Show Me The Evidence

The Blog of Lippincott's Evidence-Based Practice Network

Meeting nutritional needs of hospitalized patients can be challenging. We know using the gut is superior to parenteral nutrition because it maintains intestinal function, has fewer complications, and is less costly (Cerra, 1997). If a patient is unable to swallow safely, enteral feeding is recommended. Enteral tube positioning has always been an area of discussion for nurses. Research has shown a malpositioned tube that has been used to deliver feedings or medication can result in aspiration, pneumothorax, and sepsis (Simons & Abdallah, 2012). Which method for verifying enteral tube placement is best according to the evidence?

The authors of the article published in the February issue of the American Journal of Nursing, "Bedside Assessment of Enteral Tube Placement: Aligning Practice with Evidence," critically appraised the research around the current methods being used to verify feeding tube placement. The authors found that the 5 most common methods used in practice are:

• X-ray visualization of the tube
• pH testing of aspirate
• Visual assessment of aspirate
• Visualization of external tube length
• Auscultation of air insufflated through the feeding tube (Simons & Abdallah, 2012).

 The research clearly shows that the most reliable method of verifying enteral tube placement is an X-Ray (Simons & Abdallah, 2012). I encourage each of you to read this article and adopt the evidence of enteral tube placement verification in your institution. This evidence-based intervention will improve your patient outcomes and decrease your costs due to complications associated with improper placement of enteral feeding tubes.

References:
Cerra, F, et al. 1997. Applied nutrition in ICU patients. A consensus statement of the American College of Chest Physicians. 111(3): 769-78.

Simons, S., Abdullah, L. 2012. Bedside assessment o f enteral tube placement: aligning practice with evidence. American Journal of Nursing, 112(2).

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP
Chief Nurse and Publisher
Wolters Kluwer Health Medical Research

Family presence has always been a hot topic in the healthcare community. I can remember when family presence in an ICU meant visiting for 15 minutes three times per day. At least that was the policy in the local hospital where my grandparents were patients when I was a kid. We’d wait and wait for the clock to strike that magic moment and then take turns, two at a time, to visit. I’m not sure that communication with the staff even occurred during those minutes, or if it did, it may have been just a quick word or two.

It just so happens that later on, as a nurse in the medical intensive care unit (MICU) at a large teaching hospital, our unit transitioned from set visiting hours to open visiting hours from 11 am to 8 pm. It was then up to the discretion of the staff if family could come in earlier or stay later, even all night. Interdisciplinary rounds, led by the attending physician, took place each morning outside of each patient’s room. If family members were present, sometimes the attending updated them at that time and teaching of interns and residents occurred in front of the patient and family. More often, however, he or she told the family that they’d get an update when rounds were completed.

Much has been written about family presence, especially with regard to visitation and emergency care and resuscitation efforts, however little has been studied about including family members in medical or interdisciplinary rounds. In Family Presence on Rounds, the author performed a systematic review of 17 studies on this topic. The PICO question guiding this study was “In critical and noncritical pediatric and adult patients, does family presence on rounds compared with non-inclusion of family members lead to positive outcomes and increased satisfaction?”

While it is clear that further research is warranted on this topic, the author does a nice job of organizing results from the review based on family members’ outcomes, both positive and negative, and health care staff outcomes, both positive and negative. She even takes it one step further, by dividing the health care staff outcomes among nurses (although only 5 of the 17 studies addressed nurses’ perceptions) and medical staff. Positive outcomes outnumbered the negative outcomes for all groups, but interestingly, the nurses did not perceive any negative outcomes to family presence on rounds.

What is the policy where you practice? What’s been your experience with family presence during interdisciplinary rounds?

Reference:
Cypress, B.S. (2012). Family Presence on Rounds: A Systematic Review of the Literature. Dimensions of Critical Care Nursing, 31(1).

As I work through my Doctor of Nursing Practice program, I am intrigued by the different models of evidence-based healthcare that are available. While all of the models have similarities, there are subtle nuances to each of the models which make them a good fit for particular healthcare institutions. Each of the models strive to faciliate an understanding, analysis, improvement and / or replacement of the healthcare process as it is currently conceived and practiced (Pearson, Weeks, & Stern, 2011).

Some of the most common popular models of evidence-based practice include:

• The ACE Star Model of Knowledge (Stevens, 2004)
• The Stetler Model of Evidence-Based Practice (Stetler, 1985)
• The Iowa Model of Evidence-Based Practice (Melnyk, Fineout-Overholt, 2011)
• Joanna Briggs Institute's Model of Evidence-Based Practice (Pearson, Weeks, & Stern, 2011).

When your institution decides to begin an evidence-based practice program, it is imperative you evaluate the different EBP models that have been developed and choose the one that best suits your institution's culture. For evidence-based practice to be truly successful, it must combine scientific research/evidence with clinical expertise and patient preference. It is only then that the evidence can transform practice and improve patient outcomes.

References:
Melnyk, B., & Fineout-Overholt, E. 2011. Evidence-Based Practice in Nursing & Healthcare. 2nd edition. Lippincott Williams & Wilkins.

Pearson, A., Weeks, S., & Stern, C. 2011. Translation Science and The JBI Model of Evidence-Based Healthcare. Lippincott Williams & Wilkins.

Stetler, C. (1994). Refinement of the Stetler/Marram model for application of research findings to pracitce. Nursing Outlook, 42(1), 15-25.

Stevens, K. (2004). ACE Star Model of EBP: Knowledge Transformation. Academic Center for Evidence-Based Practice. Retrieved 20 January 2012, from http://www.acestar.uthscsa.edu.

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher

I read with interest the article "Central Venous Pressure Monitoring: What's the Evidence", that was published in the January issue of the American Journal of Nursing (AJN). AJN is running a series called Critical Analysis Critical Care, which will appraise the evidence regarding common critical care practices. So much of what we do in nursing is not based on evidence, rather based on how we have always done things in practice or based on research that was not credible.

This article looks at the evidence behind using central venous pressure (CVP) monitoring alone to guide treatment decisions for patients. According to the article, a 2008 systematic review by Marik and colleagues concluded that CVP is not an accurate indicator of intravasuclar volume, nor is it an accurate predictor of fluid responsiveness-that is, whether a patient will respond to a fluid bolus with an increase in stroke volume (Marik, P., 2008). The authors of the AJN article critically appraised the evidence and determined:

• The relationship between intravascular volume and CVP is a weak relationship and clinicians should not use CVP to estimate a patient's intravascular volume.
• The absolute CVP value or a change in CVP should not be used to predict a change in the stroke volume or cardiac index.
• There is not an absolute CVP value that can be used to determine what the next step of treatment should be, either a fluid bolus or the use of a vasoactive medication (Kupchik, N. & Bridges, E., 2012).

What does the evidence tell us? It tells us we can not base treatment decisions on one hemodynamic indice. Rather, when making treatment decisions, the clinician needs to look at the entire hemodynamic picture including heart rate, BP, MAP, and urine output for example, when determining what is the best treatment option for the patient.

References:
Kupchik, N. & Bridges, E., 2012. Central venous pressure monitoring: what's the evidence? American Journal of Nursing. 112 (1).

Marik, P. et al. 2008. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 134(1).

Anne Dabrow Woods MSN RN CRNP
Chief Nurse and Publisher

How many of us have taken care of someone who had experienced a cardiac arrest and ended up in the hospital on a ventilator never to wake up the same again. The frustration and sadness we as caregivers feel with caring for a patient in this situation and dealing with their family can be overwhelming. I can remember several years ago when I had several patients in one week who experienced cardiac arrest in the field and ended up on the ventilator and were diagnosed as being brain dead or severely neurologically impaired.

Luckily, research has taken us beyond this situation by using therapeutic hypothermia. The American Heart Association has guidelines in their Advanced Cardiac Life Support Guidelines that recommend healthcare providers consider therapeutic hypothermia for patients who have return of spontaneous circulation after cardiac arrest.

The Advanced Emergency Nursing Journal's October/December2011 issue published an article titled, "Pharmacologic Management During Therapeutic Hypothermia" that I have found to be very helpful in managing these patients. The article outlines how to handle pain/sedation requirements, rigors/shivering, electrolyte balance and anticonvulsant therapy. For those of you in emergency and critical care who care for patients who are receiving therapeutic hypothermia, this evidence-based article will be extremely useful to your practice.