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Level of implementation and beliefs about evidence-based practice among respiratory therapists in clinical setting in saudi arabia..

Ahmad M. Alharbi Follow

Date of Award

Fall 11-29-2021

Degree Type

Degree name.

Master of Science (MS)

Respiratory Therapy

First Advisor

Dr. Lynda Goodfellow

Second Advisor

Prof. Robert Murray

Third Advisor

Prof. Kyle Brandenberger

BACKGROUND : Evidenced-based practice (EBP) is applying or translating research findings in our daily patient care practices and clinical decision-making. EBP also involves integrating the best available evidence with clinical knowledge and expertise, while considering patients’ unique needs and personal preferences. Since the role of RTs has increased, the importance of choosing the most effective treatment available is vital. Therefore, it is essential to evaluate RTs' EBP beliefs and their implementation level and obtain important information about their daily clinical practice. PURPOSE : The purpose of this study was to measure the level of implementation, describe beliefs about EBP among respiratory therapists in the clinical setting in Saudi Arabia. METHODS : The study utilized an online, cross-sectional survey with 34 questions administered to a convenience sample of RTs in Saudi Arabia. The survey is divided into three sections: belief and implementation, and demographics questions. Data were analyzed using descriptive statistics and one-way ANOVA tests. A significance level was set at 0.05. All analyses were performed in SPSS version 26. RESULTS : The total sample consisted of 49 respiratory therapists consisting of three experience levels: less than 5 years (n=38, 77.55%), 5 to 10 years (n=6, 12.24%), and more than 10 years (n=5, 10.20%). The majority of the respondents were males (57%, n=28), while the females comprised (40% n=20). Most of the respondents in the study are between 25 and 30 years old (59% n=29), under 25 years (32% n=16), and over 35 years old (8% n=4) There were no statistically significant differences between male and female respondents or years of experience in the belief or implementation scales. CONCLUSION : In conclusion, the respiratory therapists' community in Saudi Arabia reported their positive beliefs about EBP, but most of them did not frequently implement it in their daily clinical practice. Further research is required due to a lack of literature on evidence-based practice in respiratory therapy, and to assess the correlates of negative EBP' implementation levels among RTs in Saudi Arabia

https://doi.org/10.57709/26879965

Recommended Citation

Alharbi, Ahmad M., "Level of Implementation and Beliefs about Evidence-Based Practice among Respiratory Therapists in Clinical Setting in Saudi Arabia.." Thesis, Georgia State University, 2021. doi: https://doi.org/10.57709/26879965

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Evidence-Based Practice Project (Poster) Overview

This EBP Project is a culmination of a semester-long project to include an EBP poster in which student groups are answering their developed clinical question by presenting evidence found in literature to help inform and improve clinical outcomes.

You will be critically appraising primary, quantitative, peer-reviewed research articles in order to answer the nursing clinical question that you develop.

Project Includes:

Throughout the semester, the course will cover general guidelines that parallel the portions of the EBP project to include:

• Selecting a group.
• Completing a group contract.
• Choosing a clinical nursing topic in which to develop a nursing clinical question and gather data.
• Further narrowing the nursing topic into which population to explore, which nursing intervention to measure, the comparison (or opposite) of the intervention, and the outcome that you are questioning.
• Developing a PICO statement.
• Development of a clinical question based on the inadequacies or gap in knowledge of current practice.
• Locate the best evidence with methodology of data gathering via a literature search.
• A synthesis of literature via systematic methods
• Design/discuss the potential change, applying the synthesized evidence to present & discuss implications in practice that reflects this new understanding.
• Peer review of another group’s poster
• Application of edits from received peer review
• Presentation of findings/dissemination of knowledge via a poster presentation.
• Self-evaluation
• Peer evaluation of others in your group

EBP Poster Content Overview (see below in document for detailed descriptions):

The Final EBP Poster will include the following sections, utilizing the template provided:

• Introduction, including nursing clinical question
• Methodology (Databases utilized, inclusion/exclusion criteria, Boolean operators, key terms and/or phrases, publication years, etc.)
• Results (Objective)

In addition, a presentation will be required as part of the Final EBP Project grade.

A template for the poster has been provided. Please see rubric under the assignment. Students will present their poster in a live presentation in which all headings/points of discussion must be covered in a semi-formal presentation. This presentation serves as a method of dissemination of your findings.

The EBP Poster will be submitted through Canvas and will generate a Turn It In score in order to avoid unintended plagiarism.

Rubrics are posted in Canvas for each of these assignments for further details, criteria, and grading schemes.

What is this EBP Project?

Person-centered care is holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate. Person-centered care builds on a scientific body of knowledge that guides nursing practice regardless of specialty or functional area.

As one of the key attributes of professional nursing, clinical judgment refers to the process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning (Manetti, 2019). This process is used to understand and interpret information in the delivery of care. Clinical decision making based on clinical judgment, is directly related to care outcomes.

Evidence-based practice in nursing focuses on the idea that nursing practices ought to be developed and adapted on an ongoing cycle of evidence, theory, and research. As changes in practice prompt further research, the theories developed from that research serve as evidence to produce more changes in practice. The investigation of evidence-based practice in nursing, also called Systematic Review (or Literature Review, for the sake of our EBP Project in this course), requires the review of such research with the intention of targeting and improving inadequate practice.

The delivery of optimal health care requires the integration of current evidence and clinical expertise with individual and family preferences. Evidence-based practice is a problem-solving approach to the delivery of health care that integrates best evidence from studies and patient care data with clinician expertise and patient preferences and values (Melnyk, Fineout-Overhold, Stillwell, & Williamson, 2010). In addition there is a need to consider those scientific studies that ask: whose perspectives are solicited, who creates the evidence, how is that evidence created, what questions remain unanswered, and what harm may be created? Answers to these questions are paramount to incorporating meaningful, culturally safe, evidence-based practice.

The review of outside research attempts to make sense of the large body of information available in order to implement change effectively. How can this research be applied on an individual basis to improve patient care?

Evidence-based practice involves the following six steps*:

• Assess the need for change : Formulate the research question based on the inadequacies of current practice.
• Locate the best evidence : Obtain sources and assess their credibility and relevancy to the research question.
• Synthesize evidence : Compare and contrast the available sources to find similarities and differences in the various approaches taken.
• Design the change : Apply the synthesized evidence to create a change in practice that reflects the new understanding.
• Implement and evaluate : Apply the necessary changes and assess the changes to acquire new evidence.
• Integrate and maintain changes : Reassess based on new evidence to continue improvement.

The structure of an evidence-based practice research paper typically requires 4 parts, and often includes subheadings:

• Introduction.
• Methodology.
• Discussion.

Detailed Sections of the EBP Poster:

For our EBP Project Poster, which is basically in lieu of a paper, you are to summarize your findings. We will include the following sections:

Introduction – This includes the “background” as to why this topic is important, what might be known/unknown, and the problem. This section will be much bigger than the methods section. You will need to include your clinical question here (in a question format, clearly defined as “Nursing Clinical Question”). You need to provide a reason for reviewing literature for your clinical question. For example, if you are reviewing evidence regarding adjunctive pain management, your background may include data that opioids have many side effects, perhaps that patients often ask about alternative pain management modalities, and that your population (ex: patients with cancer) has a well-documented poor pain management plan. All of this needs to come from evidence before you start reviewing additional evidence that answers your specific clinical question. This is basically your first review of literature for your poster. You will need to state facts from evidence that proports the underlying issue, and then cite.

Methodology – This is how you found your information. What databases did you search (CINAHL, PubMed, Cochrane, etc.)? Years? Search terms/phrases? Inclusion/exclusion criteria? Boolean operators? This section will be very brief. However, it needs to be very specific. Did you search for heart failure or “heart failure” (big difference with the quotation marks around a phrase)? It needs to be specific enough, that another person could replicate exactly what you wrote in your methodology section and find the exact same articles that you found. Selecting evidence can be difficult, especially when you are considering suggesting making changes to common practices. You must assess the dependability of the source itself. Do not select sources simply because they work well with your topic. Using sources that are not credible will only serve to discredit your own ideas. Be prepared to discuss the following in a concise, scientific manner:

• What databases did you search? What search terms did you use? How many total articles on the subject did you find? A search that returns few results may be the results of using search terms that are too narrow. Search terms need to use the specific vocabulary of the specific field of research. Try varying terms to match the genre of research you need.
• What criteria led you to include or exclude sources? You may wish to present these criteria in the form of lists or tables. When evaluating sources, consider the following:

Credibility: Is the study from reputable researcher or journal? Databases can produce results from magazines or general reading material; these are not always peer-reviewed. Limit your search to scholarly journals.

Validity: Does the study measure what it says it measures? What demographic sample did the study survey? The methods of examination and procedures of analysis make a big different in the validity of results. Does the study present a margin of error? If so, is it narrow enough to make the results accurate?

Reliability: Will the same test yield the same result? Did the study end as soon as favorable results were obtained? Were the reports consistent? A study should mention its own limitations; did the study have limitations that were not noted?

You will want to use similar studies as much as possible. Because quantitative and qualitative studies measure different things, it will be difficult to integrate and synthesize the sources you acquire unless they are fairly similar. Your evidence-based practice review may use quantitative reviews, qualitative reviews, or other evidence-based practice reviews; comparing mixed methods will likely make your methodology more difficult to understand.

If you are having trouble telling the different between quantitative and qualitative studies, look at the methodology listed. Quantitative studies deal only with objective figures that can be measured, counted, and calculated. Qualitative studies will still use numbers to describe the sample and/or control groups, but they will focus on subjective analysis, descriptions, and interviews.

Results –This is objective data. These are the results that the researchers found.

Your results/findings will be an analysis. You should present the studies you selected as the most appropriate sources for studying your problem and instituting your proposed change.

Be sure to compare the following aspects of each study:

• Demographics, pools, and samples
• Methods of discovery and analysis
• Results and limitations

Remember that these studies are supposed to be the most reliable and valid studies available for answering the problem you found or the practice you wish to change. Your findings should lay the groundwork for you to make this argument in your discussion section.

Discussion – Here is the “meat” of what you found or didn’t find. It is usually a pretty big section. Is there a trend? Is there an even bigger gap in evidence than you expected? With the information you found, what are the implications? How does this relate to literature you found? What where the most major findings (don’t repeat from your results section, but highlight it in different terms)? Should more research be done, or is there more than enough evidence to support a change? The subheadings should be: Implications, Strengths, Limitations, and Future Recommendations/Studies.

In a professional research environment, the discussion should discuss the changed practice, its implementation, and its evaluation. However, this is impossible to do in a classroom situation. Therefore, do the following:

• Argue that the findings lead to the specific change in practice you identified in your institution.
• Suggest a strategy for implementation. Will the change you recommend (and that these studies probably also recommend) work in your situation or not? Why? What changes might be needed?

For further help in evidence-based practice, read samples of published evidence-based practice studies to get a good idea of how other healthcare professionals write these studies. Databases like CINAHL are good sources for these articles.

References – The top 8 (it is difficult to fit more than that onto the poster) that best address your clinical question are to be on your poster. There is a requirement for much more than 8 (see requirements) for your Synthesis of Evidence.

Course Outcomes and BSN Essentials:

This project provides each student the opportunity to master the following Course Outcomes:

• Person-Centered Care: Demonstrate an understanding of the basic elements of the research process, differentiate questions and methods suitable for quantitative and qualitative nursing research, and apply strategies and resources to promote evidence-based practice, especially in areas of quality and safety.
• Clinical Judgment: Appraise clinical decisions based on appraisal on the triad of evidence-based practice: evidence, patient preferences, and clinical expertise.
• Communication: Using information technology to retrieve hierarchical levels of evidence, appraise the credibility of sources of information, including but not limited to databases and internet resources to address clinical questions.
• Compassionate Care: Distinguish the role of evidence-based practice in organizational and systems leadership to support quality patient care and apply principles of evidence-based practice with diverse populations.
• Professionalism: Assess practice discrepancies between identified standards and practice that may adversely impact patient outcomes and utilize the process of retrieval, appraisal, and synthesis of evidence to improve patient outcomes.

This EBP Project also covers the following American Association of Colleges of Nursing BSN Essentials:

Domain 2.5d: Incorporate evidence-based intervention to improve outcomes and safety. Domain 4.2: Integrate best evidence into nursing practice Domain 4.1: Advance the scholarship of nursing. Domain 4.1a: Demonstrate an understanding of different approaches to scholarly practice. Domain 4.2a: Evaluate clinical practice to generate questions to improve nursing care. Domain 4.2b: Evaluate appropriateness and strength of the evidence. Domain 4.2c: Use best evidence in practice. Domain 4.1d: Demonstrate an understanding of basic elements of the research process. Domain 4.1e: Participate in scholarly inquiry as a team member. Domain 4.1f: Evaluate research. Domain 4.1g: Communicate scholarly findings. Domain 4.3: Promote the ethical conduct of scholarly activities. Domain 4.3a Explain the rationale for ethical research guidelines, including Institutional Review Board (IRB) guidelines. Domain 4.3b: Demonstrate ethical behaviors in scholarly projects including quality improvement and EBP initiatives. Domain 4.3c: Advocate for the protection of participants in the conduct of scholarly initiatives. Domain 4.3d: Recognize the impact of equity issues in research.

Larrabee, J. H. (2009). Nurse to nurse: Evidence-based practice. New York: McGraw-Hill.

Manetti, W. (2019). Sound clinical judgment in nursing: A concept analysis. Nursing Forum, 54(1), 102-110.

Melnyk, B., Fineout-Overhold, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Igniting a spirit of inquiry. American Journal of Nursing, 109(11), 49-52.

Evidence-Based Practice & Research Methodologies Copyright © by Tracy Fawns is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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What is evidence-based practice.

Evidence-based practice helps ground professional decisions in the literature of the discipline and in the context of the patient(s), subjects (human or otherwise) or situation-- such studies are done and used in architecture, ecology and public policy as well as health, social work, and education. The biggest single question is some form of: "What has been shown to work, in ____situation?"

Sometimes, there is enough to suggest relevant practices but not count them as proven, what Adams and Sandbrook refer to "evidence-informed practice" ( Conservation, evidence and policy. 2013. Oryx , 47,3: 329-335)

While the majority of evidence-based practice studies relate to health of human beings, the practice is spreading to other fields. Appropriate sources may vary by discipline; IF in doubt, consult your advisor/professor.

Some Databases with Systematic Reviews

• Guide to Community Preventive Services (from the Centers for Disease Control). "The Guide to Community Preventive Services is a free resource to help you choose programs and policies to improve health and prevent disease in your community. Systematic reviews are used to answer these questions: Which programs and policy interventions have been proven effective? Are they right for my community? What is the cost? What is the likely return on investment?"

• National Quality Measures Clearinghouse From the U.S. Dept. of Health and Human Services-- look for the Agency for Healthcare Research and Quality (AHRQ).
• TRIP database: clinical search engine "The TRIP Database is a clinical search tool designed to allow health professionals to rapidly identify the highest quality clinical evidence for clinical practice." Usually you'll find summaries rather than full reports, but this varies. They have a "Pro" version that costs $, but some material is still freely available.
• National Center for Biotechnology Information "As a national resource for molecular biology information, NCBI's mission is to develop new information technologies to aid in the understanding of fundamental molecular and genetic processes that control health and disease."
• Physiotherapy Evidence Database, PEDro

Levels of Evidence

Example levels of evidence.

Robey, R. R. (2004, April 13). Levels of Evidence. The ASHA Leader. http://www.asha.org/Publications/leader/2004/040413/f040413a2.htm

There are other examples. This is a commonly-used hierarchy.

Another Hierarchy for EBM

Rating System for the Hierarchy of Evidence: Quantitative Questions

Level I: Evidence from a systematic review of all relevant randomized controlled trials (RCT's), or evidence-based clinical practice guidelines based on systematic reviews of RCT's Level II: Evidence obtained from at least one well-designed Randomized Controlled Trial (RCT) Level III: Evidence obtained from well-designed controlled trials without randomization, quasi-experimental Level IV: Evidence from well-designed case-control and cohort studies Level V: Evidence from systematic reviews of descriptive and qualitative studies Level VI: Evidence from a single descriptive or qualitative study Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Above information from "Evidence-based practice in nursing & healthcare: a guide to best practice" by Bernadette M. Melnyk and Ellen Fineout-Overholt. 2005, page 10. From: http://researchguides.ebling.library.wisc.edu/content.php?pid=325126&sid=2940230

In addition:.

Practice that is based on empirical research is more likely to be sound. Looking for systematic reviews of the literature allows you to have some confidence that the practices recommended are based on more than just a few patients. Systematic reviews that include meta-analyses of the data in the articles are more likely to be reliable.

What rules did the authors follow when doing the meta-analysis or systematic review? There should be:

• a summary of findings,
• details on where they searched (names and dates covered of databases, for example),
• how and when searched (more than one searcher or replicated searches are better),
• how the studies were selected (criteria),
• how many studies out of X number of possible studies,
• what quality (and what indications of quality were used), and
• whether they limited the search to English language sources, among other possibilities.

Did they cover the relevant, important literature in the field? Is the number sufficient? How did they define useful studies? Does their definition make sense? Did they include randomized controlled studies as at least part of their selection? Did they suggest implications of the results of the study for practice and research? Are recommendations or protocols included, or are you directed to them in another document?

Things to consider: Did they ask a good question? the 'right' question? Did they make their methods explicit? Was their search detailed? Was it comprehensive? What did they miss, and why?

A different model for evaluation that I also like is called the rhetorical triangle: the three points of the triangle are author, audience and purpose (Laura Wukovitz, http://Research Guides.hacc.edu/milex). This brings into the consideration that there are often social dimensions to even the most data-driven science ("Whose ox is being gored?"), another way of asking who benefits or loses from a particular publication or study, and in what way?

• Health Care Standards for Systematic Reviews from the Institute of Medicine A very detailed description of how these kinds of reviews should be done in medical fields.

Even the Best Studies May Have Flaws--

• A Retrospective Self-critique by One Scholar of His Own Studies--Food for Thought
• Ask for Evidence-- points to consider

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Fostering evidence-based quality improvement in nursing practice

Nursing professionals are highly skilled experts in their field and make a significant impact on so many lives every day in a fast-paced, safety-critical environment. When it comes to patient care, outcomes, and overall healthcare delivery, evidence-based practice is an essential component in nursing and beyond. It promotes a culture of continuous learning and development, crucial in ensuring that nurses provide effective and efficient care based on the most current research and knowledge available.

Scientific evidence should inform decisions rather than anecdotal narratives, to help phase out outdated practices, increase satisfaction rates, and promote patient safety measures and quality care initiatives.

Unlocking the power of evidence-based nursing

Evidence-based nursing integrates the latest research findings, clinical expertise, and patient values to inform patient care decisions. It emphasizes a more systematic approach over traditional methods or personal beliefs, with a core focus on integrating scientific evidence to support high-quality care. This becomes ever more important as the volume of health information expands at an exponential rate, alongside a proliferation of misinformation.

But how can nurses translate evidence into meaningful and actionable decisions to improve the quality of care at the bedside? It can be a daunting task, but the nursing process is a key focus area for applying evidence in practice.

Practical application

The five phases of the nursing process are designed to deliver patient-focused care and develop critical thinking skills in a systematic way. 1 The theoretical framework can serve as a way of injecting evidence into one’s workflow. A practical implementation of its steps could translate as follows:

• Assessment : reflection, questioning, description of the problem, and gathering of the latest evidence for relevant data collection.
• Diagnosis : critical appraisal of the latest data, and relevance of its application to the clinical situation.
• Planning : goal-setting process to develop a tailored course of action.
• Implementation : application of evidence-based interventions based on clinical situation to be addressed.
• Evaluation : results assessment phase to ascertain that evidence promoted quality improvement (QI) outcomes, and/or identify gaps in care delivery processes, leading to enhanced safety protocols that minimize errors and adverse events.

From novice to expert, it can help nurses think through a course of action. It works as an iterative process that invites reflection, promotes professional behaviors in an interdisciplinary setting, and fosters evidence-based decision making. 2

Quality improvement

Quality improvement (QI) in nursing focuses on enhancing processes, systems, and practices within healthcare settings to optimize patient outcomes and experiences (recovery rates, satisfaction levels, and overall well-being, among others). Nurses play a crucial role in QI initiatives by actively participating in quality assessment activities, suggesting improvements based on their clinical experiences, and collaborating with interdisciplinary teams to implement changes effectively.

The evidence-based approach follows a structured process that includes asking clinical questions, searching for relevant evidence, critically appraising the evidence, applying it to practice, and evaluating outcomes. This systematic approach ensures that decisions are based on the best available evidence and are tailored to meet not only individual patient needs, but also financial goals of the healthcare system, with length of stay and mortality topping the list of performance metrics. 3

Impacting the nursing workflow

The spread of too much information, either accurate or false, is referred to as an infodemic. Healthcare is an ever-evolving ecosystem where this prevails. Distinguishing fact from fiction becomes difficult, especially when misleading information is spread on social media. The World Health Organization (WHO) encourages health professionals to evaluate and manage the information they receive more judiciously. 4 The U.S. Surgeon General also suggests that in addition to continuing education endeavors, using the right clinical decision support (CDS) tool can effectively support the evidence-based decision-making process. 5

Spotlight on intravenous infusion

As the number of intravenous (IV) medications continues to expand, there is increased likelihood that nurses need to administer multiple IV medications concurrently. Lack of knowledge of a drug is one of the most systemic causes of administration errors when it comes to IV infusion. 6 Being able to rely on a CDS tool that supports a robust evidence-based approach is key to appropriately identifying parameters such as physical compatibility, chemical stability, and reconstitution, which are essential to safe drug administration interventions.

Nurse-led initiatives can help to reduce unnecessary costs associated with ineffective treatments or preventable complications. 7 What’s more, implementing evidence-based practice increases nurses’ satisfaction and has been identified as a determining factor in staff retention. 8

Evidence-based practice and quality improvement are integral aspects of nursing that drive innovation, excellence, and improved patient outcomes. The benefits of embracing these principles into the nursing workflow elevate the standard of care nurses provide, contribute to a culture of continuous improvement within healthcare organizations, whilst addressing health misinformation and ensuring a return-on-investment (ROI) for healthcare facilities.

Learn about evidence-based clinical decision support from Micromedex.

• Wayne, G. (2024). NurseLabs. The Nursing Process. Retrieved May 1, 2024 from https://nurseslabs.com/nursing-process/
• Johns Hopkins Medicine. (2024). Center for Evidence-Based Practice: The Johns Hopkins Evidence-Based Practice Model. Retrieved on May 1, 2024 from https://www.hopkinsmedicine.org/evidence-based-practice/model-tools
• Connor, L., et al. (2023). Evidence-based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review. Worldviews on evidence-based nursing, 20(1), 6–15. https://doi.org/10.1111/wvn.12621
• World Health Organization (WHO). (2024). Infodemic. Retrieved on May 1, 2024 from https://www.who.int/health-topics/infodemic#tab=tab_1
• U.S. Department of Health and Human Services (USDHHS). (2024). Health Misinformation. Retrieved on April 30, 2024 from https://www.hhs.gov/surgeongeneral/priorities/health-misinformation/index.html
• Massoomi, F., Burger, M., & de Vries, C. (2021). Advances in safe insulin infusions. Drugs in context, 10, 2021-1-6. https://doi.org/10.7573/dic.2021-1-6
• Edumerson. (2024). Improving Patient Outcomes and Reducing Health Care Costs Through Nurse-Led Initiatives. Retrieved on May 1, 2024 from https://edumerson.com/improving-patient-outcomes-and-reducing-healthcare-costs-through-nurse-led-initiatives/
• Melnyk, B. M., Tan, A., Hsieh, A. P., & Gallagher-Ford, L. (2021). Evidence-Based Practice Culture and Mentorship Predict EBP Implementation, Nurse Job Satisfaction, and Intent to Stay: Support for the ARCC© Model. Worldviews on Evidence-Based Nursing, 18(4), 272-281. https://doi.org/10.1111/wvn.12524 .

https://www.merative.com/blog/nurse-burnout-efforts-should-target-younger-nurses https://www.merative.com/blog/considerations-for-hospital-leadership-on-cdss-investments

https://www.merative.com/blog/rare-diseases-gene-therapy

Good practice recommendations on add-ons in reproductive medicine†

Affiliations.

• 1 Department Reproductive Medicine, Sahlgrenska University Hospital, Göteborg, Sweden.
• 2 The Fertility Department, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark.
• 3 Department Obstetrics and Gynecology, Koc University School of Medicine, Istanbul, Turkey.
• 4 Department of Gynecology, Obstetrics, and Gynecological Endocrinology, Kepler University, MedCampus IV, Linz, Austria.
• 5 Institute for Women's Health, London, UK.
• 6 European Society of Human Reproduction and Embryology, Brussels, Belgium.
• 7 Department of Pathology, University of Cambridge, Cambridge, UK.
• 8 Progress Educational Trust, London, UK.
• 9 Department Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain.
• 10 Fertility Europe, Brussels, Belgium.
• 11 Hygeia IVF Embryogenesis, Athens, Greece.
• 12 Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Brussels, Belgium.
• PMID: 37747409
• PMCID: PMC10628516
• DOI: 10.1093/humrep/dead184

Study question: Which add-ons are safe and effective to be used in ART treatment?

Summary answer: Forty-two recommendations were formulated on the use of add-ons in the diagnosis of fertility problems, the IVF laboratory and clinical management of IVF treatment.

What is known already: The innovative nature of ART combined with the extremely high motivation of the patients has opened the door to the wide application of what has become known as 'add-ons' in reproductive medicine. These supplementary options are available to patients in addition to standard fertility procedures, typically incurring an additional cost. A diverse array of supplementary options is made available, encompassing tests, drugs, equipment, complementary or alternative therapies, laboratory procedures, and surgical interventions. These options share the common aim of stating to enhance pregnancy or live birth rates, mitigate the risk of miscarriage, or expedite the time to achieving pregnancy.

Study design, size, duration: ESHRE aimed to develop clinically relevant and evidence-based recommendations focusing on the safety and efficacy of add-ons currently used in fertility procedures in order to improve the quality of care for patients with infertility.

Participants/materials, setting, methods: ESHRE appointed a European multidisciplinary working group consisting of practising clinicians, embryologists, and researchers who have demonstrated leadership and expertise in the care and research of infertility. Patient representatives were included in the working group. To ensure that the guidelines are evidence-based, the literature identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, recommendations were based on the professional experience and consensus of the working group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 46 independent international reviewers. A total of 272 comments were received and incorporated where relevant.

Main results and the role of chance: The multidisciplinary working group formulated 42 recommendations in three sections; diagnosis and diagnostic tests, laboratory tests and interventions, and clinical management.

Limitations, reasons for caution: Of the 42 recommendations, none could be based on high-quality evidence and only four could be based on moderate-quality evidence, implicating that 95% of the recommendations are supported only by low-quality randomized controlled trials, observational data, professional experience, or consensus of the development group.

Wider implications of the findings: These guidelines offer valuable direction for healthcare professionals who are responsible for the care of patients undergoing ART treatment for infertility. Their purpose is to promote safe and effective ART treatment, enabling patients to make informed decisions based on realistic expectations. The guidelines aim to ensure that patients are fully informed about the various treatment options available to them and the likelihood of any additional treatment or test to improve the chance of achieving a live birth.

Study funding/competing interest(s): All costs relating to the development process were covered from ESHRE funds. There was no external funding of the development process or manuscript production. K.L. reports speakers fees from Merck and was part of a research study by Vitrolife (unpaid). T.E. reports consulting fees from Gynemed, speakers fees from Gynemed and is part of the scientific advisory board of Hamilton Thorne. N.P.P. reports grants from Merck Serono, Ferring Pharmaceutical, Theramex, Gedeon Richter, Organon, Roche, IBSA and Besins Healthcare, speakers fees from Merck Serono, Ferring Pharmaceutical, Theramex, Gedeon Richter, Organon, Roche, IBSA and Besins Healthcare. S.R.H. declares being managing director of Fertility Europe, a not-for-profit organization receiving financial support from ESHRE. I.S. is a scientific advisor for and has stock options from Alife Health, is co-founder of IVFvision LTD (unpaid) and received speakers' fee from the 2023 ART Young Leader Prestige workshop in China. A.P. reports grants from Gedeon Richter, Ferring Pharmaceuticals and Merck A/S, consulting fees from Preglem, Novo Nordisk, Ferring Pharmaceuticals, Gedeon Richter, Cryos and Merck A/S, speakers fees from Gedeon Richter, Ferring Pharmaceuticals, Merck A/S, Theramex and Organon, travel fees from Gedeon Richter. The other authors disclosed no conflicts of interest.

Disclaimer: This Good Practice Recommendations (GPRs) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation.ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or bedeemedinclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results.Theydo not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type.Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.

Keywords: ART; ESHRE; ICSI; IVF; add-on; good practice; guidelines; infertility.

© The Author(s) 2023. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.

Publication types

• Research Support, Non-U.S. Gov't
• Infertility* / therapy
• Pharmaceutical Preparations
• Reproductive Medicine*
• Treatment Outcome