Care of the Patient With Enteral Tube Feeding: An Evidence-Based Practice Protocol. 
Deborah  J. Kenny 
Petra Goodman 

Nursing Research
January 2010 
Volume 59 Number 1 - Supplement
Pages S22 - S31

Abstract

Background: Care of patients with enteral feeding tubes often is based on tradition and textbook guidance rather than best evidence. Care practices can vary widely both between and within institutions, and this was the case at a northeastern military medical center that served as the site for this evidence-based protocol development and implementation project.

Objectives: The purpose of this study was to describe the development and implementation of an evidence-based clinical protocol for care of patients with enteral feeding tubes.

Methods: This was an evidence-based implementation project with pretest-posttest measures. Protocol data collection occurred both before and after implementation of the protocol. Data collection tools were based on the literature review and included three domains: (a) documentation of patient procedures, (b) nursing knowledge of each of the specific procedures, and (c) environment of care. Descriptive statistics and data were analyzed using independent samples t tests.

Results: Overall staff knowledge of enteral feedings and methods used to unclog both large- and small-bore feeding tubes differed significantly before and after implementation (p< .05). Staff knowledge regarding the danger of using blue dye in feeding solution was significant (p < .001). There was improvement also in administration of medications separately rather than mixed together and in head of bed elevation of patients with feeding tubes. There was a 10% improvement in documentation of patient family education and a 15% improvement in recording fluid flushes during medication administration. After implementation, environment of care data collection showed 100% of patients with head of bed elevated and with functioning suction available, an improvement over levels before implementation.

Discussion: Care must be taken in the interpretation of these findings because it was generally not the same nurses who answered both surveys. High staff turnover within this military hospital also affected sustainment of the protocol implementation. Maintenance activities must be constant and visible within the organization. A champion for evidence-based practice greatly enhances uptake and maintenance of nursing practice change.


Development and implementation of evidence-based practice (EBP) protocols is a performance improvement activity that has been shown to improve both patient care and outcomes and to improve the skill sets of nurses (Ciliska, Pinelli, DiCenso, & Cullum, 2001; Hutchinson & Johnston, 2006; Kleinpell & Gawlinski, 2005; Newell-Stokes, 2004). In addition, the Joint Commission for the Accreditation of Hospital Organizations (JCAHO) mandated EBP initiatives to be launched in 2004 as a part of hospital performance improvement (JCAHO, 2003).

The development of an EBP program at a large northeastern military medical center was done as a funded subaward under the larger funded TriService Nursing Research Program designed to initiate an EBP program for development of various projects in military hospitals throughout the United States. The objective of the nationwide EBP program was to create and to implant a culture of the use of best evidence into military nursing practices as described in Duong's article in this supplement. The goal of the subaward given to the northeastern military medical center was to develop and to implement three nursing practice protocols on the basis of best evidence. These new protocols included prevention and treatment of patients with pressure ulcers, care of patients receiving enteral feedings, and assessment and prevention of deep vein thrombosis/pulmonary embolus. Secondarily, a separate research arm of the program was formed to determine the uptake of the use of evidence in practice through surveys given to nurses before implementation of the three protocols. Only the development and implementation of the protocol on enteral feeding will be reported in this article. Development and implementation of the pressure ulcer and deep vein thrombosis/pulmonary embolus protocols and the results of the evidence uptake surveys will be reported elsewhere.

The primary purpose of this project was (a) to conceptualize the evidence base for management of enteral tube feedings in adult patients, (b) to develop an EBP protocol based on review of the literature, (c) to implement the new protocol, and (d) to evaluate its impact. A secondary indirect aim of the project was to educate the nursing staff about the EBP process and to stimulate the independent development and implementation of EBP processes.

The medical center used in the study consists of 16 inpatient wards and approximately 900 nursing personnel. The nursing staff are military and civilian registered nurses, licensed practical nurses, and nursing assistants. The daily census of the hospital is typically 150-175 inpatients. The patient demographics had changed recently from a patient population resembling civilian hospitals to a younger population who had suffered multiple traumatic injuries because of the wars in Iraq and Afghanistan. This population provided the triggers for development of the protocols; many of these patients required enteral feedings because of serious injuries suffered in the war zone.

At the time of project commencement, nursing practice at the medical center was based on standard operating procedures and other nursing text references available on the individual wards. Bedside nurses had few readily available written or electronic resources from which to base their practice. Nursing procedures for the same types of patients varied from ward to ward and even from nurse to nurse within the same wards. Practice was based primarily on individual past experience and tradition, with older nurses teaching procedures to the younger nurses. Evidence-based nursing practice was not the standard for care. The aim of this project was to develop consistent standards for specific nursing care procedures on the basis of the current evidence.

Institutional review board approval for this project was given through the medical center's Department of Clinical Investigations for the performance improvement portion of this project, solely for publication and other dissemination efforts, not for practice protocol approval.

The Iowa model for EBP (Titler et al., 2001) was identified as the model to be used to develop and to implement the evidence-based protocols for the medical center, and training in the use of this model for the medical center's advanced practice nurses was provided by Dr. Titler as described in another article in this supplement. Description of the protocol development follows the Iowa model.

Management of enteral tube feedings in adult patients based on the best evidence is critical to realizing healthcare improvements and cost savings. The decision to select enteral feedings as a process for which to develop and to implement an EBP nursing protocol was based on a single serious patient sentinel event. Wishing to prevent further patient harm, the medical center's nursing practice council viewed this as a problem-focused trigger to be addressed immediately. The nursing council believed that patient safety could be compromised because the procedures being used varied between wards. Procedures were described as "the way they had always been done," and the current policy was not based on scientific evidence. Nurse managers anecdotally identified the number of clogged tubes, equipment malfunctions, and observed performance gaps as significant safety and risk management concerns. Each procedural variation could be associated with unique adverse events and risk for the patient. Questions were posed concerning the quality of the outcomes and alternative means that would be more efficient or cost effective. Improvements or benefits could result if best practices were identified that would improve outcomes of care or decrease costs or risks associated with the identified problem-focused triggers. The nurse managers asked that best practices be sought without delay rather than gather data that would objectively quantify the extent of problems discussed.

In addition to the problem-focused triggers, the topic was assessed for fit with organizational priorities. This was important to garner support of key individuals such as head nurses, section supervisors, and executive nurses. Equally important was the selection of this topic by clinical nursing staff. Because this topic was embraced by the staff, changes had a greater likelihood of adoption (Titler, Everett, & Adams, 2007).

The performance gaps and high variance in procedures related to management of enteral tube feedings indicated lack of standardization and use of evidence for performance of efficient and effective patient procedures. An external factor bearing on this problem was the JCAHO mandates for achievement and maintenance of high standards of practice and the quality that are based on evidence (JCAHO, 2008).

In keeping with the Iowa model, after identification of enteral feedings as a problem, a team was formed of nurses from representative inpatient services, a physician from the surgical intensive care unit (ICU), a clinical nurse specialist (CNS), and a nutrition care specialist. Because the EBP process was new to most of the team members, education in the process of putting evidence into practice was necessary. The team also needed training in reviewing and critiquing literature. Also necessary was support from senior nursing leadership to allow administrative time for team members to work on the protocol and to lessen team turnover. A schedule was planned for team members to gather for a full day once a month for 4-6 months to work on the protocol. These sessions were structured and had objectives, and team members were given continuing education units for their participation. The first full day involved training in basic research procedures, data collection, literature review, and the process of implementing evidence into practice. Funding for the project allowed the hiring of contract nurses to replace, at the bedside, those who were given administrative time to work on the project.

Outcomes were measured at three levels: patient, nursing, and organization. The patient outcome was difficult to measure directly as events such as clogged feeding tubes are not considered reportable events and its occurrence was not consistently documented in the patient electronic medical record, especially if the clog was easily removed. Only clogs requiring replacement of the tube were likely to be documented, and then only inconsistently; thus, this outcome was not able to be captured easily. Thus, we measured this outcome indirectly through anecdotal reports of tube clogging incidents and patient responses to medication administration. Although not objective, these reports did provide low-level evidence of the clinical effectiveness of the implemented protocol. Events such as aspirations/aspiration pneumonia are generally reported in organizational incident reports, but again only inconsistently.

Nursing outcomes included staff knowledge of evidence-based interventions for patients with enteral feeding tubes and process measures to examine compliance with implementation of the EBP protocol. Staff knowledge was defined as the percentage of correct items on the assessment of staff knowledge worksheet consisting of seven multiple-choice questions on the basis of the evidence found in the literature review. For example, questions were asked in the topical areas of use of blue dye in feeding solutions, methods of tube placement verification, unclogging procedures, residual limits, aspiration risk, rate calculation, and caloric needs. There were also four short-answer questions asking nurses to describe procedures related to enteral feedings, such as how to unclog tubes or administer medications. The purpose of these questions was to determine variance in practice. Compliance with implementation was defined as the percentage of the presence of 23 selected criteria on the documentation checklist and the percentage of the presence of nine selected criteria on the environment of care checklist. Criteria selected for these two checklists were based on evidence in the literature review. The aggregate scores on each of these measures were compared across nursing staff before and after implementation. The scores on these measures were also compared across nursing units before and after implementation.

The organizational outcome was objective actions performed by executive leaders demonstrating support of the EBP model. This outcome was measured using organizational processes such as approval and implementation of an organization-wide policy for the EBP of management of enteral tube feedings in adult patients and incorporation of EBP into job descriptions, orientation programs, annual competency evaluations, and performance evaluations.

A search for the most current evidence related to nursing care of the patient receiving enteral feeding was performed in the Cumulative Index to Nursing and Allied Health Literature and Medline databases using the terms enteral feeding and tube feeding. The search was limited further to research articles, written in English, and between the years 1995 and 2005. This search yielded 146 articles. Titles were included for abstract review if they were applicable to nursing practice. For example, a research article examining the nutrient value of tube feeding additives was not considered applicable for nursing practice. After review of the article titles, 56 were included for abstract review. Review of the abstracts further excluded 16 articles because they did not provide evidence pertinent to nursing care of a patient with enteral feedings, giving a final yield of 40. A second search using the terms enteral feeding and medication administration was done in the same manner, resulting in three more articles. A subsequent search using the term clogged feeding tube with the above limits yielded three articles. Four older, seminal research articles were also included. As the project progressed, three recent articles were added as new evidence. A total of 53 full-text articles were reviewed for evidence from which to develop the nursing care protocol. Review of the articles revealed several topical areas where there was evidence regarding enteral feedings (Table 1).

Table 1 - Click to enlarge in new window TABLE 1. Topical Areas of Literature Reviewed

Literature Review

The evidence was evaluated using the 2003 Agency for Healthcare Research and Quality rating scheme for evidence (Concato, Shah, & Horwitz, 2002) and the U.S. Preventive Services Task Force rating for evidence recommendations (Agency for Healthcare Research and Quality, 2009).

Before evaluating articles, team members were taught basic research principles and were given the opportunity to practice evaluating literature in groups and pairs before being assigned articles to rate themselves. The ratings were reviewed by the primary author for validity of team-member ratings. To determine a final evidence rating for each of the topical areas outlined in Table 1, a matrix (Figure 1) was developed to provide a visual depiction of the level at which the preponderance of the evidence was found, which formed the basis for the recommendation. Evidence was evaluated also for applicability to use in practice with the unique patient population in the military medical center. Research related to care of patients with enteral feedings was summarized according to nursing practice in this topic area.

Figure 1 - Click to enlarge in new window FIGURE 1. Sample evidence matrix depicting preponderance of evidence related to enteral feeding tube insertion and placement.

Overall, the research for enteral feedings was descriptive in nature and provided only low levels of evidence for the practice recommendations. However, despite the overall low strength of the evidence, the team members believed it was acceptable for policy change in the medical center and more up to date than current texts and procedure manuals. After the literature synopsis in each section is the recommendation that was instituted in the enteral feeding policy and the strength of the evidence in that area.

Rakel et al. (1994) stated that the best and most accurate method for initial tube placement assessment is via X-ray. Nurses in teaching hospitals (29%) were more likely to use radiography to assess initial tube placement than community hospitals (9%) (Schmieding, Waldman, & Desaulles, 1997). The most common methods to assess tube placement were auscultation and aspiration. However, a study by Neumann, Meyer, Dutton, and Smith (1995) showed that auscultation resulted in a 6.3% specificity in determining accurate tube placement. The aspiration method was accurate when pH is less than 4 and only if pH-altering medications were not used. Six studies were reviewed in this category. Five were descriptive (Evidence Level III) and one was a quasi-experimental study (Evidence Level II-3). It has been determined previously that auscultatory methods cannot be used to determine enteral tube placement confidently (Metheny, McSweeney, Wehrle, & Wiersema, 1990), and reliance on aspirates should be used with caution (Metheny et al., 1989); verification via X-ray was the recommended method. Additional studies indicated that use of pH testing of aspirates shows promise as a method to determine feeding tube placement (Metheny, 1993). Metheny and Meert (2004) conducted a literature review and recommended that a combination of nonradiological methods be used to identify when X-rays should be used to further confirm both initial placement and continued correct positioning of feeding tubes.

Although the evidence is not strong for use of X-rays for determining tube placement, it remains the gold standard while other methods are being investigated. The recommendation for the new protocol was that placement of feeding tubes must be verified by X-ray and no feeding would be administered until a verification order was written by a physician (Evidence Grading: III B).

Schmieding and Waldman (1997), in a study of registered nurses at 11 hospitals, found that most refer to an agency policy book for information regarding the management of enteral tube feedings and that those policies may have contained more ritualistic practices than EBP. Tube flushing practices varied to include the amount of flush and frequency of flushing (Reising & Neal, 2005). Most were reports on flushing enteral feeding tubes describing nursing practice and not research in frequency and volume of flushes.

The questionnaire of Schmieding et al. (1997) revealed that nurses used many methods for unclogging enteral feeding tubes. Substances such as coffee and meat tenderizer were used to unclog tubes (Schmieding et al., 1997) in descriptive studies, but their effectiveness is unproven and may be contraindicated (e.g., meat tenderizer may be high in sodium). Marcuard and Stegall (1990) found that the two most common causes of clogged tubes were protein formulas and instillation of crushed medication into the tube. They examined the use of pancreatic enzymes in unclogging tubes and found them to be effective in unclogging enteral feeding tubes 72% of the time, as opposed to using water which was successful only 27% of the time (n = 24 clogged tubes). They provided recommendations on the proper method of using pancreatic enzymes to unclog tubes. Sriram, Jayanthi, Lakshmi, and George (1997) found the use of a pancreatic enzyme-sodium bicarbonate suspension to be effective in preventing clogged tubes. Ensuring proper tube placement before using pancreatic enzymes is vital as they can lead to severe complications if instilled into the respiratory tract (Kohn & Keithley, 1989). Lower levels of evidence pointed to the use of water as the best method to unclog feeding tubes; juices and cola may cause precipitates and further clog tubes (Marcuard & Stegall, 1990).

Because use of pancreatic enzymes requires a physician's order and should be used judiciously, initial attempts at flushing should be with water only. Juice, soda, or meat tenderizer should not be used. For tenaciously clogged tubes, physicians should be contacted for orders for pancreatic enzymes (Evidence Grading: III B).

Heyland et al. (2003) found that 16% of patients who remained in the ICU more than 3 days did not receive any nutritional support, and all patients (n = 423) received only 56-62% of their caloric and protein needs, whether receiving total parenteral nutrition, enteral feedings, or both. Evidence supported that early feeding versus delayed feeding was shown to be beneficial without increasing the risk for complications (Lewis, Egger, Sylvester, & Thomas, 2001; Minard, Kudsk, Melton, Patton, & Tolley, 2000; Spain, 2002; Wicks et al., 1994). Belknap, Davidson, and Smith (1997) concluded that Metamucil(TM) added to tube feeding did not decrease the amount of stool but did result in gelatinous or formed stools rather than diarrhea.

Recommended practice for the new protocol was that a nutritional consult for all patients receiving enteral tube feedings would be instituted as soon as possible (Evidence Grading: III B).

Hussain, Roy, and Young (2003) used modified glucose oxidase testing to determine aspiration of gastric contents and found that only 43% of confirmed aspirations could be detected clinically. Blue dye added to feeding formula to detect possible aspiration has been implicated with serious side effects, including death, when it is absorbed into the blood stream because of increased gut permeability in critically ill patients (Maloney & Metheny, 2002; Maloney & Ryan, 2002). Heyland, Drover, Dhaliwal, and Greenwood (2002) conducted a meta-analysis and found that the incidence of aspiration-related pneumonia decreased as the head of the bed was elevated to 45[degrees]. Heyland et al., in their meta-analysis of 10 previously conducted studies, found that small bowel feedings were associated with less gastroesophageal reflux, increased nutrient delivery, shorter time to achieve desired nutritional goals, and decreased incidence of ventilator-associated pneumonia.

Practice recommendations to prevent aspiration required the head of patients' beds to be maintained at 30[degrees] to 45[degrees] at all times during feeding and for 30 to 60 minutes after feeding is completed or stopped for any reason. Blue dye had been removed previously from all patient care wards, but because many nurses still considered the use of blue dye appropriate for detecting aspiration, the protocol stated that it would not be used in any enteral feeding formula (Evidence Grading: III B).

Most of the studies about medications were not research but rather informational articles descriptive of current practice. Marcuard and Stegall (1990) attributed most enteral feeding clogs to medication administration techniques and recommended providing nurses a list of medications that would flow easily through enteral feeding tubes and ones that were more likely to cause clogs. They also recommended flushing both before and after instilling medications. Kohn-Keeth (2000) recommended using elixir forms of medication when possible and flushing before and after administering medications. It was recommended that medications be administered separately.

The new protocol contained a list of medications, which could not be crushed or administered through feeding tubes. A recommendation was made also that medications were to be administered separately and the tube was to be flushed with water before and after each medication (Evidence Grading: III, I).

McClave et al. (2005) contended that residuals may be a poor marker of gastrointestinal functioning or risk of aspiration. Their study revealed that 31.3% of oropharyngeal samples (n = 1,118) were gastric and that the mean residual volume for those patients was 35.1 ml. They also found that there was no difference in aspiration risk if cessation of feeding was based on 400 ml rather than 200 ml. Booker, Niedringhaus, Eden, and Arnold (2000) evaluated the effects of reinfusing residuals and determined there were no significant differences in returning versus discarding residuals in a small sample of ICU patients.

Evidence showed that residuals should not be checked with small-bore feeding tubes. Aspiration of gastric contents, especially in small-bore tubes, can cause precipitates when mixed with high pH feedings and cause clogging (Marcuard & Stegall, 1990). In addition, small-bore feeding tubes tend to collapse more easily, making assessment of residuals inaccurate.

Residual gastric contents should be reinfused in the absence of abdominal pain or distention; continue infusion if residual is >200 ml and if there is no abdominal pain or distention; recheck in 1 hour; if residual is still >200 ml, stop infusion for 4 hours and recheck; if still >200, call physician; and if <200 ml, restart the infusion at 50% the original rate and monitor (Evidence Grading: III B).

The above synopsis of the literature reflects the most up-to-date literature in 2005, when this protocol was developed and implemented. Since then, there has been continued research in nursing practice related to care of the patient with an enteral feeding tube. For example, Metheny, Schallom, Oliver, and Clouse (2008) studied the relationship between gastric residual volumes and aspiration with inconsistent results. However, they also found that larger residual volumes were associated with large bore feeding tubes and contend the possible reasons for this are the relative ease of withdrawing fluid from a large bore tube and the increased likelihood it is lying in gastric fluid. Metheny (2008) also discussed the results of several studies regarding enteral feeding practices and makes recommendations for residual volume measurements. Kyle et al., (2006) compared caloric needs of ventilated versus nonventilated patients and found all patients to be underfed, but this problem was particularly prevalent among ventilated patients. There continues to be a plethora of informational articles surrounding management of enteral feeding tubes and various issues such as medication administration (Clarke, 2008; Williams, 2008), infection control (Best, 2008), aspiration (Serna & McCarthy, 2006), and guideline development (Bourgault, Ipe, Weaver, Swartz, & O'Dea, 2007). As new evidence becomes available, ongoing evaluation is required to determine of the protocol needs to be updated or revised.

Process for Change

The team constructed the outcome measures on the basis of the literature. For example, they wrote a staff knowledge quiz with seven multiple-choice questions on the basis of their reviews (Table 2). They determined which outcome measures (i.e., residual checks and flush documentation) would be used to gauge success of protocol implementation (Table 3). The team spent a day conducting preimplementation measurements for every patient with an enteral feeding tube (n = 20).

Table 2 - Click to enlarge in new window TABLE 2. Staff Knowledge Quiz for Enteral Feeding: Multiple-Choice Questions

Table 3 - Click to enlarge in new window TABLE 3. Measurement Criteria for Documentation and Environment of Care

The literature evaluations were discussed with the team and other multidisciplinary members, and the protocol was written with the recommendations developed from the literature. The new protocol incorporated a residual check algorithm already being used by the surgical ICU that was based on up-to-date evidence. To educate the staff about the new protocols, the team devised a tabletop education stand using a tripanel acrylic sign holder. They created three colorful 81/2 x 11-in. signs containing pertinent and current information on the basis of the evidence to put in these displays (Figure 2). The team conducted inservice sessions on each ward, outlining the new protocol and educating the staff about the evidence they had reviewed. After the inservice sessions, the displays were left on each ward as a visible reminder. One-sheet Nursing Cliff Notes were also created, detailing the salient features of the new protocol. These were placed in each nurse's mailbox, and a laminated copy was distributed in each ward to place in the nursing station. The new protocol was given to multidisciplinary managers for their input and approval. Once it was finalized, it was implemented hospital-wide using the strategies identified above. After approximately 6 months, the team members reassessed outcome measures to determine if the change was successful and being sustained on the nursing units.

Figure 2 - Click to enlarge in new window FIGURE 2. Tabletop displays for staff education on best practices for care of patients with enteral feeding tubes.

Results

Patient-level outcomes were reported anecdotally as a decrease in the number of incidents of clogged tubes, leading to patients having to tolerate fewer incidents of tube reinsertions. Because patients did not lose feeding time due to clogged tubes, they were able to have increased amount of tube feeding administered, presumably improving nutritional status. Because there were no data before implementation on the rate of clogged feeding tubes, it was not possible to make a comparison after implementation. In addition, because of the difficulty in getting accurate data regarding clogs and need for replacement, the nurses' subjective observations were used. There were no reports of aspiration/aspiration pneumonia.

Some practice changes were slow (i.e., not mixing medications for administration, not using cola for unclogging tubes), but progress was made. Instant, positive feedback for the nurses was important in gaining support for implementing the new protocol. The nurses on one ward were very diligent in giving medications separately as recommended in the protocol, and they noted the following positive results:

I was in there 30 minutes pushing meds and I had [a] basin full of meds each in their own individual cups, and it did take me 30 minutes, but I was with the patients and we were talking and they feel better because you're in there more and they see you more [horizontal ellipsis] on our ward our Dobhoffs don't clog any more or haven't clogged off for a long time and we've had a constant Dobhoff on the floor for the last two months and they haven't been clogged.

After evaluation of the implementation of the EBP process, several positive effects of change were apparent. First, we used independent sample t tests to compare percentages of correct answers on the seven-question survey assessment of staff knowledge before and after implementation (n = 89 and n = 79, respectively). Results indicated a significant increase in overall staff knowledge and implementation of evidence-based processes for management of enteral tube feedings (p =.05), especially in the areas of unclogging procedures, aspiration prevention, and the dangers of using blue dye in feeding solutions. Furthermore, in the short-answer section of the staff knowledge quiz after implementation, 86% and 89% of the nurses listed water as the primary solution used to unclog large- and small-bore feeding tubes, respectively, and 85% of the nurses stated that they should administer the oral medications separately by crushing, mixing, and administering one medication at a time.

Evaluation of documentation and environment of care also indicated a significant improvement in compliance with evidence-based processes (Table 4). Before implementation (n = 20), 30% of the patient charts indicated documentation of tube placement verification and only 25% of the patient charts included documentation of flushing before and after administration of medication, whereas after implementation (n = 5), only 20% of the patient charts included documentation of tube placement verification, but documentation of flushing before and after medication administration improved to 40%. The Environment of Care Worksheet revealed that 100% of patients after implementation had the head of the bed elevated >30[degrees] and 100% of patients had working suction in their rooms.

Table 4 - Click to enlarge in new window TABLE 4. Enteral Feeding Before and After Implementation: Documentation and Environment of Care Data

It was not possible to assess outcomes at the unit level accurately for the medical-surgical wards because there were no patients with enteral feeding tubes on the day of data collection. However, because there were similar patient numbers for ICU patients with enteral tube feedings both before (n = 7) and after (n = 5) implementation, comparisons were made with this group of patients. Documentation of tube placement verification increased from 57.1% to 80% after the protocol was implemented. Also, documentation of medication flushes increased from 14.3% to 40%. Most significant was that before protocol implementation, 43% of patients with enteral tubes did not have the head of bed elevated more than 20[degrees], whereas after implementation, all of the patients' beds were elevated at least 30[degrees].

The project has infused the creation of a culture of value for EBP from the level of the clinical staff nurse to the nursing executive level. To build capacity and to demonstrate commitment, nurse leaders have encouraged the use of EBP and incorporated EBP into job descriptions, orientation programs, annual competency verification, and policies. For all nurses, the nurse leaders encourage EBP and the questioning of practice regarding what evidence supports this practice. To champion the development and implementation of EBP processes, the Department of Nursing allocated $1,000,000 for additional CNSs on the inpatient units. These advance practice nurses would be involved actively in analyses of current procedures, review of literature, development of protocols, evaluation of new processes, and mentorship of team leaders and members. In addition, the CNSs would support nursing staff in the implementation of current EBP processes and periodic evaluation of such processes for continued sustainment. The CNSs job descriptions list explicit job performance criteria for the use of evidence to guide practice.

Measures of EBP were included also in education and training. At each hospital nursing orientation, the wound-ostomy nurse provides a presentation on the EBP processes related to prevention and management of pressure ulcers and provides additional training at periodic skill fairs. In addition, nurse researchers at the hospital also provide an overview of EBP, and they periodically offer EBP inservice sessions and education. Now, initial competency incorporates educating new staff on EBP processes and annual competency verification involves demonstration of competency in EBP processes. Finally, a policy dictating the EBP processes was written and approved by nursing and other disciplines within the organization.

Discussion

The development and implementation of this EBP project provided outcomes related directly to this project and facilitated the use of EBP at an individual nursing and organizational level. For individual nurses, the translation of theory and research into practice provided validation to the nurses that what they do is of value and that different processes have varying degrees of evidence to support that process. The collaborative relationship between the nursing research service and the clinical nursing staff, inclusive of the executive nursing leadership, has improved significantly and more nurses at all levels are seeking consultative nursing research services and initiating new EBP projects. Clinical staff nurses are in an ideal position to question nursing practice and to develop EBP protocols. After completion of this project, many more nurses are thinking critically about their practices, inquiring if the practices are based on evidence, seeking assistance to appraise scientific and other quantitative and qualitative evidence, and seeking to work in teams to change the standards by translating the evidence into practice.

To enhance sustainment of the change, practice prompts were developed and implemented, and an evaluation plan was developed. The trifold displays and the Nursing Cliff Notes provided easy reference material to maintain knowledge of the evidence. Across the units, the nurses have verbalized that these reminders have been extremely useful for maintenance of knowledge and quick and easy access to information in times of busy workload.

Computer-based automatic cues were established within the electronic medical record. For example, on the invasive device flow sheet, rows labeled as placement verification, tube care, and residuals and frequency were inserted to cue the nurse to document on these parameters. The evaluation plan calls for performance measures, both process and outcomes, that monitor and evaluate the continued implementation and results. Biannually, nurses will be assessed for knowledge competency, patient charts are audited for compliance with EBP procedures and documentation, and nurses will be observed for use of appropriate procedures. Since the implementation of this protocol, there has been continued research in nursing practice related to care of the patient with an enteral feeding tube.

Despite positive outcomes for this EBP protocol, there were many inherent limitations. This protocol was not designed to be generalizable to other medical facilities. It was developed for the setting in a single military medical center and the unique organizational characteristics related to mission, staff, and patient population. Most the staff members are active duty and reserve soldiers, with a high turnover due to deployments and new assignments. However, low numbers of experienced military nurses were available because of deployments or assignments in nonclinical areas such as administration, education, or graduate school and Army courses. The nursing units were staffed primarily with junior military nurses having fewer than 3 years of nursing experience. The patient population also has changed after the beginning of the Operation Enduring Freedom and the Operation Iraqi Freedom. Before the conflicts in Afghanistan and Iraq, the patient population consisted largely of elderly patients with chronic and acute diseases. Today, casualties from the conflicts comprise about 25% of the patient population. Care of the casualties includes management of various types of trauma. Adaptation of the protocol would be necessary for use in other environments.

The small sample size for patient- and unit-level outcomes was a significant limitation. The number of patients and patient charts (n = 20) that were evaluated before implementation of the EBP protocol was significantly higher than the number of patients and patient charts (n = 5) that were evaluated after implementation of the EBP protocol. Evaluating all the adult patients with enteral tube feedings on inpatient units on just one preselected day before and after implementation contributed to this limitation. A better representation of success after implementation could have been made if evaluations were extended across multiple days to capture a larger sample of patients. However, extended evaluation could have been confounded by the influence of time on sustainment of an EBP protocol.

Having to rely on anecdotal evidence of effectiveness was another significant limitation of the project. Ideally, preimplementation data collection would provide for comparison with postimplementation outcomes as an objective measure of effectiveness. Pragmatically, this is not always possible. Implementing EBP protocols is not a linear process, and organizational need may preclude the collection of quantifiable data when a process needs immediate change due to the potential for patient harm.

The implementation of this protocol proved to be difficult, and barriers existed within the organization and among the nurses. This protocol was developed and implemented in 2005 on the basis of the most up-to-date literature for that time. New literature necessitates a reevaluation and revision of the protocol. New evidence points out an important factor in implementation science. The process of applying evidence into practice does not end with the implementation of a protocol but requires continuous evaluation of outcomes and evaluation of new evidence as it emerges.

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