Wednesday, May 23, 2007
On April 26, 2007, I went to the 6th Annual Evidence-Based Practice Conference at UCLA, “Empowering Patients and Nurses As Partners in Evidence-Based Care.” I thought I would share some of the keynote speaker’s ideas on evidence-based practice. The keynote speaker, Bernadette Mazurek Melnyk, PhD, RN, CPNP/NPP, FAAN, FNAP, is the Dean and Distinguished Foundation Professor in Nursing at Arizona State University. She kindly emailed me and gave me permission to use excerpts from her lecture to put on our blog.
According to Dr. Melnyk, evidence-based practice (EBP) is a problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician’s expertise as well as patient preferences and values. The aim of EBP is to make decisions about types of care . Resources available also must be considered in decision-making.
As nurses, we must accelerate EBP because despite an aggressive research movement, the majority of findings from research often are not integrated into practice. Dr. Melnyk poignantly noted that it takes approximately 17 years to make a change, so we as health providers need to get a move on to make things happen. Often practices within nursing are routed in tradition and are often outdated; they do not lead to the best patient outcomes. Even traditional continuing education conferences do not significantly improve clinical performance and as nurses we need to improve clinical outcomes and performance. Also EBP must be implemented to advance our profession and enhance life-long learning and keep our practices up to date. In the future, it is quite possible that 3rd party payers will only provide reimbursement for healthcare practices that are supported with evidence. Therefore we need to be practicing EBP.
EBP affects patient’s physiological, psychosocial, and functional status. As pointed out by Melnyk, EBP improves outcomes and outcomes reflect IMPACT! This then leads to a positive effect on the health system.
A study by Pravikoff, Tanner, and Pierce (2005) looked at registered nurses in the U.S. The researchers found that 34.5% of the sample only needed information infrequently, almost half were not familiar with the term “evidence-based practice,” and more than half believed that their colleagues use research findings in their practice. This study also showed that most nurses do not search information resources to gather practice information and only 27% had any instruction in using electronic databases.
Barriers to evidence-based practice in the Pravikoff et al. study included “lack of value for research.” Organizational barriers for using information in practice included “presence of other goals with a higher priority.” Researchers concluded that “RNs in the United States aren’t ready for evidence-based practice because of the gaps in their information literacy and computer skills, their limited access to high quality information resources, and above all, the attitudes toward research” (Pravikoff et al., 2005 p. 50).
Knowing this information, how do we get EBP into practice? This is the burning question when there are such visible barriers. According to Melnyk, we must become key facilitators of EBP or champions. This roles involves obtaining knowledge and skills of EBP, understanding that EBP improves care and outcomes, believing in the ability to implement EBP, developing mentor(s)/teachers who are skilled in EBP, and gaining administrational/organizational support. In making patient care decisions, we must use our clinical judgment and expertise, access up-to-date evidence, and consider patient’s preferences and values to make a decision.
Dr. Melnyk lists five steps as the process of EBP:
1. Ask the burning clinical question in PICO format
Intervention of interest
Comparison intervention or group
2. Collect the best evidence. Search first for systematic reviews (e.g., the Cochrane Database of Systematic Reviews) and evidence-based clinical practice guidelines (http://www.guideline.gov/).
3. Critically appraise the evidence.
4. Integrate evidence, clinical expertise, and patient factors/preferences to implement a decision.
5. Evaluate the outcome.
So remember, evidence-based practice improves outcomes for patients, and nursing is all about the patients! This conference again renewed my own enthusiasm for EBP. I would again like to thank Bernadette Melnyk and Arizona State University for sharing her power-point presentation.
Melnyk, B. (April 2007). Empowering patients and nurses as partners in evidence-based practice. Power-point presentation given at UCLA Conference.
Pravikoff, D., Tanner, A., & Pierce, S. (2005). Readiness of U.S. nurses for evidence-based practice. American Journal of Nursing, 105(9), 40-50.
Monday, May 21, 2007
Selling, Kathleem, M.D., Theodore E. Warhentin, M.D., Andreas Greinacher, M.D., “Heparin-induced Thromocytopenia in Intensive Care Patients”, Critical Care Medicine, April 2007: vol.35:4 pp.1165-1176.
“Objective: To summarize new information on frequency of heparin-induced thrombocytopenia (HIT) in patients treated in intensive care units (ICU), developments in the interpretation of assays for detecting anti-PF4/heparin antibodies, and treatment of HIT patients.
Study Selection: All data on the frequency of laboratory-confirmed HIT in ICU patients were included; for laboratory testing of HIT and treatment of patients, this review focuses on recent data that became available in 2005 and 2006.
Data Extraction and Synthesis: HIT is a potentially life-threatening adverse effect of heparin treatment caused by platelet-activating antibodies of immunoglobulin G class usually recognizing complexes of platelet factor 4 and heparin. HIT is more often caused by unfractionated heparin than low-molecular-weight heparin and is more common in postsurgical than in medical patients. In the ICU setting, HIT is uncommon (0.3-0.5%), whereas thrombocytopenia from other causes is very common (30-50%). For laboratory diagnosis of HIT antibodies, both antigen assays and functional (platelet activation) assays are available. Both tests are very sensitive (high negative predictive value) but specificity is problematic, especially for the antigen assays, which also detect nonpathogenic immunoglobulin M and immunoglobulin A class antibodies. Detection of immunoglobulin M or immunoglobulin A antibodies could potentially lead to adverse events such as bleeding if a false diagnosis of HIT prompts replacement of heparin by an alternative anticoagulant. For treatment of HIT, three alternative anticoagulants are approved: the direct thrombin inhibitors, lepirudin and argatroban, and the heparinoid, danaparoid (not approved in the
Conclusions: HIT affects <1%>
Have you experienced any episodes of HIT in your unit?
Wednesday, May 16, 2007
Monday, May 14, 2007
Friday, May 11, 2007
NLM Serial ID Number
Monday, May 07, 2007
Newhouse, Robin P., RN, PhD, CNA, CNOR
“Creating Infrastructure Supportive of Evidence-Based Nursing Practice: Leadership Strategies” Worldviews on Evidence-Based Nursing 4 (1), 21–29.
“Nursing leadership is the cornerstone of successful evidence-based practice (EBP) programs within health care organizations. The key to success is a strategic approach to building an EBP infrastructure, with allocation of appropriate human and material resources.
This article indicates the organizational infrastructure that enables evidence-based nursing practice and strategies for leaders to enhance evidence-based practice using "the conceptual model for considering the determinants of diffusion, dissemination, and implementation of innovations in health service delivery and organization."
Enabling EBP within organizations is important for promoting positive outcomes for nurses and patients. Fostering EBP is not a static or immediate outcome, but a long-term developmental process within organizations. Implementation requires multiple strategies to cultivate a culture of inquiry where nurses generate and answer important questions to guide practice.
Organizations that can enable the culture and build infrastructure to help nurses develop EBP competencies will produce a professional environment that will result in both personal growth for their staff and improvements in quality that would not otherwise be possible.”
We were just discussion promotion of evidence-based “thinking” in the research council this week. Even though putting research into practice is clear, using this evidence in practice is not always easy, especially when your physician says “I don’t like to use Versed.” I think we as nurses are used to looking toward the physician as the absolute leader. It is a shift in our way of practice to realize we must now, perhaps, remind the physician that that is “not what the literature supports” or that "our new policy" now asks us to do things another way. But if everyone thought and acted this way, it would become part of the work culture.
I like the way this article talks about resources. We have generated a lot of good ideas in our critical care unit. How does the manager decide how much time and money to allocate to each idea?
I would like to thank the Burlew’s librarian, Julie Smith, for her EBN articles in “picks from the literature.” See April 13, 2007, in this blog.
Wednesday, May 02, 2007
Callen, B. L., Mahoney, J.E., Grieves, C.B., Wells, T.J., & Enloe, M. (2004). Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatric Nursing, 25, 212-217.
Lack of activity during hospitalization may contribute to functional decline. The purpose of this study was to determine the frequency of hallway walking by older adults hospitalized for medical illness. The study was an observational time-sampled study, which was conducted in the hallways of 3 medical units of a 485-bed academic health care center. Each unit was observed weekdays for eight 3-hour intervals covering 8 AM to 8 PM. Before each observation, nursing staff were questioned about walking abilities of patients aged > 55 years. During observation, frequency and minutes of patients’ hallway ambulation were recorded. Of 118 patients considered by nurses as able to walk in the hallways, 18.6% walked once, 5.1% twice, 3.4% more than twice, and 2.9% did not walk at all per 3-hour period. The median minutes for ambulation was 5.5. Frequency of ambulation was as low for patients independent in walking as for those dependent (28% vs. 26%, P=.507). Of the 32 patients who walked in the hallways, most did so alone (46.8%, n=15) or with therapy staff (41%, n=13); few walked with nursing staff (9.4%, n=3) or family (18.8%, n=6). In this setting, hallway walking was very low for hospitalized older patients. If this trend of limited walking is found to be prevalent across other settings, then both independent and dependent patients will require additional interventions to improve ambulation during hospitalization.
Commentary by Dana Rutledge, RN, PhD, Nursing Research Facilitator
This is one of few studies that document anything about ambulation in hospitalized patients. Its limitations include the fact that it was an observational study, that determination of patients’ ability to ambulate and need for assistance was based upon nursing judgment, that no data were collected on motivation to walk, and that the study only occurred on weekdays. Despite these limitations, study results point out that medical/surgical patients do not ambulate a lot, and that much ambulation may be driven by “therapy” goals rather than optimizing patient physical function (normal conditioning). This implies that patients who do not have ambulation “ordered” may lose function even if they entered the hospital fully functional. We are all aware of the “hazards of immobility” (Olson, 1967): pathology including cardiovascular, respiratory, gastrointestinal, musculoskeletal, urinary, metabolic, and psychosocial health changes.
When I read this abstract, I was surprised at the low proportion of walks where the patient was with nursing staff or family. So, in the article, I searched for how they measured this. Walking was observed by a non-staff observer who “sat in a corner of the middle section of the unit;” walking in the rooms was not observed. Each of 3 medical/surgical units were sampled during 3-hour intervals between 8 a.m. and 8 p.m. Each unit was observed for 24 hours. For patients who would be observed (> 55 years), the observer first gathered information about patient activity from the nursing staff. Per observation period and per patient, the observer noted time and duration, route taken, apparent purpose, and presence of human assistance or assistive device. The definition of the walk’s purpose was confusing to me:
· For therapy – patient walking with a nurse or off-unit health professional
· For a purpose other than therapy – walking with a definite goal (e.g., walking to elevator)
· For exercise – walking along or with family with no observable goal
I was unable to reconcile how the researchers differentiated walking with therapy staff or with nursing staff.
So, the actual percentages of walks per category may not make sense, but overall, patients did not walk much. I wonder how much patients at St. Joseph are walking.
Olson, E.V. (1967). The hazards of immobility. American Journal of Nursing, 67, 779–97.
Q. What is your study about?
A. “We are looking at transcutaneous bilirubins at 36 hours in babies who are born here at St. Joseph’s Hospital during a 3-month period who are not discharged before 36 hours post delivery. The standard of care has been 24-hour bilirubins and then on a PRN (as needed) basis if a baby looks jaundiced. Most babies’ average length of stay is 2 days for a vaginal delivery and three days for a C-section. We are trying to catch babies who are in trouble with abnormal (high) bilirubins to try to avoid complications such as increased dehydration, poor feeding, and ultimately kernicterus.”
Q. Is it an EBP/Research Study?
A. “This is a quantitative research study.”
Q. What made you interested in this project?
A. “We had a baby whose bilirubin was normal at 24 hours. At 40 hours the nurse noticed the baby looked jaundice and took a transcutaneous bilirubin, the level was high. The baby went home and was then readmitted to CHOC for still increased bilirubin. A few other babies were also readmitted post discharge from the Mother/Baby Outpatient Center due to high bilirubins.”
Q. How did you go about doing your research?
A. “I decided to look into the research already available and realized there weren’t any other studies that looked at bilirubins greater than 24 hours. After discussing with a colleague, she suggested I make this a research study. I then went to Dana Rutledge, the Nurse Research Facilitator, and we organized the information. I then had to go the Institutional Review Board (IRB) for approval of my study. Now I am doing chart reviews looking at trending in 24 and 36-hour bilirubins of babies.”
Q. What are your expected outcomes?
A. “We have already started the practice change and the study in the units looking at 36-hour bilirubins and so far, empirically, there are more babies already requiring phototherapy. Hopefully, we will be able to find these “high risk” babies and give intervention, supplementation, and closer follow-up.”
Q. Have you done research before? If so what did you learn?
A. “I did a small project for my Master’s, which looked at finger feeding preterm infants versus bottle-feeding. I learned that although research is interesting there is some frustration with the amount of time it takes. There can be a lot of limitations. You must review policy and procedures, look at articles, go to councils for approval, and possibly change a practice.”
Q. Will you do an EBP/research project again?
A. “I would like to. I definitely have an interest. The mother baby unit based council and myself are looking at alcohol application versus natural cord drying in infants, this may lead to another study.”