Posts Tagged ‘evidence-based practice’

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Emergency Contraception: Why It Matters and How Nurses Can Improve Access

April 16, 2012

By Sylvia Foley, AJN senior editor

Family planning counseling, by Dick Schmidt / Sacramento Bee / Zuma Press

Unintended pregnancy can, in some circumstances, be detrimental to the health of both the women who become pregnant and the children born as a result. And such pregnancies happen far more often than you might think, accounting for nearly half of all pregnancies in this country, with even higher rates among women ages 18 to 24 and low-income women. Yet we have had the means to safely prevent such pregnancies for decades, through emergency contraception. Why isn’t emergency contraception used more often?

That’s a question author Kit Devine explores in “The Underutilization of Emergency Contraception,” one of April’s CE features. First, Devine describes the four methods currently available: conventional oral contraceptives and the copper intrauterine device (IUD)—both are used for birth control and can also be used to prevent pregnancy after intercourse has occurred—and the agents levonorgestrel and ulipristal acetate, which are FDA-approved for emergency contraception. Effectiveness ranges from 51% to 62% (for conventional oral contraceptives) to as high as 99% (for IUDs).

Known and likely barriers to their use include Read the rest of this entry ?

Posted in audio interviews, continuing education, ethical issues, nurse practitioners, nurses | Tagged , , | 1 Comment »

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Critical Care: Where’s the Evidence for Central Venous Pressure Monitoring?

January 13, 2012

Editor’s note: This post is by Anne Dabrow Woods, MSN, RN, CRNP, who is AJN‘s publisher and chief nurse and publisher of Wolters Kluwer Health Medical Research. It was originally published on the blog of Lippincott’s Evidence-Based Practice Network.

I read with interest the article “Central Venous Pressure Monitoring: Where’s the Evidence?” (purchase required for nonsubscribers) in the January issue of AJN. It’s part of 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 but on how we have always done things in practice—or on research that was not credible.

This article looks at the evidence supporting the use of 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 intravascular volume, nor is it an accurate predictor of fluid responsiveness (whether a patient will respond to a fluid bolus with an increase in stroke volume). The authors of the AJN article critically appraised the evidence and determined the following:

  • 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, be it a fluid bolus or the use of a vasoactive medication.

In brief, the evidence tells us that we can’t base treatment decisions on just one hemodynamic indice. The clinician needs to look at the entire hemodynamic picture, including, for example, heart rate, blood pressure, mean arterial pressure, and urine output, when determining 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).

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From the Blogs: Negotiating Medicare, Nurses Doing Research, Reader Comments

November 29, 2011


Medicare is confusing for providers who aren’t yet familiar with it. Here’s a Nursetopia post that draws attention to its complexity and notes the useful video above (it’s one of a series of videos on different aspects of Medicare). Those of you who know all about it already: Drop by her thoughtful (and consistently updated!) blog and let her know your own tips on handling the ins and outs of Medicare and Medicaid.

EBP matters. Terri Schmitt at Nurse Story has a frank and engaging post on evidence-based practice (EBP): “Translation of EBP: Why Creating Nurse Scientists is the Way to Improve Patient Outcomes.” Here’s what she promises to cover in it:

  • Research is sometimes far removed from bedside nurses
  • Research is COOL!
  • Research is about PATIENTS and not fame/fortune of researcher
  • Research is critical to practice and there are big gaps that nurses need to fill
  • Bedside nurses may be the most crucial link in research ideas, translation, and practice.

(Shameless plug for related AJN content: See our recent, amazingly useful step-by-step CE series on how nurses can get involved in evidence-based practice.)

Plus a brief note on reader comments: we’ve been getting a lot of great comments lately on this blog, and we’re grateful for that. So thank you. A fair number of the comments were on posts from previous months, such as this post comparing U.S. and Australian health care systems. Is somebody by chance teaching a nursing course that requires students to leave thoughtful, respectful, engaged comments in the blogosphere? If so, bless you!—JM, senior editor/blog editor

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On Protocols, Shortcuts, and the Unforgettable Smell of Ether

November 9, 2011

By Linda Johanson, EdD, RN, associate professor of nursing at Appalachian State University, Boone, NC

In nursing school my professors warned us of the dangers of taking shortcuts when performing procedures. They cautioned that deviations from protocols could lead to serious error. I had to learn this lesson the hard way, and although it’s been about 30 years since I made this mistake, I still remember the occasion like it happened yesterday.

The patient was in ICU bed #10, a glassed-in isolation room across from the nursing station. He was in his mid-60s, but he was mentally handicapped, so he appeared and acted younger. He was in the unit recovering from a respiratory arrest, and on the day I was caring for him he was still intubated, but breathing spontaneously.

by james bowe, via flickr

I was completing an assessment on him when the charge nurse called to me from the nursing station, and I stuck my head out the door to see what she wanted. She told me there was a new order to remove the patient’s indwelling urinary catheter. I checked my pockets for a 10 mL syringe to perform the procedure but didn’t find one.

When I complained about having to go all the way to the supply room to collect one, the charge nurse queried, “Well, you have scissors, don’t you? You can just cut the catheter with them. The balloon will deflate, and it will pull right out. I’ve done it a hundred times.”

Cut the catheter? I had never heard of that before, but I was a relatively new nurse, so I hadn’t been exposed to a lot of things yet. Of course I had scissors right in my pocket, and I got them out. Was this an example of one of those unacceptable shortcuts we’d been warned about in nursing school? It would sure be quicker and easier than running all the way to the supply room.

I approached the patient, who although unable to comprehend what was happening, seemed to regard me with a trusting expression. I exposed the catheter and opened my scissors to a spot about one inch from its point of entry. I hesitated for one brief second, then snipped the tube. I gave the catheter a little tug, and the patient winced. The tube stayed firmly in place, the balloon obviously fully inflated. Read the rest of this entry ?

Posted in nursing perspective | Tagged , , , , , , | 8 Comments »

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One Take on the Top 10 Issues Facing Nursing

October 31, 2011

By Shawn Kennedy, MA, RN, AJN editor-in-chief

So I’ve been in Dallas at the Sigma Theta Tau International (STTI) biennial meeting. The venue is the Gaylord Texan, a large, climate-controlled resort under a glass dome—as you leave your building and walk “outside,” you’re really not. Don’t believe the flowing stream or flowers or gardens (all real) along the walkways, or the Longhorn steer (fake) behind a fence that stands outside my building—you’re still inside. And to make it even more surreal, there are Christmas holiday decorations everywhere, including a gingerbread house the size of a small hotel room. It will be strange to step back in time to Halloween when I get back home.

A daunting list. There are a few thousand people here for the meeting, way too many sessions to choose from (20 different topics for each concurrent session period), plus rows of posters and exhibit booths. And of course, great networking. One lively session I attended was standing room only—and that’s after any floor space had been occupied by people sitting cross-legged. It was a discussion of the top 10 issues facing nursing, led by STTI’s publications director Renee Wilmeth (she’s not a nurse, which probably makes her less biased). The issues were compiled from responses provided by 30 nursing leaders, and were presented in question form:

  1. Is evidence-based practice (EBP) helpful or harmful? (Amazing how many interpretations there were of EBP, some of them—as I know from our EBP series—quite incorrect.)
  2. What is the long-term impact of technology on nursing?
  3. Can we all agree that a bachelor’s degree should be the minimum level for entry into practice? (General agreement here, despite concerns regarding the adequacy of financial support for achieving this goal.)
  4. DNP vs PhD: separate but equal? (Not much discussion—I think no one wanted to really get into this.)
  5. How do nurses get a seat at the policy table?
  6. How do nurses cope with the growing ethical demands of practice? (This generated the most discussion, especially around whether society should provide unlimited costly care to those whose personal choices contribute to their health problems.)
  7. How do we fix the workplace culture of nursing?
  8. What role do nurse leaders play in the profession?
  9. What are we doing about the widening workforce age gap?
  10. How do we make the profession as diverse as the population for whom it cares?

Your turn: would you agree that these are the ‘top 10’ issues? What’s missing? What’s here that shouldn’t be?

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Posted in ethical issues, nursing students, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , , , | 11 Comments »

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Killing Traditional Nursing Duties #2

September 6, 2011
This 2006 image depicted an adolescent female ...

Image courtesy of CDC

Editor’s note: In early August, on our Facebook page, we asked if there were “old nursing habits” that should be killed off. We received a lot of feedback, which we described in a blog post, “Killing Traditional Nursing Duties #1.” We’re back now with feedback from our second question: “When you give IM injections, what site do you most often use—dorsogluteal (upper outer quadrant of
buttocks), ventrogluteal (lateral hip), or deltoid (upper arm)? Why?”

Hands down, the deltoid injection site was preferred for intramuscular (IM) injections, especially for immunizations and if the patient was an adult. (“People don’t have to drop their drawers” was my favorite reason cited.) A few of those who favored that site noted that, if they didn’t use the deltoid (because of the volume of the injection), they would then go to the ventrogluteal site. One person preferred the vastas lateralis (the outer middle third of the thigh), which wasn’t listed as a choice, but is certainly a site that’s used, especially in infants. And several respondents said they prefer the dorsogluteal site. Reasons given were “more comfort” and “more muscle.”

This is actually contrary to current evidence and teaching, which is that the preferred site is the ventrogluteal site. As noted in an article we did in February 2010, evidence indicates we should avoid the dorsogluteal site because “it poses unnecessary and unacceptable risks of injury to the superior gluteal artery and sciatic nerve.” Also, the traditional dorsogluteal site, especially in obese
individuals, may have excess subcutaneous fat that can reduce the chances of having the medication injected into the muscle.

And it’s not just a few nurses who continue using the traditional dorsogluteal site—a recent Canadian study (see our report on the results) showed that only 14% of hospital nurses use the recommended ventrogluteal site. So, for those of you who still prefer the dorsogluteal site, think again.

Our new question is this: “Does your institution routinely follow ‘NPO after midnight’ for preoperative patients?” Give your feedback here or on our Facebook page.—Shawn Kennedy, editor-in-chief

Posted in nursing perspective, nursing research, practice tips, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , | 6 Comments »

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Killing Traditional Nursing Duties #1

August 24, 2011

By Shawn Kennedy, MA, RN, AJN editor-in-chief

We recently had a lot of feedback to a question we posted on our Facebook page: “We know old habits die hard and nursing has a lot of them. What old habits do you think we should kill? NPO after midnight? Routine temps on every patient?”

We got several good responses:

- Waking patients up at 4am for blood drawing, routine vital signs

- Measuring intake and output on every patient

- Taking routine temps

- Giving dorsogluteal IM injections

- Doing a skin prep for an IV by swabbing the site in a circular motion, inside to out (some manufacturers of products are instructing that skin prep be done by a scrubbing motion)

- Enemas before childbirth

- Double documenting

- Rushing to give medications right on time (which makes one prone to error)

- NPO after midnight

Choosing from the above, we then asked this: “Survey question #1: Do you routinely wake patients up at night to check their vital signs? If not, when would you?”

This question received many comments, from “Of course not” and “only when necessary” to “If a doc orders q 4 vs and you don’t do it and something happens to the patient, that would not be good for you AT ALL.” Also this: “Orders are orders which we must follow.”

Commenters cited several stories of recent postoperative patients (who, I agree, should have vital signs frequently monitored) who could have suffered grave consequences had the nurse not woken them to check their vital signs or level of consciousness. I do like what one response noted—“critical thinking.” This is key, regardless of what the physician order may be—if the physician order is “q4h” but a patient’s condition may warrant more frequent checks, we would all hope the nurse wouldn’t stick to q4h.

Of course, for those working in ICUs or in postanesthesia units, the answer is simple: the patients are there precisely because they need close monitoring. As one responder indicated, “If you don’t check, you don’t know. I don’t want to be that nurse!”

Our next question was this: “When you give IM injections, what site do you most often use: dorsogluteal (upper outer quadrant of buttocks), ventrogluteal (lateral hip), or deltoid (upper arm)? Why?” Weigh in here or on our Facebook page.

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Posted in nursing perspective, practice tips, Shawn Kennedy, AJN editor-in-chief | Tagged , , , , | 6 Comments »

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The Five Most Popular Articles at AJN

July 18, 2011

Amanda Geer, AJN administrative coordinator—We look at the statistical views and visits of users at AJN‘s home page to determine our most viewed articles, how many visitors listen to our podcasts, what day of the week we get the most traffic, and a number of other categories to make sure we keep up to date on what matters to our readers. We also look at what our users search for. Some of the most common keyword(s)/phrases are evidence-based practice, research, diabetes, cancer, and stroke. We also look at our most popular articles. For the last few months, the following five articles have dominated our top 10 chart (in an upcoming post, we’ll look at the most popular articles on this blog):

Posted in nursing perspective, pain control | Tagged , , | Leave a Comment »

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So What? An Invitation to Nurses To Tell Us How They’re Translating Research into Practice

June 17, 2011

By Inge B. Corless, PhD, RN, FAAN, professor at the MGH Institute of Health Professions, Boston, and Brian Goodroad, DNP, RN, AACRN, nurse practitioner and associate professor at Metropolitan State University in Minneapolis–St. Paul, Minnesota

by centralasian/via Flickr

Crossing the Quality Chasm, an Institute of Medicine report from 2001, bemoans the chasm between our current research knowledge and the current state of care. Back in 2003, Don Berwick, now the Administrator of the Centers for Medicare and Medicaid Services, provided the following pithy codification of the problem in a JAMA article called “Disseminating Innovations in Health Care” (subscription required; click here for the abstract): “Failing to use available science is costly and harmful; it leads to overuse of unhelpful care, underuse of effective care, and errors in execution.” Berwick pondered the slow pace of innovation adoption and attributed it to three factors:

  • the characteristics of the innovation
  • the characteristics of the potential adopters
  • contextual factors

Berwick also made this observation about innovations that do get adopted: “Health care is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly—if at all.”

Given these obstacles, what can be done to facilitate the integration of research findings into practice? What can be done to change this situation, and what would this entail?

One step is to share our knowledge and our successes in making changes, along with the obstacles to doing so. We invite nurses to identify research that has changed or somehow influenced their practice and to share their experiences with us for potential publication on this blog. We’re not asking for formal academic work here; what’s we’d like is simple, brief (one to five paragraphs) summary description in your own voice. Briefly describe the study and its findings, as you understand them—and then describe how the findings were integrated into practice and any outcomes (whether they were formally measured or anecdotally reported). Read the rest of this entry ?

Posted in nursing innovations, nursing perspective, nursing research | Tagged , , , , , , | 2 Comments »

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What Is the Role of the Staff Nurse on a Medical Emergency Team?

May 25, 2011

By Sylvia Foley, AJN senior editor

There is strong evidence that a hospital’s use of a medical emergency team (MET) helps to decrease the rates of in-hospital cardiac arrests, unplanned ICU admissions, and overall hospital mortality. (A MET is similar to a rapid response team, but is typically led by a physician rather than by a nurse.)

But our understanding of such teams is incomplete. Nurse researcher Margaret Pusateri and colleagues set out to explore, in particular, the role of non-ICU staff nurses during a MET call. They wanted to better understand such nurses’ familiarity with and perceptions of the MET, and possibly, to increase the team’s effectiveness. So they sent a survey to 388 non-ICU staff nurses at a large urban teaching hospital; 131 nurses (34%) responded.

The authors report on the results in May’s CE feature (for optimum reading, open the PDF version). Among their findings:

  • Nearly three-quarters of the respondents had participated in a MET call.
  • The most common actions they reported taking during the call included relaying patient history, initiating the call, and documenting MET data.
  • But fewer than half of the respondents agreed or strongly agreed with the statements “I feel comfortable with my role as a member of the MET” and “I know what my role as a member of the MET is.” Read the rest of this entry ?

Posted in continuing education, nurses, nursing perspective, nursing research, patient safety | Tagged , , , , , | 1 Comment »

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