Critically Appraised Topics (CATs): A method of integrating best evidence into general practice nursing

As we think about how to prepare for revalidation, one question we need to address is how to demonstrate that we are practising effectively and preserving safety: integrating best evidence into practice and recording the process can help us to do so

The Royal College of Nursing’s (RCN) eight principles of nursing practice stipulated that ‘Nurses and nursing staff need to have up-to-date knowledge and skills, and use these with intelligence, insight and understanding in line with the needs of each individual in their care’(principle ‘F’).¹ Similarly, the NMC Code suggests that one component of practising safely is to practise in line with the best available evidence.²

Health care professionals recognise the need to integrate best evidence into clinical practice but have historically found it difficult in busy clinical settings.³ A key component of nurses’ knowledge and skills in delivering quality health care is basing their practice on information emerging from the best evidence.⁴ Nurses are generally familiar with the term evidence-based practice (EBP) which takes its origins from evidence-based medicine (EBM), famously described by Sackett et al as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’.⁵ Although medicine was historically the first of the health disciplines to adopt EBP, the principles can be adopted by all health care professions as the language, tactics and strategies are universal.⁴

One such method of adoption is the use of critically appraised topics (CATs). CATs provide a summary of the best available evidence to answer a clinical question.⁶ A CAT is a clinical question derived from a specific patient situation or problem and therefore has direct relevance to nurses who may have previously felt that the concepts of research evidence were far removed from day to day clinical practice.⁶ A CAT aims to present research in a way that is accessible and allows nurses to read and adopt the findings in order to influence their practice. However, simply having access to the best available evidence does not constitute EBP. It is the appropriate use of this best evidence for the patient group or problem that marks the transition from best evidence simply being information to becoming best practice.⁴

THE CAT GROUP

A group of practice nurses and nurse practitioners working within the North Staffordshire and Stoke-on-Trent Clinical Commissioning Groups are being supported by academics at Keele University’s Research Institute for Primary Care and Health Sciences to identify, appraise and use best evidence to influence day to day practice.

The Keele nurse CAT group was formed in June 2015 with nurse representation from general practices, primary care nurse leads and clinical researchers in primary care. Meetings (every three months) are based on a successful CAT group format already undertaken by GPs and Allied Health Professionals at Keele University. (www.keele.ac.uk/ebp/).

The group identified several areas of need at their initial launch event:

• Further support was requested around literature searching, methodological and statistical understanding;
• A lead facilitator to coordinate and maintain momentum, and
• Good communication between members.

As an add-on to launch the group, new members attended a ‘CAT-in-a-Day’ training event in September 2015 where they were invited to complete a CAT within a day, with the support of academics. This event enabled the nurses to see the output of the CAT process, working through the CAT stages to deliver a ‘clinical bottom line’ answer to their question. The event answered a clinical question decided upon by the group and created the opportunity to deliver short ‘bite size’ skills training sessions around the stages of a CAT. The CAT-in-a-Day event enabled members to understand the process and benefits of being involved in a CAT group.

THE APPROACH

The group undertakes several stages when formulating a CAT. Once a patient or practice problem is identified within the group, an answerable clinical question is formulated that summarises the problem. The question uses a PI(E)CO framework (Population or Patient; Intervention (or Exposure); Comparison; Outcome) to identify search terms .⁷

A search strategy is formulated from the question before searches are undertaken by the team with support from a member of the University’s Health Library to identify and collect the best available evidence. The evidence is then appraised for validity and clinical relevance using recognised appraisal tools (www.casp-uk.net; www.cebm.net/critical-appraisal/) in order to produce a clinical bottom line and generate a CAT.

IMPLICATIONS FOR PRACTICE

Dependent on the findings, consideration is then given to the adoption and implementation of new evidence to influence clinical decision making. Finally, if changes in day-to-day practice take place, evaluation of those changes in practice is essential.

Although the stages suggest this is a lengthy process, CATs can be generated and answered in a relatively short space of time, dependent on the amount and quality of the evidence available and the skills of the CAT group.⁶ Combining the clinical experience of practice nurses and nurse practitioners with that of clinical academics provides a cross-fertilisation of skills and knowledge. This allows clinical academics to keep up to date with current practice issues whilst nurses are supported to improve their literature searching, evidence interpretation and appraisal skills, and supported to translate evidence into clinical practice.

A CAT QUESTION

In patients requiring wound cleansing or irrigation is sterile saline solution superior to tap water in reducing or preventing wound infection and promoting healing?

PICO

Population – Adults requiring wound irrigation/ cleansing/ care

Intervention – Tap water

Comparison – Sterile saline solution

Outcome – Prevention/reduction of infection, wound healing

Databases searched:

Medline, TRIPS, Cochrane library

Key words searched:

P – Wound cleansing, wound irrigation, wound care, surgical wound, chronic wound, laceration, traumatic wound, ulcers

I – Tap water, non-sterile water

C – Sterile water, normal saline, saline solution, steri-pod, saline

O – Wound healing, wound infection, infection, reduction of infection

Results

One Cochrane systematic review (SR) (Fernandez and Griffith, 2012) and one Randomised Controlled Trial (RCT) (Weiss et al, 2013) were reviewed for their potential to answer the question. Several relevant abstracts were identified but were found to be part of the SR. The SR consisted of eleven trials of differing quality. The heterogeneity of the studies prevented the review from producing a meta-analysis but several outcomes were pooled across studies. Thus, the evidence suggests that tap water is neither superior nor inferior to saline solution for wound cleansing/ irrigation.

Clinical bottom line

There is no evidence to suggest that saline solution is superior to tap water in promoting healing or reducing infection in wound cleansing. Evidence from a SR and an RCT suggest that tap water is unlikely to be harmful if used for wound cleansing.

Implications for practice

Nurses from the group are auditing and comparing local practice and examining the cost implications of replacing sterile saline solution with tap water in chronic wounds. Results from the local audit and the identified empirical evidence will be presented as a report for clinical leads within the local CCG to recommend changes in practice.

CONCLUSION

The process of forming a CAT group targeting practice nursing to answer locally driven clinical questions is a positive one. Creating clinical bottom line answers to specific questions can lead to positive changes to local practices and be incorporated into local pathways of care. Secondary benefits come from forming links between academic and clinical primary care settings whilst developing nurses’ research understanding and highlighting areas of future research in primary care.

Acknowledgements

Members of the CAT group are Victoria Shone, Charlotte Harper, Rachel Viggars, Shirley Holdcroft, Kathy Gatensbury. Karin Lund, Karen Smith, Jackie Edwards & Sue Ashby

REFERENCES

1. Royal College of Nursing. Principles of Nursing Practice, 2010: http://www.rcn.org.uk/development/practice/principles/the_8_principles

2. The NMC Code, 2015 http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-new-nmc-code.pdf.

3. Metcalfe C. Barriers to implementing the evidence base in four NHS therapies: dieticians, occupational therapists, physiotherapists, speech and language therapists. Physiotherapy 2001; 87 (8): 433-441.

4. Gordon J, Watts C. Applying skills and knowledge: Principle F. Nursing Standard. 2011; 25 (33): 35-37.

5. Sackett DL, Richardson WS, Rosenburg WMC, Haynes RB. Evidence-based Medicine: How to practise and teach EBM. Edinburgh: Churchill Livingstone; 1997

6. Foster N, Barlas P, Chesterton L, et al. Critically Appraised Topics (CATs): one method of facilitating evidence-based practice in physiotherapy. Physiotherapy 2001; 87 (4): 179-190.

7. Richardson WS, Wilson MC, Nishikawa J, et al. The well-built clinical question: a key to evidence based decision making. ACP Journal Club 1995; 123 (3): A12-13.