Clinical Inquiry Series

Question: I’ve heard that inductions increase the cesarean section (C/S) rate. An article from AWHONN email this week reports research showing that inductions decrease the C/S rate. Which is true? And how can we decrease our C/S rate?

Answer: A review of the literature proves to be quite controversial. There were no randomized control trials found in the literature most likely due to the fact that pregnant women are a vulnerable population because of the risks to mother/infant. The majority of studies are retrospective and findings conflict. Two studies, one a systematic review and a large retrospective study found a decrease in C-section(C/S) rate when induction was used compared to usual care (spontaneous labor, induced at a later time, etc.)(Caughey et al., 2009; Wilson et al.,2010).
Other studies (Ehrenthal, Jiang & Strobino 2010; Glantz, 2010) discussed that problems exist in how researchers define the study population. These authors highlight that multiple factors, including increasing gestational age, alter the results mentioned above. Therefore after including these additional variables, they report that induction increases the C/S rate.
Two other articles (Klein 2010; Nicholson et al. 2009) mention the AMOR-IPAT scoring system. AMOR–IPAT stands for Active Management of Risk in Pregnancy at Term- Upper limit of Optimal Delivery. In their studies utilizing this scoring system (algorithm) assists with finding the ideal gestation for each woman and determines her best delivery date. This scoring system in two studies states that when this scoring system is utilized for induction it reduces the C-Section rate.
Final answer is the evidence is conflicting and there are many factors that influence the C-section rate. Maternal obesity for instance was not taken into consideration. Awareness and informed consent is imperative when deciding whether or not to induce. Ultimately this is something that should not be taken lightly and should be discussed thoroughly by the patient and her provider.

References: Akinsipe, C. D., Villalobos, L. E., & Ridley, R. T. (2012). A systematic review of implementing an elective labor induction policy. Journal of Obstetrics and Gynecology and Neonatal Nursing, 41(1) 5-16. doi:10.1111/j.1552-6909.2011.01320.x
Caughey, A. B., Sundaram, V., Kaimal, A. J. Gienger, A., Cheng, Y. W., McDonald, K. M., . . .Bravata, D. M. (2009) Systematic review: Elective induction of labor versus expectant management of pregnancy. Annals of Internal Medicine, 151(4) 252-263.
Ehrenthal, D. B., Jiang, X., & Strobino, D. M., (2010) Labor induction and the risk of cesarean delivery among nulliparous women at term. Obstetrics & Gynecology, 116(1) 35-42.
Glantz, J. G. (2010) Term labor induction compared with expectant management. Obstetrics & Gynecology, 115(1).
Nicholson, J. M., Cronholm, P., Kellar, L. C., Stenson, M. H., & Macones, G. A. (2009). The association between increased use of labor induction and reduced rate of cesarean delivery. Journal of Women’s Health, 18(11) 1747-1758.
Wilson, B. L., Effken, J., & Butler, R. J. (2010) The relationship between cesarean section and labor induction. Journal of Nursing Scholarship, 42(2) 130-138. doi:10.1111/j.1547-5069.2010.01346.x

St. Joseph Hospital Nurses Publish Article

Congratulations to Mary Gonzales, RN, MSN & Dana Rutledge, RN, PhD for their newly published article on pain and anxiety during IR procedures.  SJO employees have access to the full article through Burlew Medical Library.  Contact library staff for more details.

Pain and Anxiety During Less Invasive Interventional Radiology Procedures
Mary Gonzales, MSN, RN
Dana N. Rutledge, PhD, RN
Journal of Radiology Nursing
June 2015; 34(2) 88-93

Abstract

The purpose of this study was to describe patient-reported pre-, intra-, and postprocedure pain and anxiety levels for adults undergoing less invasive interventional radiology procedures. Most of the 53 outpatients were males, English speakers (91%), aged between 40 and 70 years, and having a chest port or arm port insertion procedure. Pain levels greater than 4 (0-10 scale) were experienced by a minority of participants (before, n = 1; during, n = 7; and after, n = 3). Many patients undergoing arm port and chest port insertions (22-68%) experienced some level of preprocedural anxiety. This is the first study to document the presence of pain and anxiety levels of outpatients receiving dialysis arteriovenous graft fistulogram or declotting procedures, chest port or arm port insertions, or tunneled dialysis catheter placements. Radiology nurses need to be aware of the pain and anxiety experiences of these patients and should be assessing and managing these in collaboration with their medical colleagues.

 

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.

References

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:

19614874.

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.

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.

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.