Seven Evidence-Based Practice Habits: Putting Some Sacred Cows Out to Pasture

Bridging the Gap Between Clinical Practice and the AACN Practice Alert on Pulmonary Artery/Central Venous Pressure Monitoring in Adults

Measuring and documenting accurate data from pulmonary artery and central venous pressure catheters is an important responsibility of critical care nurses. The American Association of Critical-Care Nurses Practice Alert titled Pulmonary Artery/Central Venous Pressure Monitoring in Adults provides evidence-based standards against which nurses can compare their practice related to obtaining valid hemodynamic data. Identifying and acting on improvement opportunities is also a nursing responsibility and helps to ensure that patients with pulmonary artery or central venous pressure catheters receive high-quality care. This article reviews various strategies to compare nursing practice to the Pulmonary Artery/Central Venous Pressure Monitoring in Adults Practice Alert and to close identified gaps in clinical practice.

Searching for the “sacred cow”: a conceptual analysis of the term in nursing literature

Purpose

The idiom “sacred cow” is problematic due to its inaccuracy and cultural insensitivity. The purpose of this paper is to examine the term’s meaning within the nursing literature, describe connotations in religious contexts, explore subject headings applied to research using the phrase, and discuss alternative terminology.

Design/methodology/approach

This paper employs Rodgers’ evolutionary concept analysis methodology to identify the concept “sacred cow” and surrogate terms, collect and analyze sample articles and headings, explore an exemplary case, and look for concept implications.

Findings

The term “sacred cow” appears frequently in the healthcare literature, particularly within the nursing literature. Its meaning within this literature pertains primarily to practices not supported by empirical evidence and performed to maintain a status quo. Headings applied to the relevant literature do not describe this concept, and more accurate headings could not be found within widely used controlled vocabularies.

Research limitations/implications

“Sacred cow” is an inaccurate descriptor for practices not supported by evidence as these practices do not usually apply to holiness or cattle. The term’s implied meaning comes only when viewed within a context satirizing beliefs considered as “other.”

Originality/value

This paper appears to be the first to methodically explore the concept of “sacred cow” within the nursing literature. The paper breaks ground in proposing solutions for the lack of applicable controlled vocabulary. By exploring these topics, it is hoped future authors use more accurate, culturally neutral terminology when discussing non-evidence-based practices and indexers increase discoverability by using more descriptive headings.

Methods used by critical care nurses to verify feeding tube placement in clinical practice

BACKGROUND

The American Association of Critical-Care Nurses practice alert on verification of feeding tube placement makes evidence-based practice recommendations to guide nursing management of adult patients with blindly inserted feeding tubes. Many bedside verification methods do not allow detection of improper positioning of a feeding tube within the gastrointestinal tract, thereby increasing aspiration risk.

OBJECTIVES

To determine how the expected practices from the American Association of Critical-Care Nurses practice alert were implemented by critical care nurses.

METHODS

This study was part of a larger national, online survey that was completed by 370 critical care nurses. Descriptive statistics were used to analyze the data.

RESULTS

Seventy-eight percent of nurses used a variety of methods to verify initial placement of feeding tubes, although 14% were unaware that tube position should be confirmed every 4 hours. Despite the inaccuracy of auscultation methods, only 12% of nurses avoided this practice all of the time.

CONCLUSIONS

Implementation of expected clinical practices from this guideline varied. Nurses are encouraged to implement expected practices from this evidence-based, peer reviewed practice alert to minimize risk for patient harm.

Continuing to challenge practice to be evidence based

Practice habits continue in clinical practice despite the availability of research and other forms of evidence that should be used to guide critical care practice interventions. This article is based on a presentation at the 2014 National Teaching Institute of the American Association of Critical-Care Nurses. The article is part of a series of articles that challenge critical care nurses to examine the evidence guiding nursing practice interventions. Four common practice interventions are reviewed: (1) weight-based medication administration, (2) chest tube patency maintenance, (3) daily interruption of sedation, and (4) use of chest physiotherapy in children. For weight-based administration of medication, the patient's actual weight should be measured, rather than using an estimate. The therapeutic effectiveness and dosages of medications used in obese patients must be critically evaluated. Maintaining patency of chest tubes does not require stripping and milking, which probably do more harm than good. Daily interruption of sedation and judicious use of sedatives are appropriate in most patients receiving mechanical ventilation. Traditional chest physiotherapy does not help children with pneumonia, bronchiolitis, or asthma and does not prevent atelectasis after extubation. Critical care nurses are challenged to evaluate their individual practice and to adopt current evidence-based practice interventions into their daily practice.

Confirming nasogastric tube placement: Is the colorimeter as sensitive and specific as X-ray? A diagnostic accuracy study

BACKGROUND

The effect of delivering enteral nutrition or medications via a nasogastric tube that is inadvertently located in the tracheobronchial tract can cause respiratory complications. Although radiographic examination is accepted as the gold standard for confirming the position of patients' enteral tubes, it is costly, involves risks of radiation, and is not failsafe. Studies using carbon dioxide sensors to detect inadvertent nasogastric tube placements have been conducted in intensive care settings. However, none involved patients in general wards.

OBJECTIVE

The objective of this study was to ascertain the diagnostic measure of colorimeter, with radiographic examination as the reference standard, to confirm the location of nasogastric tubes in patients.

DESIGN

A prospective observational study of a diagnostic test.

SETTING

This study was conducted in the general wards of an approximately 1100-bed acute care tertiary hospital of an Academic Medical Center in Singapore.

PARTICIPANTS

Adult patients with nasogastric tubes admitted to the general wards were recruited into the study.

METHODS

The colorimeter was attached to the nasogastric tube to detect for the presence of carbon dioxide, suggestive of a tracheobronchial placement. The exact location of the nasogastric tube was subsequently confirmed by a radiographic examination.

RESULTS

A total of 192 tests were undertaken. The colorimeter detected carbon dioxide in 29 tested nasogastric tubes, of which radiographic examination confirmed that four tubes were located in the tracheobronchial tract. The colorimeter failed to detect carbon dioxide in one nasogastric tube that was located in the tracheobronchial tract, thus, demonstrating a sensitivity of 0.80 [95% CI (0.376, 0.964)]. The colorimeter detected absence of carbon dioxide in 163 tested nasogastric tubes in which radiographic examination confirmed 160 gastrointestinal and one tracheobronchial placements, demonstrating a specificity of 0.865 [95% CI (0.808, 0.907)]. The colorimeter detected one tracheobronchial nasogastric tube placement that the radiographic examination was misinterpreted.

CONCLUSION

The study found that the use of the colorimeter in the general ward setting was not 100% sensitive or specific in ascertaining the location of a nasogastric tube as previously reported by many studies undertaken in intensive care settings. This is the first study on the use of a colorimeter to confirm the placement of a nasogastric tube in adult patients in the general ward setting. More research on the use of a colorimeter in the general ward setting and its potential use in certain processes for confirming the placement of a nasogastric tube is warranted.

The wicked question answered: positive deviance delivers patient-centered care

BACKGROUND

How nurses respond when faced with the dilemma of providing patient-centered care in the absence of patient-centered practice guidelines remains relatively unreported. Standards may not be available to guide nurses or may not be realistic for implementation at the point of care. Nurses may be forced to react creatively to meet the needs of their patients.

OBJECTIVES

The purpose was to understand nursing care when standard practice guidelines did not meet patient-specific care needs and to develop various viewpoints related to the use of positive deviance in providing patient-centered care.

METHODS

Complexity theory and the framework of a wicked question were used to guide a 3-round online national Delphi study from November 2011 to February 2012. The panel was accessed through the American Association of Critical Care Nurses to expose the care provided when standard practice guidelines were lacking.

RESULTS

Findings support the presence of positive deviance and expose care provided by nurses when standard practice guidelines lacked the ability to provide patient-centered care. Dominant themes of positive deviance are recommended as priorities for future research.

DISCUSSION

Better guidelines are needed that work for nurses, instead of against them, that would not force a nurse into actions that are not patient centered. Guidelines should guide practice and assist in allowing nurses to provide care that is centered on the best needs of the patient in the specific care situation.

Examining the evidence to guide practice: challenging practice habits

Nurses are the largest segment of the nation's health care workforce, which makes nurses vital to the translation of evidence-based practice as a practice norm. Critical care nurses are in a position to critically appraise and apply best evidence in daily practice to improve patients' outcomes. It is important for critical care nurses to continually evaluate their current practice to ensure that they are applying the current best evidence rather than practicing on the basis of tradition. This article is based on a presentation at the 2013 National Teaching Institute of the American Association of Critical-Care Nurses. Four practice interventions that are within the realm of nursing are critiqued on the basis of current best evidence: (1) turning critically ill patients, (2) sleep promotion in the intensive care unit, (3) feeding tube management in infants and children, and (4) prevention of venothromboembolism…again. The related beliefs, current evidence, and implications for practice associated with each topic are described.

Building a protocol to guide mobility in the ICU

Professional experience and wisdom have taught us that immobility is a risk factor for various adverse outcomes, such as deep vein thrombosis, joint contractures, pulmonary dysfunction, and bone demineralization to name a few. Balancing bed rest and mobility may improve both short- and long-term outcomes for our patients. Moreover, early, routine mobilization of critically ill patients is safe and reduces hospital length of stay, shortens the duration of mechanical ventilation, improves muscle strength, and functional independence. At the University of Michigan, we have turned the tides by creating a structured process to get our patients moving through the use of a standardized mobility protocol. Our protocol is simple and can easily be adapted for all patient populations by simply modifying some of the inclusion and exclusion criteria. The activities are grounded in the evidence and well thought out to prevent complications and promote mobilization. The purpose of this article was to present the science behind the development of a multidisciplinary protocol for early mobilization of critically ill patients that can be adapted to any intensive care unit patient with minor modifications.

Mobilisation in critical care: a concept analysis

OBJECTIVES

The aim of this paper is to analyse the concept of mobilisation within the context of the critical care setting. Mobilisation is a widely used term that belies the complexity of its use in practice. Whilst facilitating movement is a significant nursing concern, mobilisation practices vary widely amongst nurses, perhaps due to conceptual incongruence.

METHODS

Evolutionary methodology was used in this concept analysis. Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews and PsycInfo databases were searched from 1966 to present. Search terms included mobilisation, mobility and passive exercise, yielding 61 articles suitable for analysis.

FINDINGS

Findings indicate that mobilisation is an interdisciplinary, goal-directed therapy used to facilitate movement and improve outcomes. It involves energy expenditure and has both physical and psychological domains. Disciplines vary in applications of mobilisation and therapy parameters are essentially undefined. The energy expenditure attribute has been well-exemplified in physical therapy literature, but only to a minimal degree in nursing literature.

CONCLUSION

In spite of the wide use of mobilisation, the concept requires further development, particularly in the critical care setting. Barriers to mobilisation require further delineation as does the psychological domain. Ongoing concept analysis can be used to inform practice and guide research activities.

Postanesthesia patients with large upper arm circumference: is use of an "extra-long" adult cuff or forearm cuff placement accurate?

The purpose of this study was to determine if blood pressure (BP) measured in the forearm or with an extra-long BP cuff in the upper arm accurately reflects BP measured in the upper arm with an appropriately sized BP cuff in patients with large upper arm circumference. A method-comparison design was used with a convenience sample of 49 PACU patients. Noninvasive blood pressures were obtained in two different locations (forearm; upper arm) and in the upper arm with an extra-long adult and recommended large adult cuff sizes. Data were analyzed by calculating bias and precision for the BP cuff size and location and Student's t-tests, with P < .0125 considered significant. Significantly higher forearm systolic (P < .0001) and diastolic (P < .0002) BP measurements were found compared to BP obtained in the upper arm with the reference standard BP cuff. Significantly higher systolic (t(48df) = 5.38, P < .0001), but not diastolic (t(48df) = 4.11, P < .019), BP differences were found for BP measured with the extra-long cuff at the upper arm site compared to the upper arm, reference standard BP. Findings suggest that the clinical practice of using the forearm or an extra-long cuff in the upper arm for BP measurement in post anesthesia patients with large upper arm circumferences may result in inaccurate BP values.

Skilled Cardiac Monitoring at the Bedside: An Algorithm for Success

The ECG lead monitoring algorithm was developed to provide a tool to assist bedside nurses in monitoring ST segments and dysrhythmias.

Physiological rationale and current evidence for therapeutic positioning of critically ill patients

Prolonged bed rest is common in critically ill patients, and therapeutic positioning is important to prevent further complications and to improve patient outcomes. Nurses use therapeutic positioning to prevent complications of immobility. This article reviews therapeutic positions including stationary positions (supine, semirecumbent with head of bed elevation, lateral, and prone) and active repositioning (manual, continuous lateral rotation, and kinetic therapy). The physiological rationale and current evidence for each position are described. Applicable evidence-based practice guidelines are summarized. Special considerations for therapeutic positioning of critically ill obese and elderly patients are also discussed.

Staff nurses creating safe passage with evidence-based practice

Patient safety is one of the most critical issues for health care today. The escalating need to decrease preventable complications serves as a significant catalyst to identify and use evidence-based practice (EBP) at the bedside. Decreasing preventable complications requires a synergistic relationship between the nurses at the bedside and nursing leadership. This article presents an overview of the concepts and the specific structures and processes used at Baylor Health Care System to increase the use of EBP and improve patient safety.