Translating Research into Practice

Transformational leadership required to design and sustain evidence-based practice: a system exemplar

In a pay-for-performance environment, implementing and sustaining evidence-based practice (EBP) is no longer a luxury but a necessity. A critical driving force for EBP is that our communities-the people we serve-expect to receive care based on the best available evidence. Transformational nursing leadership is required to create an infrastructure that influences organizational factors, processes and expectations, thus enabling the sustainability of EBP. The American Nurses Credentialing Center and the American Organization of Nurse Executives provide a framework for nursing leaders to consider when designing EBP implementation structures. This exemplar illustrates nursing leadership competencies with regard to implementation and sustainability of EBP within a multihospital system.

Using the TRIP model to disseminate an IT-based pressure ulcer intervention

Pressure ulcers (PUs) are among the most common harms experienced by patients in health care facilities. Despite the existence of evidence-based guidelines and protocols for PU prevention and treatment, the sustained success in reducing the development of PUs is elusive. The purpose of this article is to describe how the Translating Research Into Practice (TRIP) model was used to support implementation of a care management solution (i.e., the Daily Project) aimed at preventing PUs. Using a case study approach, the development and implementation of the Daily Project is described in relation to the TRIP model. Initial success was evidenced by a 34% reduction in PU rates and an 86% reduction in missed patient turns 3 months postimplementation of the Daily intervention. Based on our experiences, the TRIP model successfully can assist with the implementation and diffusion of a tool that addresses a complex clinical issue such as PU prevention and treatment.

An advanced educational program promoting evidence-based practice

Evidence-based practice has led to improved health care quality and safety; greater patient, family, and staff satisfaction; and reduced costs. Despite these promising outcomes, use of evidence-based practice is inconsistent. The purpose of this article is to describe an advanced educational program for nurses in leadership roles responsible for guiding teams and mentoring colleagues through the challenges inherent in the evidence-based practice process. The Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice is an innovative program designed to develop advanced skills essential for completing evidence-based practice projects and building organizational capacity for evidence-based practice programs. Learning is facilitated through group discussion, facilitated work time, networking, and consultation. Content includes finding and synthesizing evidence, learning effective strategies for implementation and evaluation, and discussing techniques for building an EBP program in the nurses' organization. Program evaluations are extremely positive, and the long-term impact is described.

"Stars" aligned for evidence-based practice: a Triservice initiative in the Pacific

BACKGROUND

Establishing system-wide evidence-based nursing practice requires the support of senior leadership as well as adherence to a model that is sensitive to the challenges of practice change.

OBJECTIVE

The purpose of this study was to establish a level of skill and knowledge among Army, Navy, and Air Force nurses to develop, to implement, and to evaluate best evidence-based practices (EBPs) for improved patient care.

METHODS

Using the Iowa Model to guide their work, nurses from the Air Force, the Army, and the Navy joined efforts to establish EBP as a standard of nursing practice at four different military healthcare facilities in Hawaii: one tertiary medical center and three clinics on the island of Oahu. With the support of senior leadership at all four sites, four nurse researchers and a project director facilitated the work of advance practice nurses and staff nurses.

RESULTS

Twelve different EBP projects were developed, implemented, and evaluated over 18 months by more than 50 nursing personnel across the three branches of service on Oahu. The result was a positive contribution to patient care throughout the healthcare system, affecting all areas of military nursing practice. Supporting goal was the improvement in the attitudes of nurses about research and their skills in applying evidence to their practice by way of a year-long internship program. Also influenced was the development of a foundation for evidence-based clinical and administrative military nursing decision making in the Pacific.

CONCLUSION

A successful EBP program requires (a) consistent long-term vision and support from senior leadership; (b) resources such as trained personnel, finances, and time; and (c) structured approach to create an environment that facilitates the process. However, the success of an EBP program relies heavily on each nurse's commitment to change designed to improve nursing care for patients.

Building a learning collaborative

BACKGROUND

Development and dissemination of evidence-based practice (EBP) guidelines are important first steps, but without active translation efforts, they do little to promote knowledge uptake by direct care providers. In order to close the gap between discovery and use of knowledge, efforts should focus on methods to speed translation of research findings into practice.

AIM

To facilitate this process, the National Nursing Practice Network (NNPN) was established to provide participating health care organizations with access to resources, information, opportunities for learning and knowledge transfer, and legitimacy and credibility with internal and external stakeholders.

APPROACH

Designed as a practice collaborative learning network, the NNPN uses an interactive learning approach by valuing and learning from the experiences of members and encouraging active participation through conferences, teleconferencing, and use of an interactive member Web site. Use of a network of acute care sites to increase the uptake of EBP is based on social network theory; the NNPN is a network of acute care hospitals through which data, information, knowledge, practices, and behaviors flow.

DISCUSSION AND CONCLUSION

The use of a collaborative nursing network provides an innovative way to address the difficulty of implementing and sustaining EBP in organizations and also for maximizing resources and knowledge. Early evaluation data are promising. This approach is offered as one possible method of moving use of EBP in nursing forward.

A before-after implementation trial of smoking cessation guidelines in hospitalized veterans

Background

Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA) hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM) to improve inpatient smoking cessation.

Specific objectives

The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention.

Design

Pre-post study design in four VA hospitals

Participants

Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day.

Intervention

The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy), computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units.

Outcomes

The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the intervention and baseline periods, we will use random effects logistic regression models, which take the clustered nature of the data within nurses and hospitals into account. We will assess attitudes of staff nurses toward cessation counseling by questionnaire and will identify barriers and facilitators to implementation by using clinician focus groups. To determine the short-term incremental cost per quitter from the perspective of the VA health care system, we will calculate cessation-related costs incurred during the initial hospitalization and six-month follow-up period.

Trial number

NCT00816036

Redesigning care processes using an electronic health record: a system's experience

BACKGROUND

Implementation of health information technology (HIT) has encountered many difficulties and produced mixed outcomes. Yet Trinity Health, a major integrated delivery system, successfully leveraged implementation of a systemwide electronic health record (EHR) to promote process redesign and continuous quality improvement.

IMPLEMENTING A SYSTEMWIDE EHR

After several years of planning, two waves of EHR implementation were launched, in 2001 and 2003. One system HIT team collaborated with each hospital team for 18 months before its 24-hour transition to the EHR. During EHR planning, the system HIT team used five principles of redesign of care processes: (1) identify and address safety problems, (2) promote evidence-based practices, (3) reduce practice variations and standardize terminologies and care processes, (4) improve communication and relationships among clinician roles, and (5) augment multiple uses of data in HIT-supported care processes. Patient-centered work flows were developed to design improved patient care processes for different types of patients, such as medical inpatients and emergency outpatients. These admission-to-discharge work flows addressed gaps in quality, safety, and efficiency and helped ensure that the EHR and decision supports reflected crucial interactions among clinicians and with the patient. By the end of 2008, 13 of Trinity Health's 17 major health care organizations ("ministries") made the transformation to using EHRs.

DISCUSSION

EHR-supported care redesign requires development of substantial system capacities in clinical informatics, customization and standardization of vendor's products, collaboration and coordination between system and hospital implementation teams, quality training for clinicians and change agents, and significant clinician participation in local preparations.

Use of Evidence-Based Practice in School Nursing: Survey of School Nurses at a National Conference

Primary and acute care settings are the focus of a concerted effort to implement evidence-based practice (EBP) in health care; yet, little attention has been given to use of EBP among school nurses. The aims of this study were to (a) describe current use of EBP among school nurses attending a national school nurse conference, (b) describe demographic, individual, and organizational factors associated with EBP use, and (c) identify resources needed to enhance EBP use. A survey designed for this study was distributed during a national school nurse conference. Descriptive statistics, correlations, and independent t tests were used to analyze respondent data regarding the current level of EBP use, awareness, skills, and information sources. Respondents also identified resources needed to increase use of EBP, which included networking opportunities, predeveloped EBP guidelines, and education on outcome evaluation. The results from this study will be used to develop strategies to increase the use of EBP in the school setting.

Translating research into practice intervention improves management of acute pain in older hip fracture patients

OBJECTIVE

To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults.

STUDY DESIGN

Experimental design with the hospital as the unit of randomization.

STUDY SETTING

Twelve acute care hospitals in the Midwest.

DATA SOURCES

(a) Medical records (MRs) of patients > or =65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients.

DATA COLLECTION

Data were abstracted from MRs and questions distributed to nurses and physicians.

PRINCIPAL FINDINGS

The Summative Index for Quality of Acute Pain Care (0-18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001).

CONCLUSION

The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.

Engaging communities in evidence-based interventions for dementia caregivers

Caring for a family member with dementia is associated with unique stressors and burdens related to caregiving. Delivering interventions with proven efficacy to dementia caregivers remains a challenge because of the complexity of providing psychosocial support and skills training for caregivers within current models of formal healthcare services. This article focuses on implementation research and presents a dementia caregiver model program that merges an evidence-based intervention with a proven volunteer program, resulting in the implementation research program called Support Teams for Caregivers. In this article, we delineate our implementation model, describe the program, and present a case study.

Presence of Innovation Adoption-Facilitating Elements in Hospitals, and Relationship to Implementation of Clinical Guidelines

Background:

Despite evidence of benefit from implementation of clinical guidelines, numerous studies have found suboptimal guideline compliance among health professionals.

Objective:

To determine the presence in US hospitals of innovation adoptionfacilitating elements (IAE), assess associations between organizational characteristics and presence of IAE, and assess associations between presence of IAE and implementation of specific clinical guidelines.

Methods:

A mail survey of pharmacy directors in a national random sample of 236 general medical and surgical hospitals with more than 25 beds stratified by state was conducted. Key variables were presence of IAE, the leader's openness to change, centralization, formalization, complexity, size, and guideline implementation. Survey items from preexisting scales were revised for this study. Content validity of survey scales was assessed using expert panel ratings. Cognitive interviews were conducted during survey development to confirm that items were interpreted consistently across respondents. A modified Dillman approach was used to survey 236 hospitals.

Results:

The survey response rate was 69.5%. On average, sample hospitals had implemented 66.9% of IAE inquired about in the survey. Openness to change (p < 0.001), participation in decision-making (p < 0.001), and formalization (p < 0.001) were significantly associated with presence of IAE. However, complexity (p = 0.135) and hospital active bed size (p = 0.195) were not associated with presence of IAE. There was a positive association between presence of IAE and guideline implementation based on an overall score (p = 0.045); however, when guidelines were examined individually, only 1 of the 4 had a positive association (p = 0.029).

Conclusions:

There was a modest presence of IAE in the US hospitals reported here and significant positive association of leaders' openness to change, centralization, and formalization with presence of IAE in hospitals. Findings also indicate that presence of IAE within a hospital is associated with higher levels of clinical guideline implementation.

Managerial leadership for nurses' use of research evidence: an integrative review of the literature

BACKGROUND

Integration of research evidence into clinical nursing practice is essential for the delivery of high-quality nursing care. Leadership behaviours of nurse managers and administrators have been identified as important to support research use and evidence-based practice. Yet minimal evidence exists indicating what constitutes effective nursing leadership for this purpose, or what kinds of interventions help leaders to successfully influence research-based care.

AIMS

(1) To describe leadership activities of nurse managers that influence nurses' use of research evidence; and (2) to identify interventions aimed at supporting nurse managers to influence research use in clinical nursing practice.

METHODS

A search of electronic databases was conducted for studies on behaviours or activities of nurse managers/administrators and the use of research evidence by nurses. Sifting, screening, and quality assessments were done by two reviewers. Results were synthesized by study type (quantitative and qualitative) and reported.

RESULTS

Twelve studies met inclusion criteria (eight quantitative, four qualitative). Three activities were found in quantitative studies that influenced nurses' use of research: managerial support, policy revisions, and auditing. Qualitative studies showed organizational issues as barriers to managers' abilities to affect research use, while role modeling and valuing research facilitated research use. Four studies, one of which was experimental, included an intervention to support managers, but all had insufficient information about leadership development.

CONCLUSIONS

To date, important descriptive work highlights the strategic role managers have in research transfer. Both facilitative and regulatory activities appear to be necessary for managers to influence research use. These findings have important implications for evolving theoretical models describing factors that affect the process of research utilization. It is time to move the science forward and test a hypothesis linking leadership to outcomes. Qualitative methods are essential for understanding the process of leadership for research transfer.

Implications for implementation science

Implementing evidence into healthcare practice is essential to maximize the benefits of research and billions of dollars spent generating new knowledge. Implementation science is the investigation of methods, interventions (strategies), and variables to influence adoption of evidence-based healthcare practices by individuals and organizations to improve clinical and operational decision making, and includes testing the effectiveness of interventions to promote and sustain use of evidence-based healthcare practices. Estabrooks and her research team are to be applauded not only for the excellent contributions to the understanding of research utilization but also for setting forth a series of articles to stimulate thinking and comments across national boundaries and lines of inquiry. Described here are the implications for implementation science with regard to conceptual frameworks, measurement issues, and research designs, stimulated by the papers of the Estabrooks investigative team set forth in this special issue.

Nursing lessons from the MHA keystone ICU project: developing and implementing an innovative approach to patient safety

Given the pivotal role of nurses in providing and supervising patient care, it is essential that nursing professionals are engaged fully in making care safer. Nursing involvement was instrumental in the Michigan Health and Hospital Association Keystone ICU Project, which resulted in rapid reduction in catheter-related blood stream infection rates and ventilator-associated pneumonia rates. Nurses of every credential and every nursing position participated in this broad scale improvement effort. This article describes the MHA Keystone ICU Project, including challenges implicit in changing nursing practice and team behavior in the ICU. The improvement strategies implemented by Keystone ICU teams, and lessons learned by nurses engaged in the work, are likely to have application in other clinical settings.

Translating evidence-based falls prevention into clinical practice in nursing facilities: Results and lessons from a quality improvement collaborative

OBJECTIVES

To describe the changes in process of care before and after an evidence-based fall reduction quality improvement collaborative in nursing facilities.

DESIGN

Natural experiment with nonparticipating facilities serving as controls.

SETTING

Community nursing homes.

PARTICIPANTS

Thirty-six participating and 353 nonparticipating nursing facilities in North Carolina.

INTERVENTION

Two in-person learning sessions, monthly teleconferences, and an e-mail discussion list over 9 months. The change package emphasized screening, labeling, and risk-factor reduction.

MEASUREMENTS

Compliance was measured using facility self-report and chart abstraction (n = 832) before and after the intervention. Fall rates as measured using the Minimum Data Set (MDS) were compared with those of nonparticipating facilities as an exploratory outcome.

RESULTS

Self-reported compliance with screening, labeling, and risk-factor reduction approached 100%. Chart abstraction revealed only modest improvements in screening (51% to 68%, P < .05), risk-factor reduction (4% to 7%, P = .30), and medication assessment (2% to 6%, P = .34). There was a significant increase in vitamin D prescriptions (40% to 48%, P=.03) and decrease in sedative-hypnotics (19% to 12%, P = .04) but no change in benzodiazepine, neuroleptic, or calcium use. No significant changes in proportions of fallers or fall rates were observed according to chart abstraction (28.6% to 37.5%, P = .17), MDS (18.2% to 15.4%, P = .56), or self-report (6.1-5.6 falls/1,000 bed days, P = .31).

CONCLUSION

Multiple-risk-factor reduction tasks are infrequently implemented, whereas screening tasks appear more easily modifiable in a real-world setting. Substantial differences between self-reported practice and medical record documentation require that additional data sources be used to assess the change-in-care processes resulting from quality improvement programs. Interventions to improve interdisciplinary collaboration need to be developed.

Brief Reports for Disseminating Systematic Reviews to Nurses

Much has been written about the importance of using research findings to guide nursing practice. How to best disseminate those findings to nurses remains a challenge. In many clinical settings, nurses interested in research utilization and evidence-based practice retrieve, review, and integrate knowledge from research reports to guide decisions about best practices. Major barriers to this approach, however, are staff nurses' lack of time, expertise, and resources for this process. One approach to overcoming these barriers is to disseminate the results of systematic research reviews directly to nurses in the form of brief reports, written in an easy-to-understand style, and sent via e-mail. This article describes the development of brief reports as a strategy for disseminating the results of systematic reviews to staff nurses. To demonstrate the use of brief reports for this purpose, we chose a systematic review published in the Cochrane Database of Systematic Reviews.

Knowledge transfer and utilization: implications for home healthcare pain management

Implementation of research evidence into clinical practice is a complex and dynamic process that has become the subject of investigation in the field of "translation science" or "knowledge utilization." Research shows how individuals, units, and organizations all influence the rate and extent of adoption of research evidence. Environmental factors also play an important role in this process. This article summarizes key lessons from translation science and examines the implications for the organization and delivery of home healthcare. The implementation of pain management guidelines is used as an example.

Adoption of the ASPAN Clinical Guideline for the Prevention of Unplanned Perioperative Hypothermia: A Data Collection Tool

Perioperative hypothermia remains a common occurrence despite the development and dissemination of a clinical practice guideline for the prevention of unplanned perioperative hypothermia by ASPAN. Unfortunately, a process for measuring compliance with and adoption of this guideline has yet to be developed. The purpose of this article is to describe a medical record abstraction method for determining the degree of adoption of the ASPAN Clinical Guideline for the Prevention of Unplanned Perioperative Hypothermia in the perianesthesia setting. Use of the instrument for future research is also explored.

Excellence in Evidence-Based Practice: Organizational and Unit Exemplars

The University of Iowa Hospitals and Clinics is a recognized leader in evidence-based practice. Creating organizational excellence in evidence-based practice takes leadership and a committed effort at all levels. Building the capacity, culture, and vision at the organizational and unit levels is needed to promote use of evidence in practice. Practical approaches that have been effective in promoting development of an evidence-based practice program and project are outlined. An exemplar describing development and adoption of an evidence-based project to improve sedation management led to improvements in patient care processes and outcomes.

Promoting Evidence-Based Practice: An Internship for Staff Nurses

Implementing evidence-based practice is a complex but valued process that requires support for nurses to make it a reality in care delivery. To address this, an Evidence-Based Practice Staff Nurse Internship was developed at the University of Iowa Hospitals and Clinics in the United States.

PROGRAM OVERVIEW

The objective of this internship is to promote use of evidence by staff nurses to improve patient outcomes. Through a competitive application process, six nurses are accepted in each cohort. The program provides didactic content and dedicated work time on topics interns select (e.g., family pet visitation, sedation management, bowel sounds assessment, guided imagery, family transition to pediatric floor). Interns receive paid clinical release time for participating.

ROLES AND RESPONSIBILITIES

Teams include the staff nurse, the nurse manager, and an advanced practice nurse. Responsibilities for each step are assigned to the person with the appropriate expertise.

EVALUATION

Interns report understanding the process, appreciate the opportunity for professional growth, and report their objectives are being met. Participants evaluated the program very positively and also provided recommendations for revision (e.g., revising class content). The program resulted in improved quality of care such as increased patient and family satisfaction, decreased length of stay, and cost savings.

IMPLICATIONS

Programs that support practitioners through the evidence-based practice process are needed for use in a variety of settings internationally. This unique program supports staff nurses in making evidence-based practice a reality for their work and patients and might be transferable across settings.

Translating Research on Incontinence Into Practice

BACKGROUND

Translating research evidence into clinical practice (TRIP) is an important initiative for health services so that care delivered is cost-effective, is efficient, and improves patient outcomes. Most TRIP studies have reported on disseminating and implementing clinical practice guidelines, protocols, or care pathways and have been undertaken in acute rather than community settings.

OBJECTIVES

To identify the factors that influence incontinence TRIP and to present key international studies on incontinence TRIP.

METHODS

Existing literature on TRIP was analyzed to generate a plan for future research.

RESULTS

Several methods to effect incontinence TRIP are described, including clinical practice guidelines and protocols, clinical pathways, partnerships between organizations, a model for incorporating UI research based on generic questions, and implementation strategies that incorporate change theory and consideration of barriers.

CONCLUSIONS

Future research is needed on incontinence TRIP in the following areas: barriers, the best theoretical approaches, the effectiveness of empowerment approaches, the value of mentors, effective strategies for nurses and unlicensed personnel, the impact of international collaboration, and regulations across settings.

Pressure ulcer prevention in nursing homes: views and beliefs of enrolled nurses and other health care workers

BACKGROUND In the Netherlands much attention has been paid to pressure ulcer prevention. National guidelines on pressure ulcer prevention were developed in 1985 and adapted in 1992 at the request of a national organization for quality assurance in health care. Several studies indicate that nurses seem to be insufficiently informed about pressure ulcer preventive activities. There is, however, no information available about the reasons why nurses seem to be insufficiently informed.

AIMS AND OBJECTIVES

This study was planned to elucidate the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention and about issues related with pressure ulcer prevention.

DESIGN

A qualitative study with semi-structured, tape-recorded interviews.

METHOD

Interviews were conducted with enrolled nurses, team leaders, head nurses, staff nurses and physicians. The interviews were coded and analysed.

RESULTS

Analysis of the interviews revealed that today's pressure ulcer preventive activities are very much based on old traditions in nursing. It also showed that enrolled nurses have no intention to change the care they deliver with regard to pressure ulcer prevention.

CONCLUSIONS

It is concluded that a systematic approach is necessary to change nursing thinking and acting with regard to pressure ulcer prevention.

RELEVANCE TO CLINICAL PRACTICE

This study gives an overview of the views and beliefs of health care workers (especially enrolled nurses) in Dutch nursing homes about pressure ulcer prevention. These views and beliefs can be used as a starting point for effective implementation of guidelines regarding the prevention of pressure ulcers.

Methods in Translation Science

BACKGROUND

The gap between research findings and practice has been, and continues to be, a concern for the international community. A number of descriptive studies have elucidated barriers and facilitators of evidence-based practice in nursing. It is argued that it is now time to use findings from these studies to design and test interventions that explicitly target barriers to the use of evidence in practice rather than doing further research to describe generic barriers and facilitators to evidence-based practice. This article discusses research methods to advance our knowledge regarding the efficacy of translating research into practice (TRIP) interventions that promote and hasten adoption of evidence in practice.

APPROACH

Published research is reviewed and used as exemplars of translation studies. The benefits and challenges in studying natural experiments are addressed as are the benefits and challenges in conducting TRIP studies using experimental designs.

DISCUSSION

The article discusses factors such as sample attainment, unit of analysis, intervention characteristics, outcome measurement, and sustainability. Although there are a myriad of initiatives aimed at increasing use of evidence in practice, there is little systematic evidence of the effectiveness of these initiatives. In order to advance knowledge, translation research needs more experimental studies that test TRIP interventions through, for example, partnership models.

Acute pain treatment for older adults hospitalized with hip fracture: current nursing practices and perceived barriers

This article examines acute pain management practices for patients 65 years of age and older who were hospitalized during 1999 for hip fracture. Data were collected from the medical records of patients (N = 709) admitted to 12 hospitals in the Midwest and from questionnaires on pain practices completed by nurses (N = 172) caring for these patients. The major variables examined were (1). pharmacological and nonpharmacological treatments for acute pain in hospitalized elders, (2). nurses' perceived stage of adoption for avoiding meperidine use and for administering analgesics around-the-clock, and (3). nurses' perceived barriers to optimal treatment of acute pain in elders. Acetaminophen was the most frequently administered analgesic, but administered doses were far less than the maximum daily recommended dose. More than one third (39%) of the nurses reported that they always avoided the use of meperidine, and over half reporting avoiding its use sometimes. However, the majority of patients (56.8%) received at least one dose of meperidine, even though evidence suggests that other analgesic agents are more appropriate for treatment of acute pain in elders. Only 27% of patients received patient-controlled analgesia, and only 22.3% of patients received around-the-clock administration during the first 24 hours after admission of analgesics that had been ordered on a prn basis. The majority of nurses were aware that around-the-clock administration of analgesics was preferable, but only 33.7% were persuaded (believed) that this method should be used. Intramuscular injection was used for 52.2% of patients, even though this route is not recommended for older adults. The most frequently used nonpharmacological intervention was repositioning, followed by use of pressure relief devices and cold application. Nurses reported difficulty contacting physicians and difficulty communicating with them about type and/or dose of analgesics as the greatest barriers to pain management. Findings from this multi-site study show that active and focused "translation" interventions are needed to promote adoption of evidence-based acute pain management practices by health care providers.

Lack of opioid administration in older hip fracture patients (CE)

As part of a multisite study funded by the Agency for Healthcare Research and Quality, the medical records of older adults with a hip fracture were abstracted for acute pain assessment and treatment practices. Of the 709 records reviewed, 8 patients did not have an opioid administered during the first 72 hours after admission to a non-intensive patient care unit. Using a case study approach, this article examines demographic characteristics, pain assessment, and analgesic administration for these 8 patients to illustrate specific practice problems that occur in managing acute pain in older adults. Pain intensity was documented infrequently. All 8 patients had a physician order for some type of analgesic, and 7 of the 8 had an order for an opioid analgesic. Yet none received an opioid during the first 72 hours of care on a general medical-surgical unit, and one patient received no analgesia of any kind. The medical records of these hip fracture patients indicate that acute pain was underassessed and undertreated. Provision of quality pain management will require that nurses address the specific practice behaviors identified in the article and correct problems where they exist. Key strategies that can be used to improve pain management practices include implementation of standardized assessment tools and pain flow-sheets, audit and feedback of pain management data with staff, use of pain management opinion leaders and change champions, and incorporation of research-based pain management practices into performance-evaluation criteria.