Examining the evidence to guide practice: challenging practice habits

Implementing Prone Positioning for COVID-19 Patients Outside the Intensive Care Unit

BACKGROUND

Proning intubated intensive care unit patients for the management of acute respiratory distress syndrome is an accepted standard of practice. We examined the nursing climate in 4 units and its impact on implementing a novel self-proning protocol to treat COVID-19 patients outside the intensive care unit.

LOCAL PROBLEM

Nursing units previously designated for medical/surgical populations had to adjust quickly to provide evidence-based care for COVID-19 patients attempting self-proning.

METHODS

Nurses from 4 nursing units were surveyed about the implementation process on the self-proning protocol. Their perception of unit implementation was assessed via the Implementation Climate Scale.

INTERVENTIONS

A new self-proning nursing protocol was implemented outside the intensive care unit.

RESULTS

Consistent education on the protocol, belief in the effectiveness of the intervention, and a strong unit-based climate of evidence-based practice contributed to greater implementation of the protocol.

CONCLUSIONS

Implementation of a new nursing protocol is possible with strong unit-based support, even during a pandemic.

Exemplars Illustrating De-implementation of Tradition-Based Practices

Clinical practice must be based on evidence. When evidence suggests that a certain practice may be ineffective or even harmful, that practice should be discontinued. The Choosing Wisely campaign, an initiative of the ABIM (American Board of Internal Medicine) Foundation, is intended to bring attention to tradition-based practices, or "sacred cows," which lack evidence to support their ongoing use. The complex process of discontinuing or reducing the use of tradition-based practices is known as "de-implementation." Recognizing the importance of de-implementation is necessary to fully understand evidence-based practice. This article explores the de-implementation process, examining its barriers and facilitators. Three critical care exemplars of tradition-based practices are presented and examined through the lens of de-implementation. Barriers and facilitators related to de-implementing these tradition-based practices are described, with an emphasis on the roles of various stakeholders and the need to overcome cognitive dissonance and psychological bias.

Using Gemba Boards to Facilitate Evidence-Based Practice in Critical Care

BACKGROUND

Tradition-based practices lack supporting research evidence and may be harmful or ineffective. Engagement of key stakeholders is a critical step toward facilitating evidence-based practice change. Gemba, derived from Japanese, refers to the real place where work is done. Gemba boards (visual management tools) appear to be an innovative method to engage stakeholders and facilitate evidence-based practice.

OBJECTIVES

To explore the use of gemba boards and gemba huddles to facilitate practice change.

METHODS

Twenty-two critical care nurses participated in interviews in this qualitative, descriptive study. Thematic analysis was used to code and categorize interview data. Two researchers reached consensus on coding and derived themes. Data were managed with qualitative analysis software.

RESULTS

The code gemba occurred most frequently; a secondary analysis was performed to explore its impact on practice change. Four themes were derived from the gemba code: (1) facilitation of staff, leadership, and interdisciplinary communication, (2) transparency of outcome data, (3) solicitation of staff ideas and feedback, and (4) dissemination of practice changes. Gemba boards and gemba huddles became part of the organizational culture for promoting and disseminating evidence-based practices.

CONCLUSIONS

Unit-based, publicly located gemba boards and huddles have become key components of evidence-based practice culture. Gemba is both a tool and a process to engage team members and the public to generate clinical questions and to plan, implement, and evaluate practice changes. Future research on the effectiveness of gemba boards to facilitate evidence-based practice is warranted.

De-implementation: A concept analysis

AIM

The purpose of this concept analysis is to explore the meaning of de-implementation and provide a definition that can be used by researchers and clinicians to facilitate evidence-based practice.

BACKGROUND

De-implementation is a relatively unknown process overshadowed by the novelty of introducing new ideas and techniques into practice. Few studies have addressed the challenge of de-implementation and the cognitive processes involved when terminating harmful or unnecessary practices. Also, confusion exists regarding the myriad of terms used to describe de-implementation processes.

DESIGN

Walker and Avant's method (2011) for describing concepts was used to clarify de-implementation.

DATA SOURCE

A database search limited to academic journals yielded 281 publications representing basic research, study protocols, and editorials/commentaries from implementation science experts. After applying exclusion criterion of English language only and eliminating overlap between databases, 41 articles were selected for review.

REVIEW METHODS

Literature review and synthesis provided a concept analysis and a distinct definition of de-implementation.

RESULTS

De-implementation was defined as the process of identifying and removing harmful, non-cost-effective, or ineffective practices based on tradition and without adequate scientific support.

CONCLUSIONS

The analysis provided further refinement of de-implementation as a significant concept for ongoing theory development in implementation science and clinical practice.

Night-time care routine interaction and sleep disruption in adult cardiac surgery

AIMS AND OBJECTIVES

To explore the context and the influence of night-time care routine interactions (NCRIs) on night-time sleep effectiveness (NSE) and daytime sleepiness (DSS) of patients in the cardiac surgery critical-care and progressive-care units of a hospital.

BACKGROUND

There exists a paucity of empirical data regarding the influence of NCRIs on sleep and associated outcomes in hospitalised adult cardiac surgery patients.

METHODS

An exploratory repeated-measures research design was employed on the data provided by 38 elective cardiac surgery patients (mean age 60.0 ± 15.9 years). NCRI forms were completed by the bedside nurses and patients completed a 9-item Visual Analogue Sleep Scale (100-mm horizontal lines measuring NSE and DSS variables). All data were collected during postoperative nights/days (PON/POD) 1 through 5 and analysed with IBM SPSS software.

RESULTS

Patient assessment, medication administration and laboratory/diagnostic procedures were the top three NCRIs reported between midnight and 6:00 a.m. During PON/POD 1 through 5, the respective mean NSE and DSS scores ranged from 52.9 ± 17.2 to 57.8 ± 13.5 and from 27.0 ± 22.6 to 45.6 ± 16.5. Repeated-measures ANOVA showed significant changes in DSS scores (p < .05). NSE and DSS were negatively correlated (r = -.44, p < .05), but changes in NSE scores were not significant (p > .05). Finally, of 8 NCRIs, only 1 (postoperative exercises) was significantly related to sleep variables (r > .40, p < .05).

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

Frequent NCRIs are a common occurrence in cardiac surgery units of a hospital. Further research is needed to make a definitive conclusion about the impact of NCRIs on sleep/sleep disruptions and daytime sleepiness in adult cardiac surgery. Worldwide, acute and critical-care nurses are well positioned to lead initiatives aimed at improving sleep and clinical outcomes in cardiac surgery.

Nutrition Options in Critical Care Unit Patients

Critically ill patients have increased metabolic requirements and must rely on the administration of nutritional therapy to meet those demands. Yet, according to research almost half of all hospitalized patients are not fed, are underfed, or are malnourished while in the hospital. This article demonstrates the importance of early feedings in critical care unit, and the available options open to nurses supporting initiation and management of early feedings. Enteral nutrition has proven to be an important therapeutic strategy for improving the outcomes of critically ill patients and the critical care nurse plays an integral role in their success.

Implementing early mobilisation in the intensive care unit: An integrative review

BACKGROUND

The intensive care unit provides complex care for critically ill patients. Consequently, due to the nature of critical illness and the therapies administered in intensive care, patients are often on prolonged periods of bed rest with limited mobility. It has been recognised that mobilising critically ill patients is beneficial to patients' recovery, however implementing early mobility as a standard of care remains challenging in practice.

OBJECTIVES

To identify the key factors that underpin successful implementation and sustainability of early mobilisation in adult intensive care units.

DESIGN

Integrative Review.

DATA SOURCE

A systematic search strategy guided by SPICE framework (Setting, Perspective, Intervention, Comparison, Evaluation) was used to formulate the research question, identify study inclusion and exclusion criteria, and guide the database search strategy. Computerised databases were searched from August-September 2016. Quality improvement articles that identified project implementation of early mobilisation of mechanically ventilated adult intensive care patients were included.

REVIEW METHODS

After screening the articles, extracting project data and completing summary tables, critical appraisal of the quality improvement projects was completed using the Quality Improvement Minimum Quality Criteria Set. A modified version of the Cochrane Effective Practice and Organisation of Care taxonomy was used to synthesise the multifaceted implementation strategies the projects utilised to help bring about changes in clinician behaviour.

RESULTS

Thirteen articles, reflecting 12 projects meeting the inclusion criteria were included in the final analysis. Eleven projects were conducted in the United States, and one in the United Kingdom. Quality scores ranged from 6 to 15. A formal framework to guide the quality improvement process was used in 9 projects. The three most frequently used groups of implementation strategies were educational meetings, clinical practice guidelines and tailored interventions. Managing the change process through strong leadership, designing strategies and interventions to overcome barriers to implementation, multidisciplinary team collaboration and data collection and feedback underpinned successful and sustainable early mobility practice change.

CONCLUSION

The use of a quality improvement appraisal tool can help identify high quality projects when planning a similar mobility program. Even though projects were conducted in a variety of intensive care unit settings, and implementation frameworks and strategies varied, all began with strong leadership commitment to early mobilisation. This along with using the quality improvement process and multidisciplinary team approach ensured success and sustainability of mobilising ventilated patients.

The influence of care interventions on the continuity of sleep of intensive care unit patients

Objective:

to identify care interventions, performed by the health team, and their influence on the continuity of sleep of patients hospitalized in the Intensive Care Unit.

Method:

descriptive study with a sample of 12 patients. A filming technique was used for the data collection. The awakenings from sleep were measured using the actigraphy method. The analysis of the data was descriptive, processed using the Statistical Package for the Social Sciences software.

Results:

529 care interventions were identified, grouped into 28 different types, of which 12 (42.8%) caused awakening from sleep for the patients. A mean of 44.1 interventions/patient/day was observed, with 1.8 interventions/patient/hour. The administration of oral medicine and food were the interventions that caused higher frequencies of awakenings in the patients.

Conclusion:

it was identified that the health care interventions can harm the sleep of ICU patients. It is recommended that health professionals rethink the planning of interventions according to the individual demand of the patients, with the diversification of schedules and introduction of new practices to improve the quality of sleep of Intensive Care Unit patients.

Assessment of Medical-Surgical Patients' Perception of Hospital Noises and Reported Ability to Rest

OBJECTIVES

The purpose was to determine if an enhanced privacy curtain (1) impacted ability to rest while hospitalized in the acute care setting and (2) improved patient satisfaction associated with environmental noise.

METHODS

The project evaluated a privacy curtain designed to increase speech privacy and intelligibility and reduce reverberation time (echo). The curtain was similar to the existing privacy curtain with 2 exceptions: the curtain panel had pocket inserts that absorbed sound, and curtain panels could be zipped together to reduce sound transmission through gaps. Curtains were evaluated on 2 medical-surgical units. Patients with at least 2 nights' stay and were alert and oriented without behavioral concerns were asked to complete a 12-item restful environment assessment.

RESULTS

The project demonstrated some impact on ability to rest. One unit saw an increase in the patient experience sleep measure score and demonstrated a small increase in the patient's self- reported ability to rest during the day and night when using the enhanced curtain.

CONCLUSION

Patients on medical-surgical units were bothered by the noises typically heard in those units. Small improvements in patient experience with the enhanced curtain were outweighed by cost and increased housekeeping and laundry staff workload.

Intraoperative Gastric Tube Intubation: A Summary of Case Studies and Review of the Literature

Study Objective

Establish complications and risk factors that are associated with blind tube insertion, evaluate the validity of correct placement verification methods, establish the rationales supporting its employment by anesthesia providers, and describe various deployment facilitators described in current literature.

Measurements

An exhaustive literature review of the databases Medline, CINAHL, Cochrane Collaboration, Scopus, and Google Scholar was performed applying the search terms “gastric tube”, “complications”, “decompression”, “blind insertion”, “perioperative”, “intraoperative” in various order sequences. A five-year limit was applied to limit the number and timeliness of articles selected.

Main Results

Patients are exposed to potentially serious morbidity and mortality from blindly inserted gastric tubes. Risk factors associated with malposition include blind insertion, the presence of endotracheal tubes, altered sensorium, and previous tube misplacements. Pulmonary aspiration risk prevention remains the only indication for anesthesia-related intraoperative use. There are no singularly effective tools that predict or verify the proper placement of blindly inserted gastric tubes. Current placement facilitation techniques are perpetuated through anecdotal experience and technique variability warrants further study.

Conclusion

In the absence of aspiration risk factors or the need for surgical decompression in ASA classification I & II patients, a moratorium should be instituted on the elective use of gastric tubes.

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.