Evidence-Based Practice Network

Show Me The Evidence

The Blog of Lippincott's Evidence-Based Practice Network

The Choosing Wisely® campaign was launched in 2012 by the American Board of Internal Medicine as a way to spark conversations to improve care and minimize unnecessary testing. The goals of the campaign are to ensure that care is supported by evidence; not duplicative of other tests or procedures already received; free from harm; and truly necessary (ABIM Foundation, 2014). Many organizations have released recommendations in support of the campaign – a full list is available here.

Last week, the American Association of Critical-Care Nurses (AACN) became the first nursing organization to get involved in the campaign. Its Choosing Wisely® list includes the following five evidence-based recommendations (American Association of Critical Care Nurses, 2014) :
  • Don't order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
  • Don't transfuse red blood cells in hemodynamically stable, non-bleeding critically ill patients with a hemoglobin concentration greater than 7 mg/dL.
  • Don't use parenteral nutrition in adequately nourished critically ill patients within the first seven days of a stay in an intensive care unit.
  • Don't deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
  • Don't continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
As a nursing professional, I am proud to see AACN collaborate on this important initiative. I encourage you all to remain cognizant of these recommendations, share them with your peers, and stay up-to-date on the latest evidence.

For further reading, the articles below are available for free to logged in members of Lippincott’s NursingCenter.com.  Not a member?  Join now!

In the News: Rethinking Routine Blood Work in Patients with MI
American Journal of Nursing
Blood Management: Best-Practice Transfusion Strategies
Parenteral Nutrition Risks, Complications, and Management
Journal of Infusion Nursing
Sedation Vacation: Worth the Trip
Nursing2013 Critical Care
Ethics in Critical Care: Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings
AACN Advanced Critical Care
Hoping for the Best, Preparing for the Worst: Strategies to Promote Honesty and Prevent Medical Futility at End-of-Life
Dimensions in Critical Care Nursing


ABIM Foundation. (2014). About. Retrieved from Choosing Wisely: http://www.choosingwisely.org/

American Association of Critical Care Nurses. (2014, January 28). News: Critical Care Groups Issue 'Choosing Wisely' List. Retrieved from American Association of Critical Care Nurses: http://www.aacn.org/wd/publishing/content/pressroom/pressreleases/2014/jan/choosing-wisely-aacn-ccsc.pcms?menu=aboutus

Posted by Lisa Morris Bonsall on 2/8/2014 6:20:51 AM
Tags: aacn,choosing,nursing,wisely
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My first preceptor was a nursing assistant who had been treated for breast cancer several years prior to my orientation. While I didn’t know the extent of her disease or treatment, I can still remember the tight wrap that she wore on her left arm and the arm exercises that she would do whenever we had a little “down time” on the unit. 
I couldn’t help but think of this woman, who helped me get started on my path into nursing, when I read Self-Management of Lymphedema: A Systematic Review of the Literature From 2004 to 2011, published in the August issue of Nursing Research. Self-management has long been recommended for the treatment of lymphedema as this chronic condition cannot be cured medically or surgically; lifetime self-management is necessary to control swelling exacerbations, prevent infections, and manage other lymphedema-associated symptoms, including reduced activity and fatigue.
Sixteen articles met the inclusion criteria for this systematic review and based on the review, the authors identified ten categories of self-management:
* Advanced pneumatic compression devices
* Aromatherapy
* Compression garments
* Full-body exercise
* Infection management
* Phase 2 complete decongestive therapy (CDT), which includes self-administered manual lymphatic drainage (MLD), compression garments, bandaging, exercise, and skin care
* Simple MLD
* Skin care
* Self-monitoring
* Weight reduction
This review found that full-body exercise and Phase 2 CDT are likely to be effective self-management techniques for lymphedema, however, randomized control trials supporting Phase 2 CDT are lacking. Effectiveness was not established for advanced pneumatic compression, compression garments, full-body exercise, self-monitoring, skin care, simple MLD, and weight reduction as stand-alone therapies. Also, based on the evidence, aromatherapy was deemed effectiveness unlikely and should not be recommended as a self-care technique. 
Unfortunately the evidence does not provide much guidance for self-management recommendations for lymphedema. Further research is indicated, yet in the meantime, a thorough assessment of each individual patient’s symptoms and the availability of resources should be used to guide the plan of care.
Armer, J. M., Cormier, J.N., Fu, M.R., Ridner, S.H., Stewart, B.R., Wanchai, A. (2012). Self-Management of Lymphedema: A Systematic Review of the Literature From 2004 to 2011. Nursing Research, 61 (4). 

Posted by Lisa Morris Bonsall on 8/5/2012 8:29:34 AM
Tags: lymphedema,self-care
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Preventing delirium in elderly hip surgery patients can seem like an elusive goal.  Much has been written on it but little remains of value after careful analysis.  Most sources revert to the now classic work by Marcantonio and colleagues (2001).  In this study, a geriatric consult service was the experimental focus.  Ten categories composed the “bundle” of care to be initiated.  Among these were generic expectations such as ensuring fluid and electrolyte balance and adequate nutrition, but also geriatric concept-based interventions such as eliminating excessive medications and those medications especially problematic for elders such as benzodiazepines, and promoting early mobilization.  An average of 9.5 interventions per patient were instituted.  The incidence of delirium overall was high but was lower in the intervention group (32 vs. 50%, p=0.04).  The intensity of delirium was assessed to be less in the intervention group as well, with severe delirium manifested only 12% of the time vs. 29% in the usual care group.  

The most disappointing findings were that the length of days of delirium and the overall length of stay were not significantly different.  Delirium at discharge was similar between groups as well.  The study may have been underpowered with a total sample size of only 126 patients.  Its strengths were that it was a randomized controlled trial with reasonably good adherence to protocol.  On a practical level, we are left with a large “bundle” and we don’t know which interventions are the most important to emphasize in prioritizing care.  Little different findings were found in examining the greater literature base on the topic. 

A recent topic offering some hope for improvement in the area is the work on melatonin.  Two studies have indicated that delirium is positively impacted by use of melatonin (Al-Aama, Brymer, Gutmanis, Woolmore-Goodwin, Esbaugh, & Dasgupta, 2010; Sultan, 2010).  The former study in Canada demonstrated that melatonin was associated with a 12% delirium rate compared to a 31% rate when compared to placebo.  DeJonge and colleagues (2011) expect to have additional data available on this subject in 2013.  While two studies may not be sufficient to change practice, melatonin comes with few risks to patients, as it is a naturally occurring substance.  The results of this third trial are a hopeful development in the face of little new to assist clinicians in delirium prevention and management. 

Al-Aama, T., Brymer, C., Gutmanis, I., Woomore-Goodwin, S. M., Esbaugh, J., & Dasgupta, M.  (2011).  Melatonin decreasese delirium in elderly patients:  A randomized, placebo-controlled trial.  International Journal of Geriatric Psychiatry, 26, 687-694. 
deJonghe, A, et al.  (2011). The effects of melatonin versus placebo on delirium in hip fracture patients:  study protocol of a randomized, placebo-controlled, double blind trial.  BMC Geriatrics, 11, 34. 
Marcantonio, E. R. , Flacker, J. M., Wright, R.J., & Resnick, N.M. (2001).  Reducing delirium after hip fracture:  A randomized trial.  Journal of the American Geriatrics Society, 29, 516-522. 
Sultan, S. S.  (2010).  Assessment of role of perioperative melatonin in prevention and treatment of postoperative delirium after hip arthroplasty under spinal anesthesia in the elderly.  Saudi Journal of Anesthesia, 4(3), 169-173.  

Submitted by: 
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System


Posted by Lisa Morris Bonsall on 6/18/2012 10:37:58 PM
Tags: delirium,elderly
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According to an article published in Nursing2012, “Preventing CLABSI: Central line-associated bloodstream infection,” the mortality for these infections is 12% to 15% which makes it the most deadly  healthcare associated infection and the most costly with average costs per case of $26,000 (Dumont & Nesselrodt, 2012). In 2011, the Centers of Disease Control and Prevention (CDC) released guidelines that give a comprehensive review of ways to prevent these infections (CDC, 2011).

The article by Dumont and Nesselrodt, does an excellent job outlining the causes of CLABSI and the prevention recommendations that can be easily put into practice.  The recommendations are divided into three recommendation categories:
  • Staff education
  • Appropriate selection of catheter and site
  • Sterile technique with insertion and ongoing care.
Putting evidence-based recommendations into practice can be difficult especially when researchers don’t include an evidence summary or recommendations for practice. This article does an excellent job summarizing the evidence and clarifying which recommendations will make the most impact on practice change and patient outcomes.

Centers for Disease Control and Prevention. Vital signs: central line-associated blood stream infections-United States, 2001, 2008, 2009. MMWR Morb Mortal Wkly Rept. 2011, 60(8): 243-248. http://www.cdc.gov/mmwr.
Dumont, C. & Nesselrodt, D. 2012. Preventing CLABSI: Central line-associated bloodstream infections. Nursing2012, 6.
Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health Medical Research

Posted by Kim Frylng on 6/6/2012 11:16:51 AM
Tags: none
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When you look at screening diagnostic tests to detect the presence of disease, nothing causes more discussion than colonoscopies for colon cancer, mammograms for breast cancer, and prostate-specific antigen (PSA) screening for prostate cancer. I was recently at a presentation by a colleague on diagnostic screening tests and whether they are worth it. The discussion that ensued was charged with emotion and logic but eventually it was decided that we as healthcare providers need to provide our patients with the relevant statistics and evidence and then allow them to make their own informed decisions.

Today, the U.S. Preventative Services Task Force released recommendations for prostate-specific antigen (PSA) screening in the Annals of Internal Medicine. The report gives PSA testing a “D” grade level and recommends that men should not have  routine screening for prostate cancer using the PSA test. The task force based their recommendations on several studies which show that there are 242,000 new cases of prostate cancer diagnosed in the U.S. each year and 28,000 men will die each year of it. The majority of deaths occur after age 75 years and the PSA test only helps 1/1,000 avoid dying from prostate cancer. The bottom line in the report is that the test itself causes more harm than benefit because the majority of men, who develop prostate cancer, die of other causes. Prostate cancer surgery leaves between 10 – 70 per 1,000 men with the quality of life altering adverse effects such as urinary incontinence, erectile dysfunction, and bowel dysfunction (Moyer, 2012).

Whether you agree with the recommendations in this guideline or not, the fact of the matter is that this is a recommendation not written in stone. We need to discuss this recommendation with our male patients and then honor their decisions.

Moyer, V. 2012. Screening for prostate cancer: U.S. preventative task force recommendation statement, Annals of Internal Medicine, May 22, 2012.
Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health / Medical Research Division
Lippincott Williams & Wilkins / Ovid Technologies

Posted by Lisa Morris Bonsall on 5/22/2012 1:52:38 PM
Tags: prostate cancer screening,PSA,PSA screening
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