Friday, April 10, 2015

Clinical Inquiry Series

The RNs at St. Joseph Hospital are curious and inquisitive when it comes to best nursing practice.  Our nurses are encouraged to submit their clinical practice questions to our Research Department for review of the best evidence to guide patient care.  Here is another in our series entitled "Clinical Inquiry". 

Q: What laboring positions are most effective in turning a posterior baby anterior?  We currently use far left or lateral, upper LE on over bed table, and "frog" position.  I have also seen hands on knees used.

A: What does the evidence say?
There are many beliefs regarding the best way to position a laboring woman to turn an OP baby to the occiput anterior (OA) position.  A review of the literature notes conflicting evidence for the hands and knees position (Kariminia et al., 2004) (Stremler et al., 2005).  There is not enough evidence at this time to confirm if all other positions (left lateral, right lateral or frog position) assist with rotating the baby from OP to OA position (Simkin, 2010).  The evidence does show that the hands and knees position reduces back pain during labor (Hunter et al., 2007).  None of the aforementioned positions have been shown to be harmful.  At this time, the evidence in conflicting or there is not enough evidence to say one position is better than another to rotate an OP baby.


1: Desbriere R, Blanc J, Le Dû R, Renner JP, Carcopino X, Loundou A, d'Ercole C.
Is maternal posturing during labor efficient in preventing persistent occiput
posterior position? A randomized controlled trial. Am J Obstet Gynecol. 2013
Jan;208(1):60.e1-8. doi: 10.1016/j.ajog.2012.10.882. Epub 2012 Oct 26. PubMed
PMID: 23107610.

2: Simkin P. The fetal occiput posterior position: state of the science and a new
perspective. Birth. 2010 Mar;37(1):61-71. doi: 10.1111/j.1523-536X.2009.00380.x.
Review. PubMed PMID: 20402724.

3: Stremler R, Halpern S, Weston J, Yee J, Hodnett E. Hands-and-knees positioning
during labor with epidural analgesia. J Obstet Gynecol Neonatal Nurs. 2009
Jul-Aug;38(4):391-8. doi: 10.1111/j.1552-6909.2009.01038.x. PubMed PMID:

4: Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or
labour for fetal malposition (lateral or posterior). Cochrane Database Syst Rev.
2007 Oct 17;(4):CD001063. Review. PubMed PMID: 17943750.

5: Hart J, Walker A. Management of occiput posterior position. J Midwifery Womens
Health. 2007 Sep-Oct;52(5):508-13. Review. PubMed PMID: 17826716.

6: Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan AR. Randomized
controlled trial of hands-and-knees positioning for occipitoposterior position in
labor. Birth. 2005 Dec;32(4):243-51. PubMed PMID: 16336365.

7: Kariminia A, Chamberlain ME, Keogh J, Shea A. Randomised controlled trial of
effect of hands and knees posturing on incidence of occiput posterior position at
birth. BMJ. 2004 Feb 28;328(7438):490. Epub 2004 Jan 26. PubMed PMID: 14744821;
PubMed Central PMCID: PMC351839.

Wednesday, March 04, 2015

Clinical Inquiry Series

The RNs at St. Joseph Hospital are curious and inquisitive when it comes to best nursing practice.  Our nurses are encouraged to submit their clinical practice questions to our Research Department for review of the best evidence to guide patient care.  Here is the first of our series entitled "Clinical Inquiry".

Question:  Why does St. Joseph RTs and RNs still lavage ET tubes with normal saline when evidence-based practice research shows this is not helpful and potentially harmful?

Answer: According to Lippincott’s Nursing Procedures, the use of normal saline is not included in the guidelines for suctioning. Current research is not clear.  A recent study indicates that not using normal saline before endotracheal suction decreases the incidence of ventilator-associated pneumonia and associated medical costs (Mei-Yu, Shu-Hua,  & Yi-Hui, 2012). This is contradicted by findings from another recent study which found that instillation of normal saline decreased incidence of pneumonia in intubated and ventilated patients (Caruso, Denari, Ruiz, Demarzo, & Deheinzelin, 2009).  One possible explanation for the discrepancy in results is from variations in the administration of the normal saline, time to suctioning, patient position, and dosages of saline. 

Response written by Kathleen Pentecost, SRN CBU, BA Sociology & Carla I. Morales, SRN CBU, BS Psychobiology

Caruso,P. Denari,s., Ruiz, S. A. L., Demarzo, S. E., Deheinzelin, D. (2009). Instillation of normal saline before suctioning reduces the incidence of pneumonia in intubated and ventilated adults.  Critical Care Medicine, 37, 32-38.
Lippincott Williams & Wilkins. (2009). Lippincott's nursing procedures. Philadelphia: Lippincott
Williams & Wilkins.
Mei-Yu, L., Shu-Hua, C., & Yi-Hui, S. (2012). Reducing Ventilator-Associated Pneumonia (VAP) by not using instillation saline before suctioning [Chinese]. Journal of Nursing & Healthcare Research, 8(4), 325-331.

Wednesday, February 11, 2015

Danielle's Picks from the Literature - February 2015

Here are my picks from the nursing literature for February. SJO and CHOC staff have access to the articles by contacting Burlew Medical Library.

What are the factors of organisational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review.
Williams, Brett; Perillo, Samuel; Brown, Ted;
Nurse Education Today, 2015 Feb; 35 (2): e34-41.
Abstract: Summary Background The responsibility to implement evidence-based practice (EBP) in a health care workplace does not fall solely on the individual health care professional. Organisational barriers relate to the workplace setting, administrational support, infrastructure, and facilities available for the retrieval, critique, summation, utilisation, and integration of research findings in health care practices and settings. Objective Using a scoping review approach, the organisational barriers to the implementation of EBP in health care settings were sought. Method This scoping review used the first five of the six stage methodology developed by Levac et al. (2010). The five stages used are: 1) Identify the research question; 2) identify relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and reporting the results. The following databases were searched from January 2004 until February 2014: Medline, EMBASE, EBM Reviews, Google Scholar, The Cochrane Library and CINAHL. Results Of the 49 articles included in this study, there were 29 cross-sectional surveys, six descriptions of specific interventions, seven literature reviews, four narrative reviews, nine qualitative studies, one ethnographic study and one systematic review. The articles were analysed and five broad organisational barriers were identified. Conclusions This scoping review sought to map the breadth of information available on the organisational barriers to the use of EBP in health care settings. Even for a health care professional who is motivated and competent in the use of EBP; all of these barriers will impact on their ability to increase and maintain their use of EBP in the workplace.

Back to Basics: Implementing Evidence-Based Practice.
Spruce, Lisa;
AORN Journal, 2015; 101 (1): 106-12.
Abstract: As health care transitions from volume-based care to value-based care, it is imperative that perioperative nurses implement evidence-based practices that support effective care. Implementing evidence-based practice is a challenge but improves patient outcomes, standardizes care, and decreases patient care costs. Understanding how care interventions work and how to implement them is important to compete in today's health care market. This "Back to Basics" article discusses how to identify, review, and appraise research; make recommendations to implement new practices; evaluate the outcomes of the implementations; and make necessary changes to facilitate evidence-based practice.

Development of Evidence-Based Remote Telemetry Policy Guidelines for a Multifacility Hospital System.
George, Karen J.; Walsh-Irwin, Colleen; Queen, Caleb; Vander Heuvel, Kimberly; Hawkins, Carrie; Roberts, Susan;
Dimensions of Critical Care Nursing, 2015 Jan-Feb; 34 (1): 10-8.
Abstract: Over 10 years ago, the standards for cardiac monitoring were set forth by the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young. The standards were endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. The American Heart Association printed the standards as an American Heart Association Scientific Statement. The standards provided direction related to remote telemetry monitoring to acute care hospitals. Since the standards were published, remote monitoring of cardiac patients has increased dramatically prompting research and literature related to appropriate utilization. Appropriate and safe telemetry monitoring requires clearly written evidence-based facility policies. This article describes the process whereby a team of Veterans Hospital Administration nurses from across the country reviewed 70 remote telemetry policies representing 75 Veterans Hospital Administration hospitals for clarity, consistency, and congruency to existing levels of evidence found in the literature. This article describes the processes, successes, and challenges of compiling an evidence-based remote telemetry policy guideline.
Evidence-Based Practice to Improve Outcomes for Late Preterm Infants.
Baker, Brenda;
JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 2015 Jan; 44 (1): 127-34
Abstract: Infants born between 34 weeks 0 days to 36 weeks 6 days gestation have been identified as late preterm infants (LPIs) and account for 70% of preterm births and 9% of all births. The rise in elective deliveries in the past decade is believed to have contributed to the number of late preterm births. An interprofessional team including labor and delivery, neonatal intensive care, and postpartum care providers collaborated to address this issue at an urban academic medical center.
Evidence-based nursing. Harnessing technology to promote patient-centered care.
Fisher, Cheryl A.; Feigenbaum, Kathryn;
Nursing Management, 2015 Jan; 46 (1): 14-5.
Implementing evidence-based care for patients with obstructive sleep apnea.
Bourdon, Leslie;
AORN Journal, 2014; 100 (6): C5-7.
Nursing Journal Clubs: A Literature Review on the Effective Teaching Strategy for Continuing Education and Evidence-Based Practice.
Lachance, Carly;
Journal of Continuing Education in Nursing, 2014 Dec; 45 (12): 559-65.
Abstract: Background: This literature review on nursing journal clubs evaluates the efficacy of the teaching strategy within the clinical setting. Method: Peer-reviewed articles were retrieved using an online journal database. Inclusion criteria incorporated information on efficacy of the teaching strategy, evidence-based practices, and continuing education as they related to nursing journal club initiatives. Results: The literature cited numerous benefits and proved to be in favor of nursing journal clubs. The most common benefits found were nurses remaining abreast of current research, skill development in reading and critically appraising research, and incorporation of evidence-based practices to patient care. Due to the self-motivated and voluntary nature of this teaching strategy, a limitation commonly identified was lack of participation, and further research on this limitation often was suggested. Conclusion: Nursing journal clubs proved to be an effective teaching strategy, a finding that remains consistent with the medical pioneers of the movement. J Contin Educ Nurs. 2014;45(12):559-565.
Evidence Synthesis and Its Role in Evidence-Based Health Care.
Pearson, Alan;
Nursing Clinics of North America, 2014 Dec; 49 (4): 453-60.
Promoting patient safety with evidence-based management.
Hastings, Clare;
Nursing Management, 2014 Dec; 45 (12): 11-3.

Implementing Evidence-Based Medication Safety Interventions on a Progressive Care Unit.
Williams, Tyeasha; King, Melissa W.; Thompson, Julie A.; Champagne, Mary T.;
American Journal of Nursing, 2014 Nov; 114 (11): 53-62.
Abstract: While preparing medications in complex health care environments, nurses are frequently distracted or interrupted, which can lead to medication errors that may adversely affect patient outcomes. This pilot quality improvement project, which took place in a 32-bed surgical progressive care unit in an academic medical center, implemented five medication safety interventions designed to decrease distractions and interruptions during medication preparation: nursing staff education, use o f a medication safety vest, delineation of a no-interruption zone, signage, and a card instructing nurses how to respond to interruptions. Four types of distractions and interruptions decreased significantly between the two-month preimplementation and two-month postimplementation periods: those caused by a physician, NR o r physician assistant; those caused by other personnel; phone calls and pages placed or received by the nurse during medication administration; and conversation unrelated to medication administration that involved the nurse or loud nearby conversation that distracted the nurse. The total number of reported adverse drug events also decreased from 10 to four, or by 60%. Thus, medication safety interventions may help decrease distractions and interruptions in high-acuity settings.
Improving the Culture of Evidence-Based Practice at a Magnet® Hospital.
Kaplan, Louise; Zeller, Edna; Damitio, Diane; Culbert, Sarah; Bayley, K. Bruce;
Journal for Nurses in Professional Development, 2014 Nov-Dec; 30 (6): 274-80.

Role of the Acute Care Nurse in Managing Patients With Heart Failure Using Evidence-Based Care.
Paul, Sara; Hice, Amber;
Critical Care Nursing Quarterly, 2014 Oct-Dec; 37 (4): 357-76.
Abstract: Acute heart failure is a major US public health problem, accounting for more than 1 million hospitalizations each year. As part of the health care team, nurses play an important role in the evaluation and management of patients presenting to the emergency department with acute decompensated heart failure. Once acute decompensation is controlled, nurses also play a critical role in preparing patients for hospital discharge and educating patients and caregivers about strategies to improve long-term outcomes and prevent future decompensation and rehospitalization. Nurses’ assessment skills and comprehensive knowledge of acute and chronic heart failure are important to optimize patient care and improve outcomes from initial emergency department presentation through discharge and follow-up. This review presents an overview of current heart failure guidelines, with the goal of providing acute care cardiac nurses with information that will allow them to better use their knowledge of heart failure to facilitate diagnosis, management, and education of patients with acute heart failure.
Preventing Ventilator-Associated Events: Complying With Evidence-Based Practice.
Munaco, Sandra S.; Dumas, Bonnie; Edlund, Barbara J.;
Critical Care Nursing Quarterly, 2014 Oct-Dec; 37 (4): 384-92.
Abstract: The leading cause of death due to health care-associated infections is ventilator-associated pneumonia (VAP). The lack of clarity in the definition of VAP has made it difficult to execute and evaluate the effectiveness of prevention strategies. Beginning in 2013, hospitals were expected to implement a new surveillance definition algorithm to identify ventilator-associated events (VAEs). The Institute for Healthcare Improvement recommended the use of the Ventilator Care Bundle as part of an initiative to decrease the incidence of VAP. This article outlines the results of a quality improvement project that was conducted to address this recommendation, improve current staff knowledge, identify gaps in practice, and determine the rate of compliance with prevention strategies. The major findings of this project also exposed limitations of the electronic medical record system, and suggested enhancements, which would promote the VAP Bundle initiatives, facilitate documentation, and permit straightforward data collection.

Systematic review of instruments for measuring nurses' knowledge, skills and attitudes for evidence-based practice.
Leung, Kat; Trevena, Lyndal; Waters, Donna;
Journal of Advanced Nursing, 2014 Oct; 70 (10): 2181-95.
Abstract: Aim To identify, appraise and describe the characteristics of instruments for measuring evidence-based knowledge, skills and/or attitudes in nursing practice. Background Evidence-based practice has been proposed for optimal patient care for more than three decades, yet competence in evidence-based practice knowledge and skills among nurse clinicians remains difficult to measure. There is a need to identify well-validated and reliable instruments for assessing competence for evidence-based practice in nursing. Design Psychometric systematic review. Data Sources The MEDLINE, EMBASE, CINAHL, ERIC, CDSR, All EBM reviews and PsycInfo databases were searched from 1960-April 2013; with no language restrictions applied. Review Methods Using pre-determined inclusion criteria, three reviewers independently identified studies for full-text review, extracting data and grading instrument validity using a Psychometric Grading Framework. Results Of 91 studies identified for full-text review, 59 met the inclusion criteria representing 24 different instruments. The Psychometric Grading Framework determined that only two instruments had adequate validity - the Evidence Based Practice Questionnaire measuring knowledge, skills and attitudes and another un-named instrument measuring only EBP knowledge and attitudes. Instruments used in another nine studies were graded as having 'weak' validity and instruments in the remaining 24 studies were graded as 'very weak'. Conclusion The Evidence Based Practice Questionnaire was assessed as having the highest validity and was the most practical instrument to use. However, the Evidence Based Practice Questionnaire relies totally on self-report rather than direct measurement of competence suggesting a need for a performance-based instrument for measuring evidence-based knowledge, skills and attitudes in nursing.
$trategies for Searching and Managing Evidence-Based Practice Resources.
Robb, Meigan; Shellenbarger, Teresa;
Journal of Continuing Education in Nursing, 2014 Oct; 45 (10): 461-6.
Abstract: Evidence-based nursing practice requires the use of effective search strategies to locate relevant resources to guide practice change. Continuing education and staff development professionals can assist nurses to conduct effective literature searches. This article provides suggestions for strategies to aid in identifying search terms. Strategies also are recommended for refining searches by using controlled vocabulary, truncation, Boolean operators, PICOT (Population/Patient Problem, Intervention. Comparison, Outcome, Time) searching, and search limits. Suggestions for methods of managing resources also are identified. Using these approaches will assist in more effective literature searches and may help evidence-based practice decisions.

Wednesday, August 06, 2014

Clinical Inquiry - first of a series

The RNs at St. Joseph Hospital are curious and inquisitive when it comes to best nursing practice.  Our nurses are encouraged to submit their clinical practice questions to our Research Department for review of the best evidence to guide patient care.  Here is the first of our series entitled "Clinical Inquiry".

Q: Why do we use sterile water to flush NG tubes? Why can't we use bottled or tap water?
A: Bottled or tap water is only indicated for hydration in healthy patients who are not immunocompromised.  Acutely ill patients or those with chronic conditions that have any alterations to the GI tract are vulnerable to nosocomial infections from non-sterile products including water.  This also holds true for patients who are immunocompromised but not acutely ill.  Because tap water contains metals, medications should only be diluted in sterile water to prevent reduction of bioavailability.  Tap water also has the potential to be a source of contamination when reconstituting formula.  Filtration of water may be beneficial but still poses a risk for contamination.  Sterile water is solute-free and free of chemical or microbial contaminants; therefore, it is the only type of water that should be used to flush NG tubes, dilute medications and reconstitute formula.

response written by Kathleen Pentecost, SRN CBU, BA Sociology & Carla I. Morales, SRN CBU, BS Psychobiology

Bankhead, R., Boullata, B.S., Corkins, M., Guenter, P., Krenitsky, J., Lyman, B., et al. (2009) A.S.P.E.N. Enteral nutrition    practice recommendations. Journal of Enteral and Parenteral Nutrition, 33, 122-69.

Monday, August 04, 2014

St. Joseph Hospital Staff Publishes Article

Congratulations to the following St. Joseph Hospital staff for their newly published article on blood culture accuracy: Beth Winokur, RN, PhD, CEN, Debra Pai, RN, BSN, CEN, Dana Rutledge, RN, PhD, Kate Vogel, MA, CLS, MT, Sadeeka Al-Majid, RN, PhD, Christine Marshall, RN, MSN, CEN, CPEN and Paul Sheikewitz, MD!  SJO employees have access to the full article through Burlew Medical Library.  Contact library staff for more details.

J Emerg Nurs. 2014 Jul;40(4):323-9. doi: 10.1016/j.jen.2013.04.007. Epub 2013 Jun 29.
Blood culture accuracy: discards from central venous catheters in pediatric oncology patients in the emergency department.
Winokur EJ1, Pai D2, Rutledge DN2, Vogel K2, Al-Majid S2, Marshall C2, Sheikewitz P2.

Lack of specific guidelines regarding collection of blood for culture from central venous catheters (CVCs) has led to inconsistencies in policies among hospitals. Currently, no specific professional or regulatory recommendations exist in relation to using, reinfusing, or discarding blood drawn from CVCs before drawing blood for a culture. Repeated wasting of blood may harm immunocompromised pediatric oncology patients. The purpose of this comparative study was to determine whether differences exist between blood cultures obtained from the first 5 mL of blood drawn from a CVC line when compared with the second 5 mL drawn.
During 2009-2011, 62 pediatric oncology patients with CVCs and orders for blood cultures to determine potential sepsis were enrolled during ED visits. Trained study nurses aseptically drew blood and injected the normally discarded first 5 mL and the second specimen (usual care) into separate culture bottles. Specimens were processed in the microbiology laboratory per hospital policy.
Positive cultures were evaluated to assess agreement between specimen results and to determine that the identified pathogen was not a contaminant. Out of 186 blood culture pairs, 4.8% demonstrated positive results. In all positive-positive matches, the normal discard specimen contained the same organism as the usual care specimen. In 4 matches, the normally discarded specimen demonstrated notably earlier time to positivity (4 to 31 hours) compared with the usual care specimen, which resulted in earlier initiation of definitive antibiotics.
These findings support the accuracy of the specimen that is normally discarded and suggest the need to reconsider its use for blood culture testing.