and Ramey (2007:194) as ‘the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients'. Evidence should be used alongside existing clinical expertise as well as owner and patient circumstances.
Veterinary nurses (VNs) as well as veterinary surgeons have to make clinical decisions on a daily basis. These may be related to any aspect of veterinary nursing from surgical preparation of a patient, caring for inpatients, or a question that has been asked by a pet owner in a nurse's clinic. By using EBVM, nurses are looking at up to date, current and good quality evidence in order to help guide them when making these decisions.
EBVM also forms part of the clinical auditing cycle; an audit may be carried out in one area of practice that identifies the need for a change or an update to a current protocol.
This article aims to help the VN by looking at where to start with EBVM, how to find evidence, what to do with it and how the evidence can be integrated into practice either to help make a decision or to create or update a protocol.
VNs may be daunted by the prospect of EBVM but that should not be the case and hopefully will not be the case for much longer as student VNs have EBVM introduced into their training and day one competencies (RCVS, 2014).
EBVM can be broken down into the following sections that will all be discussed in this article:
Ask
A clinical question can be related to any aspect of a VN's work but the best questions are those that are the most relevant and when answered will make a difference to patient care. It is all too easy to adopt methods for certain things because ‘that is how we have always done it’, but EBVM aims to encourage veterinary professionals to find the evidence for what they are doing.
An example of something that is very much based on tradition rather than evidence is found in a VN under-graduate dissertation study that was published in 2009. The author sent out questionnaires to 181 practices about methods used for patient preparation for elective neutering. Of the 181 questionnaires that were sent, 105 were returned. 62% did not know the correct concentration of the scrub solutions they were using and only 21% knew the correct concentration and the contact time for the solutions they were using (Evans et al, 2009). As well as being a study into patient preparation techniques, this study also highlights how many practices do not employ evidence-based protocols for such everyday aspects, or if they do, they do not educate their staff on them.
In order for a clinical question to be answered properly it is a good idea to structure the question. The best way to do this is to create a PICO question. PICO stands for patient (or population), intervention, comparison and outcome. In order to create a good PICO question you will therefore need a problem, choices to manage the problem and an outcome that can be measured (EBVM network, 2015). Organising the question like this also makes it easier when acquiring evidence if using scientific literature searching databases such as Pubmed or CAB abstracts.
Head or senior nurses in a practice may be asked to review the practice's current protocol on pre-surgical hand preparation. The following is an example of a PICO question that could be used: ‘In small animal surgery (population) are alcohol hand rubs (intervention) superior to scrubbing brushes and antimicrobial soap (comparison) at reducing bacterial counts (outcome)’ (Figure 1).
Acquire
Once the clinical question is set and made into a PICO, it is then time to look for the evidence. It is a good idea to check systematic reviews, knowledge summaries or critically appraised topics (CATs) to see whether this question may have already been covered (Table 1).
| Type of evidence | Details |
|---|---|
| Systematic review | Systematic reviews find all the relevant evidence for a question (normally in the form of randomised controlled trials), appraise and synthesise it thus answering a research question |
| Knowledge summaries and critically appraised topics | Knowledge summaries and critically appraised topics (CATs) are summaries of evidence usually produced through carrying out literature searches in response to a clinical question |
| Randomised controlled trial | Two groups of people similar in characteristics and background who are randomly assigned to a control or experimental group to compare a treatment. Randomly assigning the participants reduces bias (NICE, 2017) |
| Meta analysis | Comparison of a number of results from systematic reviews to come to an overall conclusion on the effects of a treatment (NICE, 2017) |
| Cohort studies | Two or more groups of people, one group having been exposed to a treatment or risk factor while the other has not. The participants are then followed over a certain time period (NICE, 2017) |
Veterinary systematic reviews are rare, however, the Centre for Evidence Based Veterinary Medicine (CEBVM) at the University of Nottingham have launched VetSRev, which is an open access database of veterinary-related systematic reviews. In human healthcare there is the Cochrane collaboration, which is a database of systematic reviews for primary health care.
Veterinary-related knowledge summaries can be accessed through RCVS knowledge and their journal Veterinary Evidence. These include some knowledge summaries written by VNs. The journal is very much in its infancy but already has highlighted some very good evidence with much of it being relevant to VNs.
Those who work in an academic institution will likely have access to scientific literature databases such as PubMed and CAB abstracts, both of which can be used for a literature search. Google Scholar is an excellent free resource, however, this does not have the same coverage as the scientific databases. Membership of the RCVS library gives full access to the scientific literature databases as well as discounts on support from the library staff, such as database searching and copies of scientific papers.
When searching for evidence using scientific databases use each aspect of the PICO and type out all potential variations or synonyms for that word using ‘OR’ in between each one and then separating each part of the PICO with ‘AND’. For example, for alcohol hand rubs you could also use ‘alcohol rub’ OR ‘alcoholic rub’ OR ‘ethanol’ OR ‘propanol’. This may yield a lot of evidence but many of the results may not be relevant, there will be some degree of sorting through the results and picking out the research which is relevant to the PICO question.
Unfortunately, until there is more veterinary research (especially VN specific research) available it may be that there is no evidence and human evidence found may not be transferable to a different species. This indicates a gap in the knowledge, something that the VN may want to take forward and carry out some research in practice.
Appraise
Not all evidence gained from a search of the literature is of a good quality. Table 2 summarises the types of evidence that can be found in order of quality.
| ↑ |
Systematic reviews of randomised controlled trials (RCTs), meta analysis of RCTs, an RCT of good quality |
| Controlled studies (not randomised) | |
| Cohort studies | |
| Case reports | |
| Opinion |
Evidence gained will need to be appraised for its quality and therefore relevance to the clinical question. When faced with an experimental piece of evidence there are certain questions, that should be asked in order to appraise the evidence in front of you such as ‘what is the research question?’, ‘are the participants randomised?’, ‘are all participants accounted for at the end of the study?’ and ‘does this population represent the population I am concerned with?’ (RCVS knowledge, 2015a).
Care should be taken when looking at author narratives for evidence, as although there will be some form of evidence search undertaken it is likely that the author will only discuss the evidence which they find the most interesting and that backs up what they are saying, creating some form of bias (RCVS knowledge, 2015b).
As there are a lot fewer veterinary studies than human ones, human studies may be presented when looking for evidence. When looking at specific treatments this will not be of any use, but there may be instances when some evidence could be transferred. Hopefully in the future as more research is carried out (and by VNs) there will be less reliance on human research, however, there is such a vast amount of good quality human nursing research and when possible this can be used to guide on best practice.
Apply
Once it has been appraised, the evidence found may be used to change an aspect of nursing, a protocol in practice or to answer a question that a client may have had.
There may be barriers to changing protocols, however these should be overcome if good evidence and statistics can be provided to show that the change to be made is for the better. The most difficult protocols to establish are those that do not have a solid evidence base. Clinical auditing, as mentioned at the beginning of this article, is one method of monitoring changes that have been made in response to evidence and this is discussed in more detail at the end of this article.
One of the most important aspects of finding new evidence, especially where it could make a real difference in practice, is to share the information with colleagues. This can be done in a number of ways. If a clinical question has been created and a number of good quality research papers found on the subject which all conclude the same then the production of a knowledge summary is a great way of sharing the evidence with other veterinary surgeons and VNs (knowledge summaries can also be written when there is no evidence). Veterinary Evidence, the journal published by RCVS knowledge, has a website for online submission of knowledge summaries and there is a specific veterinary nursing working group that can provide support as well as the RCVS library.
The evidence can be shared in the practice at rounds, in meetings or journal clubs. Journal clubs consist of a group of people, veterinary surgeons, VNs, the whole practice, who get together to look at a piece of evidence, normally in the form of a study. This is normally distributed before the time of the meeting to allow members to read, understand and form their own opinions of it. One person will normally lead and appraise the study with input from other members. Finding the time to do this is a very common barrier, at the author's workplace journal clubs are carried out at the beginning of the day before any clinical activity takes place, people could also be tempted with the offer of breakfast!
Assess/audit — clinical audits
If a practice protocol has changed or a new one has been written in response to current evidence the changes will need to be assessed, otherwise known as carrying out a clinical audit.
Clinical auditing is defined by Viner (2005) as a quality improvement process to establish protocols based on documented evidence, when available, and monitoring the effectiveness of these protocols.
First the area for change would need to be established, this should be an area where a need for change has been identified, for example, a breakout of haemorrhagic diarrhoea in the practice or a run of intravenous catheter-related infections. It is important to get as many people from the team on board as possible, especially those who may have a particular interest in that given area (Viner, 2003). Once the area for auditing had been identified it is then necessary to gather the correct data. This may involve looking back at computer records or hospitalisation charts, looking for patterns associated with the problem in question (Mosedale, 1998). Another useful tool for this may be the Small Animal Veterinary Surveillance Network (SAVSNET) at the University of Liverpool. An aspect of this network is to record reasons and outcomes of veterinary consultations in order to provide health and epidemiological data to individual practices, the industry as a whole but also the general public (University of Liverpool, no date). Results such as this may highlight a trend, which might identify where the change needs to be made. When the topic for auditing has been identified the gold standard in that area should be researched (Dunn, 2012), this is where EBVM intertwines with clinical auditing. It may be relevant, depending on the subject, to look at what our human counterparts are doing in a certain area as long as it can be transferred. A change in protocol may necessitate the need for staff training and education; this should also be taken into account (Dunn, 2012). Using the previous example of pre-surgical hand preparation, if a practice was to change to using alcohol hand rubs instead of the traditional scrubbing method then all staff that are involved in surgeries should receive training on using the new hand preparation products as well as being educated on the reasons why the change has been made (journal club?).
Once a protocol has been changed or established that is not the end, a re-audit will need to take place at a given time, usually 6–12 months in order to monitor effectiveness and compliance of staff with the new protocols. This will hopefully show an improvement in standards but this is not always the case. If improvement has not occurred then the audit will need to be revisited to try to identify where the problems lie (Dunn, 2012). Problems could include lack of compliance or lack of training and education.
Conclusion
In conclusion, VNs should not be put off by EBVM and should be encouraged to find evidence for the decisions they are faced with every day. It is likely that VNs will be involved in clinical auditing as they are often in the best position within the practice to take the time to carry out a clinical audit.
Another very important aspect of EBVM is that evidence is shared with colleagues within the workplace but also with the wider veterinary community. Do not be afraid to want to find evidence for aspects of nursing which you carry out often.