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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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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Studying the dying process and terminal extubation in particular, is clearly a challenge. Are the measures we choose even relevant to the person in the bed? We may never know. Nevertheless, some brave souls have attempted to offer their best effort on it. What they mostly do is retrospectively review the chart for processes of care and trends of results. This amounts to little more than consensus of expert opinion but is the best most have been able to achieve to date.

A few trends became obvious as one team reviewed this literature and offered their own local experience. Some of this is just plain common sense. For example, if you don’t need to use devices to maintain patient comfort or resting safety, then don’t. If you don’t need to start an intravenous to give medications, then don’t. Use alternate routes. We have oral morphine (Roxanol) and we can use atropine eye drops under the tongue for secretions. Never stop comfort measures already in place, such as benzodiazepines (Kompanje, 2008). Truog et al. (2008) reminded us all that the goal is to support dignity and comfort, providing quiet, comfortable spaces for the patient and family, absent the trappings of technology, full of human caring. Turn off the alarms and monitors.

Experts argue about the speed of withdrawal of the endo-tracheal tube, but are clear that there are circumstances where it is not appropriate to remove it: large volume of secretions and swollen tongue , for example (Campbell, 2007). Truog et al. (2008) cited the absence of evidence governing this subject. They further noted that rapid withdrawal may cause dyspnea and related discomfort.

Fear of causing a premature death via opioids paralyzes some. Mazer et al. (2011) found that the mean dose of morphine just before death was about 10 mg. During the last hour of life each 1 mg/hour increment of morphine infused was associated with a delay of death by 7.9 minutes. The authors encouraged practitioners to reduce their concern for premature death and act purely on the patient’s assessed needs for comfort.

Truog and colleagues (2008) did their best to summarize care recommendations in a consensus statement by the American College of Critical Care Medicine. This was published in Critical Care Medicine, in 2008. Authors included nurses and physicians knowledgeable in the field. Although many hope this will change as time goes on, around 20% of all deaths in the United States occur in ICUs. Clinicians need to apply the same vigor to dignity and comfort preservation as they do to life saving.

Kompanje, E.O., Van der Hoven, B., & Bakker, J. (2008) Anticipation of distress after discontinuation of mechanical ventilation in the ICU at end of life. Intensive Care Medicine, 34, 1593-1599.

Mazer, M. A. (2011). The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit. Journal of Pain and Symptom Management, 42(1), 44-51.

Truog, RD et. al. (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American Academy of Critical Care Medicine. Critical Care Medicine. 36(3), 953-961.

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 4/16/2012 9:59:00 AM
Tags: end of life care,terminal extubation
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When a patient has a peripheral line placed in an emergency, whether it is out in the field or in an acute care setting, the intravenous infusion device is discontinued and replaced as soon as possible and certainly within 48 hours (CDC, 2002). This policy from the Centers for Disease Control  and Prevention has been the mainstay of our practice for many years, but is it still best practice? The Infusion Nurses Society thinks differently and recommends that without signs of catheter-related complications, pre-hospital peripheral catheters should not be routinely replaced (Mermel, Farr, & Sheretz. 2001).

A study published in the Journal of Trauma Nursing, Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous Catheter, examined this issue.Their study was a descriptive, archival, retrospective study that reviewed 365 trauma patients, over the age of 17 years, who were admited to an urban level 1 trauma center. The results demonstrated that less than 1% of the patients had complications related to a prehospital peripheral intravenous catheter being left in place longer than 48 hours (Clemin, Heldt, & Jones, et. al., 2012).

What are the implications for practice? Although one study should not change practice, there is evidence in the literature that the current policy needs to be further investigated through research and revised. I encourage all of you to base your practice on evidence and recognize that evidence is not stationary, it evolves every day. What was evidence-based practice 10 years ago, may not be best practice today.

Centers for Diseas control and Prevention, 2002.
Guidelines for the prevention of intravascular catheter-related infections. MMWR,  (5)1, 1-29.

Clemin, Heldt, & Jones, et. al., 2012.
Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous CathetersJournal of Trauma Nursing, (19)1, 46-49.

Mermel, L., Farr, B., & Sherentz, R. et. al., 2001.
Guidelines for the management of intravascular catheter-related infections
. Journal of Infusion Nursing, (24)3, 180-205.

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies

Posted by Lisa Morris Bonsall on 4/9/2012 9:56:00 AM
Tags: none
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I read with interest an original research article published in the February issue of the American Journal of Nursing, Nurses' Presenteeism and Its Effects on Self-Reported Quality of Care and Costs (Letvak, Ruhm, & Gupta, 2012). I was not familiar with the term presenteeism but I was familiar with concept. Presenteeism is defined as reduced productivity on the job as a result of health problems (Letvak, et al., 2012). The most common causes of presenteeism are depression and musculoskeletal pain. How many times have you gone to work when you were not feeling well, had aches and pains or were feeling depressed? The guilt in us as nurses compels us to go to work even when we are sick or not up to it.

This study shows that nurses who go to work when they are experiencing health problems are not doing their patients any favors. Presenteeism increases the number of patient falls, increases the number of medication errors, decreases overall quality of care, and increases costs (Letvak, et al., 2012). The evidence is clear on this matter, going to work with health problems negatively impacts the quality of patient care. The next time you have a health problem and are debating about calling in sick or taking a leave of absence to deal with your health issue, think twice and do your patient a favor – call in sick.

Letvak, S., Ruhm, C., Gupta, S. 2012.
Nurses presenteeism and its effects on self-reported quality of care and costs. American Journal of Nursing, 112(2).

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies

Posted by Anne Dabrow Woods on 2/25/2012 4:33:48 AM
Tags: presenteeism
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