Posts Tagged ‘evidence-based practice’


How a Busy Hospital Reduced Its Rate of Hospital-Acquired Pressure Ulcers to Zero

August 8, 2014

By Sylvia Foley, AJN senior editor

A skin lesion monitoring form accompanies a patient. Photo courtesy of NHCH.

A skin lesion monitoring form accompanies a patient. Photo courtesy of NHCH.

In 2009, when one of the world’s largest cardiac care hospitals experienced a spike in the number of surgeries performed and a corresponding rise in hospital-acquired pressure ulcers, many people were concerned. The hospital—Narayana Hrudayalaya Cardiac Hospital (NHCH) in Bangalore, India—soon initiated a program to address the problem, and nursing superintendent Rohini Paul was tasked with designing and implementing effective preventive strategies. In this month’s CE feature, “Sustaining Pressure Ulcer Best Practices in a High-Volume Cardiac Care Environment,” Paul and colleagues describe what happened next. Here’s a brief overview.

Baseline data showed that, over the five-month observation period, an average of 6% of all adult and pediatric surgical patients experienced a pressure ulcer while recovering in the NHCH intensive therapy unit (ITU). Phase 1 implementation efforts, which began in January 2010, focused on four areas: raising awareness, increasing education, improving documentation and communication, and implementing various preventive practices. Phase 2 implementation efforts, which began the following month, focused on changing operating room practices. The primary outcome measure was the weekly percentage of ITU patients with pressure ulcers.
By July 2010, that percentage was reduced to zero; as of April 1, 2014, the hospital has maintained this result. Elements that contributed significantly to the program’s success and sustainability include strong leadership, nurse and physician involvement, an emphasis on personal responsibility, improved documentation and communication, ongoing training and support, and a portfolio of low-tech changes to core workflows and behaviors. Many of these elements are applicable to U.S. acute care environments.

The authors emphasize the importance of “absolute transparency and personal accountability” in ensuring the program’s sustained success. As one senior nurse said, “It was the personal responsibility that started making a difference. Now everybody’s aware, everybody’s cooperative and on their toes, and we have no skin ulcers.”

For more details, read the article, which is free online. And please share your experiences and insights with us below.

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AJN’s March Issue: New Series on Systematic Reviews, HIV Update, C. Diff on the Rise, Sexual Assault, More

February 28, 2014

AJN0314.Cover.OnlineAJN’s March issue is now available on our Web site. Here’s a selection of what not to miss, including two continuing education (CE) articles that you can access for free.

Advances in HIV testing and treatment. The photo on our cover, showing members of  Sexy With A Goal (SWAG), a program provided for lesbian, gay, bisexual, and transgender individuals affected by HIV and AIDS by the AIDS Service Center of New York City’s Lower East Side Peer Outreach Center, reflects the changing face of the AIDs epidemic. Thirty years ago, a diagnosis of HIV was tantamount to a death sentence. But the young men on our cover prove that this is no longer the case. With advances in treatment and patient advocacy, education, and support, HIV is now a chronic, manageable disease. A CE feature, “Nursing in the Fourth Decade of the HIV Epidemic,” discusses HIV epidemiology and policy in the United States, the HIV care cascade, advances in HIV testing and treatment, and how nurses can continue to have a positive impact on the HIV epidemic.

If you’re reading AJN on your iPad, you can watch a video describing one author’s early experience with an HIV-infected patient by tapping on the podcast icon on the first page. The video is also available on our Web site. A

New option for victims of sexual assault. Until recently, survivors of sexual assault were not entitled to a free medical forensic examination unless they reported the assault to law enforcement. The authors of “Giving Sexual Assault Survivors Time to Decide: An Exploration of the Use and Effects of the Nonreport Option,” March’s original research CE, studied the implementation of the new nonreport option, exploring its impact on survivors, the criminal justice system, and sexual assault nurse examiners. If you’re reading AJN on your iPad, you can listen to a podcast interview with the author by tapping on the podcast icon on the first page. The podcast is also available on our Web site.

New series on systematic reviews. Since the advent of evidence-based practice in health care, nurses and other clinicians have been expected to rely on research evidence to inform their decisions. But how does one uncover all the evidence relevant to a question? “Systematic Reviews, Step by Step: The Systematic Review: An Overview,” the first article in a new series from the Joanna Briggs Institute, provides a synopsis of the systematic review as a scientific exercise, and introduces nurses to the steps involved in conducting one. Read the rest of this entry ?


AJN’s Top 15 Most Viewed Articles in 2013

January 24, 2014
by rosmary/via Flickr

by rosmary/via Flickr

We thought readers might be interested in seeing which articles and topics got the most page views in 2013. Many of these articles are open access, including a number of CE articles as well as the articles from our Evidence-Based Practice: Step by Step series. Some articles require an AJN subscription or individual article purchase. Several of the articles in this list were from recent years other than 2013; a couple were much older, but are evidently still relevant, since not every idea in nursing is ephemeral or subject to improvement by the next generation.—Jacob Molyneux, senior editor

1. “Asking the Clinical Question: A Key Step in Evidence-Based Practice” – (March, 2010) – part of AJN‘s EBP series

2. “Improving Communication Among Nurses, Patients, and Physicians” – (November, 2009)

3. “The Seven Steps of Evidence-Based Practice” – (January, 2010) – part of our EBP series

4. “Nurses and the Affordable Care Act” – (September, 2010)

5. “From Novice to Expert: Excellence and Power in Clinical Nursing Practice” – (December, 1984; not HTML version; readers must click through to PDF version)

6. “COPD Exacerbations” – (CE article; February, 2013)

7. “Therapeutic Hypothermia After Cardiac Arrest” – (CE; July, 2012)

8. “From Novice to Expert” – (March, 1982; article looks at stages to mastery; no html version, so click the PDF link on the landing page)

9. “Men in Nursing” – (CE; January, 2013)

10. “Using Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections” – (June, 2013) – part of EBP series Read the rest of this entry ?


Tightly Scripted: One NP’s Experience with Retail Clinics

November 1, 2013

By Karen Roush, MS, RN, FNP-C, AJN clinical managing editor

Retail health clinics (walk-in clinics that are in a retail setting such as a drugstore or discount department store)KarenRoush have become an effective mode of providing increased access to care for many people and a growing source of employment for nurse practitioners (NPs). Their place in the health care arena may take on even more significance as the Affordable Care Act (ACA) increases access to care for previously uninsured people.

I worked as an NP in a retail clinic for about six months while working on my PhD. I left because of concerns I had about the model of practice. It didn’t have to do with the fact that I had to mop the floor at closing time or collect the fees and cash out the “drawer” every night. Nor because I spent eight hours alone in a small windowless room tucked away in the back of a drugstore. Those aspects were not great, but they weren’t deal breakers.

What was a deal breaker was the rigid programming of my practice. The computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer.

The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence. And as much as they insisted the programming was guided by evidence, it was clearly also guided by what would result in the highest level billing code.

From the moment I entered the chief complaint in the computer, it directed me on what to include in the history and what to do for the exam. The problem was that unless I filled out all the information, I couldn’t go on to the next screen. Say I have a feverish four-year-old with tonsillitis, screaming in her mother’s arms, and the computer insists I take her blood pressure. Why? Because there is strong evidence that strep throat is associated with pediatric cardiovascular disease? Nope. It’s because the more systems you include in your exam, the higher the billing code. As a result, I find myself struggling to take an unnecessary blood pressure, causing unnecessary distress for a sick toddler. But unless I put a value in the box asking for the blood pressure, I can’t proceed with the exam. Read the rest of this entry ?


The 10 Most Popular Articles on AJN Right Now

October 11, 2013
From boliston, via Flickr

From boliston, via Flickr

The 10 current “most viewed” AJN articles are below. Sometimes we’re surprised by the ones that go to the top of this list. At other times, the high interest in the article makes perfect sense. Most of these articles are currently free, either because they are CE articles or because they are shorter opinion pieces or the like. We hope you’ll have a look.—Jacob Molyneux, senior editor

“The Care of Pregnant Women in the Criminal Justice System” 

CE article. Overview: Current practices in the treatment and transfer of pregnant inmates in this country may negatively affect maternal and fetal health or well-being. Some violate federal or state laws; others conflict with standards of obstetric care and are widely considered unethical or inhumane. This article discusses these practices; their legal status; and implications for nursing practice, policy, and research.

“Developing a Vital Sign Alert System”

CE. Overview: This article describes the implementation of a nurse-designed, automated system for enhancing patient monitoring on medical–surgical and step-down nursing units. The system . . . was found to substantially reduce out-of-unit codes without increasing nurses’ workload.

“Mouth Care to Reduce Ventilator-Associated Pneumonia”

CE. Overview: Despite the well-established association between good oral hygiene and the prevention of VAP, the importance of mouth care in infection control is seldom recognized. The authors discuss the pathophysiology of VAP and why oral care is crucial to its prevention. They also provide an evidence-based, step-by-step guide to providing optimal oral care for intubated patients.

“Decreasing Patient Agitation Using Individualized Therapeutic Activities”

CE. Overview: Hospitalized patients who are suffering from cognitive impairment, delirium, suicidal ideation, traumatic brain injury, or another behavior-altering condition are often placed under continuous observation by designated “sitters.” These patients may become agitated, which can jeopardize their safety even when a sitter is present. This quality improvement project was based on the hypothesis that agitation can be decreased by engaging these patients in individualized therapeutic activities. . . .

“Loneliness and Quality of Life in Chronically Ill Rural Older Adults” 

Original Research CE. Overview: Background: Loneliness is a contributing factor to various health problems in older adults, including complex chronic illness, functional decline, and increased risk of mortality. Objectives: A pilot study was conducted to learn more about the prevalence of loneliness in rural older adults with chronic illness and how it affects their quality of life. . . .

“Evidence-Based Practice: Step by Step: Asking the Clinical Question: A Key Step in Evidence-Based Practice”

Free. Part of AJN‘s evidence-based practice (EBP) series. Excerpt: “A spirit of inquiry is the foundation of EBP, and once nurses possess it, it’s easier to take the next step—to ask the clinical question. Formulating a clinical question in a systematic way makes it possible to find an answer more quickly and efficiently, leading to improved processes and patient outcomes.” Read the rest of this entry ?


Using Evidence-Based Practice to Reduce CAUTIs

May 31, 2013

By Karen Roush, AJN clinical managing editor

Using evidence-based practice to . . .

Fill in the blank. There’s something on your unit that could be improved—the rate of ventilator-associated pneumonia (VAP), the engagement of family in care, the readmission rate of patients with heart failure, patient satisfaction with pain management. Whatever it may be, you have the ability to improve it. This month we have a CE article (link is below) about an evidence-based practice (EBP) project to reduce catheter-associated urinary tract infections (CAUTIs).

Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm/ CDC

Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm/ CDC

The really interesting thing about this article, and what makes it especially helpful for beginner quality improvers out there, is that it doesn’t just describe an effective project to reduce CAUTIs. It also describes how to do an EBP project, step-by-step. The author, Tina Magers, a novice EBP mentor, followed the seven steps outlined in AJN’s Evidence-Based Practice series and describes the actions involved in each step. It’s a great how-to on applying evidence to practice. Here’s the overview/abstract of this useful June CE article, “Using Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections”:

Overview: In November 2009, AJN launched a 12-part series, Evidence-Based Practice, Step by Step, authored by nursing leaders from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Through hypothetical scenarios, based on the authors’ collective clinical experience, the series illustrated the seven steps of evidence-based practice (EBP), defined as “a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values.” This article reports on an EBP project in which the seven-step approach to EBP described in the AJN series was used to reduce the incidence of catheter-associated urinary tract infection among adult patients in a long-term acute care hospital by reducing the duration of catheterization.

Keywords: catheter-associated urinary tract infection, evidence-based practice, hospital-acquired infection, nurse protocol, quality improvement, urethral catheterization

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AJN’s June Issue: Fracking, Assessing Sleep in Teens, Preventing CAUTI, More

May 24, 2013

AJN0613.Cover.3rd.inddAJN’s June issue is now available on our Web site. Here’s a selection of what not to miss.

Fracking hazards. Though we’re moving into summer, our cover does not depict a jar of fresh, local honey. It is a photograph of Washington County, Pennsylvania, resident Jenny Smitzer, holding a jar of contaminated tap water that turned that color af­ter natural gas drilling began in 2005 above her farm. Eleven U.S. states currently engage in natural gas hydrofracking (“fracking”), and eight more are either considering or preparing for this method of gas drilling.

For an in-depth look at the potential health hazards caused by fracking, such as air pollution, working hazards, and water pollution, see our Environments and Health article, “Fracking, the Environment, and Health.” If you’re reading AJN on your iPad, you can listen to a podcast interview with the authors by clicking on the podcast icon on the first page of the article. The podcast is also available on our Web site.

Most teens get far less than the nine hours of sleep a night they require, which could affect their mental and physical health. An understanding of sleep physiology is essential to helping nurses better assess and manage sleep deprivation in teens. “Assessing Sleep in Adolescents Through a Better Understanding of Sleep Physiology” provides an overview of sleep physiology, describes sleep changes that occur during adolescence, and discusses the influence of these changes on adolescent health. This article can earn you 2.1 continuing education (CE) credits. A podcast interview with the author is also available on our Web site.

Seven steps to evidence-based practice (EBP) were described in AJN’s popular 12-part series, Evidence-Based Practice, Step by Step. In “Using Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections,” a novice EBP mentor applied these steps in a quality improvement project aimed at reducing the incidence of catheter-associated urinary tract infection among adult patients. This article can earn you 2.4 CE credits.

Still haven’t taken the plunge into the world of social media? This month’s iNurse article, “Microblogging: Tumblr and Pinterest,” gives nurses some ideas about how they can express themselves and share information on two popular social media platforms.

There is plenty more in this issue, including strategies nurses can use to address patients with low health literacy and evidence-based interventions that may reduce risky sexual behavior in adolescents. Stop by and have a look, and tell us what you think on Facebook, or here on our blog.

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Nurse Staffing Matters at the Shift Level—Evidence-Based Scenarios Illustrate How to Apply What We Know

December 10, 2012

We know that staffing matters. Studies have shown that hospitals with lower proportions of RNs have higher rates of death overall, death following compli­cations (that is, failure to rescue), and other adverse events. But how do such data on staffing translate into what the average hospital nurse experiences on a shift?

That’s the question posed by Gordon West and colleagues, the authors of this month’s CE, “Staffing Matters—Every Shift.” To address it, they reviewed findings from the Military Nursing Outcomes Database (MilNOD). MilNOD, a quality improve­ment and research project conducted in four phases between 1996 and 2009, encompassed data from 111,500 shifts on 56 inpatient units in 13 U.S. military hospitals. The project explored “the effects of staffing levels and skill mix on the probability of patient falls, medication errors, and needlestick injuries to nursing staff.”

As the authors explain, the MilNOD data showed that the number, mix, and experience of nurses on a shift—not just on a unit—were associated with adverse events for patients and needlestick injuries to nurses. West and colleagues offer several realistic, descriptive scenarios to illustrate the potential effects of staffing changes and to show how such knowledge can be applied to daily decision making.

To learn more, read the article, which is free online.—Sylvia Foley, AJN senior editor

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Nursing Research: Alive and Well

September 17, 2012

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

Last week I spent two-and-a-half days in Washington, DC, where there are LOTS of campaign collectibles. My favorite: coffee mugs proclaiming “Friends Don’t Let Friends Vote [insert Democratic or Republican).” Also noteworthy: “Hot for Mitt” and “Hot for Barack” hot sauce (see photos). I was there attending the meeting of the Council for the Advancement of Nursing Science (CANS), where close to 1,000 nursing researchers met to share their work. It wasn’t too long ago that one would have been hard-pressed to find that many nurses doing research. The National Institute of Nursing Research (NINR) only celebrated its 25th anniversary in 2010 (see our 2010 article about their many accomplishments).

Creativity and innovation. Kathi Mooney, PhD, RN, FAAN, from the University of Utah College of Nursing, gave the keynote—and it was perfectly suited to this group, many of whose members are immersed in analytical thought and scientific methodology. Mooney talked about the importance of creativity and innovation in moving research forward—yes, applying scientific rigor to identifying knowledge gaps and building on known research is critical, but she urged attendees to step back occasionally and be open to other ways of thinking.

To do that, she said, one must create time for reflection and thinking. She also encouraged deans and faculty to foster environments that support creativity, where there’s freedom to explore non-mainstream thinking, risk taking is encouraged, and there’s time for social interaction and informal encounters.

Posters and symposiums and podium presentations filled the rest of the schedule. The presentations were akin to speed dating—researchers had less than 15 minutes to present the highlights of their work. I’m sure for those presenting and those involved in the particular area of research, it might have been frustrating, but for someone like me seeking what’s new and compelling across many areas, it was an ideal format. As one presenter said, “It’s like being a detective on Dragnet, that old TV show, where the lead detective would say, ‘Just give me the facts, please.'”

Some takeaways for me:

Creative thinking involves reframing problems and tasks (one example from Mooney: does the stone cutter see his job as cutting large chunks of stone, or as being part of a team that’s building a cathedral).

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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 ?


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