By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN.
Long ago, in an ICU far away, I picked up the habit of saying, during rounds, “Well, you know, research suggests the practice…” I have trouble remembering who taught me this tactic, but it has always been a highly effective way of advocating for my patients.
The eyes of doctors, never ones to be silenced by a nurse who reads research, usually light up at the challenge.
I’ll admit that, for a while, many of my conversational citations came from ‘clinical pearls’ or tidbits I read from certifying organizations via social media. While my knowledge was based on credible sources, my analysis was topical, at best.
Then I started graduate school. Although my program isn’t a clinical one, the need to seek out evidence for class assignments intensified my practice of trying to apply research evidence at the bedside.
It’s tricky to find and discuss credible research as a bedside nurse. Services like Lexicomp and UpToDate, which most hospitals hold subscriptions to, compile current research for clinician use and provide comprehensive information that’s far more credible than Wikipedia. But they’re exhaustive and often require a pretty hefty chunk of time to really analyze and understand. Printing out a 37-page document to hand to an attending on rounds isn’t a practice I’d recommend.
So how do we get reliable, evidence-based information efficiently when it’s needed? It wasn’t until deep into grad school that I started to realize that Cochrane Reviews were sometimes the best bedside research translator out there. The Cochrane Collaboration is an international, nonprofit organization that performs systematic reviews on peer-reviewed journal articles. The reviews are considered, by my professors at least, often the best form of evidence. Short summaries and abstracts are free to all users and are easy to find via PubMed and print. (Full access is subscription based, at least in the U.S.)
‘Sedation vacations’: yes, no, maybe? A topic I’ve always loved to use my research line on is the practice of ‘sedation vacations.’ When patients are deathly ill and ventilated, their lives depend on the use of sedatives. However, studies have linked lengthy use of sedative agents to serious complications—drug bioaccumulation, postextubation delirium, decreased quality of life, and adverse events, to name a few. Hence, the daily sedation vacation was born.
Most ICUs these days require a daily sedation vacation for intubated, sedated patients. There’s little doubt that patients are often oversedated, and the practice of pausing the sedation to see if they wake up and then readjusting their sedation according to policy can cut excess use. Some units allow nurses to perform the practice without input from an attending physician. Others rely on a case-by-case method. I’ve worked in both, and in both have said the words, “You know, research calls for daily sedation vacations, and this patient meets the criteria. Should I move forward?”
In most such instances, a sedation vacation was authorized for the patient, and sometimes a discussion of current practices was stimulated by my reference to research. I’d always thought that sedation vacations were a validated, proven, evidence-based practice, and had always advocated for them when my patients met clinical criteria.
However, this month’s Cochrane Corner column in AJN, which summarizes nursing care–related systematic reviews from the Cochrane Library, calls my bluff—reminding me of the need to rely on credible and clear sources. According to the author’s review of nine randomized controlled trials of mechanically ventilated patients, data doesn’t suggest that daily sedation interruption (DSI) leads to a strong reduction of various adverse effects or of duration of intubation.
While the Cochrane Review doesn’t support the blind use of heavy sedatives or recommend against DSI, it does show that things aren’t always as clear-cut as we think:
Maintaining a patient with a light level of sedation that enables participation in care activities should be the goal of care. This may be achieved by ongoing assessment of sedation using a validated tool and by titration of sedatives toward achieving this target via either the usual practice on the unit or a protocol. Daily interruption of sedation may not add further benefit if this goal is achieved.
An added benefit of Cochrane Reviews: unlike much news coverage of health care studies, Cochrane Reviews don’t oversimplify the strength of findings. This particular review notes the following: “[W]e advise caution should be applied when interpreting and applying our study findings. The results are based upon a small number of studies that were heterogeneous or not uniform in terms of methods…”
Either way, the review abstract and summary took me five minutes to read, and was easy to look up via Cochrane’s Web site. It even comes with a “plain language summary,” which can be quickly rephrased during rounds, with my updated tagline: “Well, you know, there’s a new Cochrane Review on this . . . ”