NK3 Clinical nurses evaluate and use evidence-based findings in their practice.
Provide one example, with supporting evidence, of how clinical nurses used evidence-based findings to implement a practice new to the organization.
AND
Provide one example, with supporting evidence, of how clinical nurses used evidence-based findings to revise an existing practice to improve care.
Example 1 – Implementing a practice new to the organization
NAME OF INITIATIVE
Enteral Feeding
BACKGROUND & PURPOSE
Clinical Nurses Involvement
Early initiation of enteral feeding in the critically ill when appropriate has been shown to improve patient outcomes. Intensive Care Unit (ICU) Clinical Nurse Mariluz Lorenzo, RN identified an area of opportunity regarding enteral feeding in the ICU. Specifically, these areas included:
- delay in initiating dietitian’s recommendations for enteral nutrition;
- patients not getting the recommended amount of nutrition; and
- feeding tube management.
The data collected prior to this initiative showed that the mean amount of enteral nutrition received by ICU patients was only 65% of the recommended amount.
METHODS AND APPROACH
Use of Evidence-Based Findings
In 2009 the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition published guidelines on the nutrition support for the critically ill. One of the recommendations was to implement nurse driven protocols for enteral nutrition to prevent gaps in nutrition support.
Implementing a New Practice
Homestead Hospital adopted the Clinical Excellence through Evidence-based Practice (CETEP) model for evidence-based practice (EBP) implementation originally developed by South Miami Hospital. It incorporates the essential elements to be considered prior to implementing a practice change making it a useful and practical model for nurses to use. (Collins, et.al., 2007). Using the elaboration sheet as a guide (NK3 01 CETEP Model and Elaboration), the team methodically went through the CETEP model steps described below.
Define
Clinical Practice Question:
Will critically ill patients receiving enteral feedings receive more prescribed nutrition after the implementation of a nurse driven enteral feeding protocol?
Assess
Evidence Based Factors:
National Guidelines
The Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) published guidelines on the nutrition support for the critically ill. Martindale RG. Et al Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Crit Care Med 2009 Vol. 37, No. 5 . http://www.learnicu.org/Docs/Guidelines/NutritionSupportAdult.pdf
Patient Factors:
Critically ill patients have increased metabolic requirements, and rely on the provision of nutritional feedings in order to meet increased demand. They frequently exhibit a catabolic stress that involves a systemic inflammatory response. Enteral Nutrition (EN) should be started within the first 24-48 hours of admission in critically ill patients who are receiving ventilator support and whose hemodynamic condition is stable (Bourgault, Ipe, Weaver, Swartz, & O’Dea, 2007, p. 17-18).
The national SCCM/ASPEN guidelines are intended for the adult medical and surgical critically ill patient populations expected to require an ICU stay of greater than 2 or 3 days and are not intended for those patients in the ICU for temporary monitoring or those who have minimal metabolic or traumatic stress (Martindale et al, 2009, p. 1).
Clinical Setting Factors:
The clinical expertise of the Enteral Feeding PI Team will be used to disseminate the protocol. This best practice is safe and feasible in the work routine of the bedside nurse. This project follows the organizational philosophy as the vision statement for Baptist Health states: “Baptist Health will offer a broad range of clinical services that are evidence-based and compassionately provided to ensure patient safety, superior clinical outcomes and the highest levels of satisfaction with a patient and family-centered focus.” It is cost neutral and can improve patient outcomes. It has the support of the Critical Care Medical Director, Performance Improvement, Nutritional Services, Pharmacy, and Nursing departments.
External Factors:
The Joint Commission requires that nutritional needs be assessed within 24 hours of admission. (TJC Standard PC.01.02.03)
Plan
An Enteral Feeding PI Team consisting of nursing, dietary, pharmacy would be formed. Their main goal would be to develop an enteral feeding protocol for critically ill patients based on the Society of Critical Care Medicine (SCCM)/ American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines. This protocol would be ordered by the physician and initiated and maintained by the nurse. It would address:
- recommendations for enteral feedings by dietitian;
- timeliness of initiating feedings for critically ill patients;
- timeliness of advancing enteral feedings towards goal; and
- managing gastric residual volumes
Implement
The Enteral Feeding PI Team first met in November 2013. ICU Clinical Nurse Specialist Rosemary Lee, ARNP presented the project proposal to the Performance Improvement (PI) Steering Council on December 2013 and received endorsement to move forward with the project. (NK3 02 PI Steering Council Meeting Minutes 12/6/13) The group met monthly. During the first few meetings, they performed extensive literature review to help them standardize definition of terms; develop a list of medications; and formulate a bowel management protocol. They also evaluated protocols and guidelines developed by other acute-care hospitals to guide them in developing their own. (NK3 03 Enteral Feeding PI Team Meeting Minutes 02/19/14). This helped them in formulating the initial draft of the enteral feeding order set and protocol in April 2014 based on the best available evidence. After several revisions, the Homestead Hospital’s Critical Care Committee approved the draft in July 2014. (NK3 04 Enteral Feeding Protocol and Order Set)
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Mariluz Lorenzo, BSN, RN, CCRN |
Clinical Nurse |
Critical Care |
Drove the practice change |
Randy Nicholson, RPh |
Pharmacist |
Pharmacy |
Member |
Mary Shaw, RD |
Dietitian |
Nutritional Services |
Member |
Kelly LaRocco, RD |
Dietitian |
Nutritional Services |
Member |
Nicole Treanor, RD |
Dietitian |
Nutritional Services |
Member |
Patricia Rubio, RD |
Dietitian |
Nutritional Services |
Member |
Rosemary Lee DNP, ARNP-BC, CCNS, CCRN |
Clinical Nurse Specialist |
Critical Care |
Facilitator |
Leslie Everett, BSN, RN, CCRN |
Patient Care Manager |
Critical Care |
Administrative Support |
Lizannette Rabelo Fraticelli, RD |
Manager |
Clinical Nutritional Services |
Administrative Support |
Juan Lopetegui, MD |
Critical Care Medical Director |
Critical Care |
Medical Support |
OUTCOME(S)
Evaluate
Lorenzo presented her findings about practices regarding enteral feedings to the ICU staff in July 2013. She compared the evidence to what ICU’s practice was, and what they should be doing. The Enteral Feeding PI group developed an order set and protocol. The protocol and order set were ready for approval. The next step was to roll out the orders and protocol once all approvals are finalized.
Lorenzo’s presentation and role modeling for staff has changed their practice so that feedings were not being held for inappropriate gastric residuals and were being advanced to goal in a timelier manner. ICU nurses addressed enteral feeding issues during the daily interprofessional rounds. Lorenzo used this project for her Professional Nurse Advancement portfolio. She was promoted from a Proficient to an Advanced Nurse.
Exhibit NK3a: Average Percentage of Enteral Feeding Received: Recommended vs. Actual Among ICU Patients
Analysis: The graph depicts that the ICU patients were receiving more of the recommended feeding after Lorenzo’s educational intervention.
References
Bourgault, A. M., Ipe, L., Weaver, J., Swartz, S., & O’Dea, P. J. (2007, August). Development of Evidence-based guidelines and critical care nurses knowledge of enteral feeding. Critical Care Nurse, 27(4), 17-29.
Martindale, R. G., McClave, S. A., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., ... The A.S.P.E.N. Board of Directors (2009, May/June 2009). Guidelines for the provision and assessment of nutrition Guidelines for the provision and Assessment of nutrition support in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 33(3), 277-316.
Summary Attachments/Hyperlinks/Evidences
NK3 01 CETEP Model and Elaboration
NK3 02 PI Steering Council Meeting Minutes 12/6/13
NK3 03 Enteral Feeding PI Team Meeting Minutes 02/19/14
NK3 04 Enteral Feeding Protocol and Order Set
Exhibit NK3a: Average Percentage of Enteral Feeding Received: Recommended vs. Actual Among ICU Patients
Example 2- Revising an existing practice to improve care
NAME OF INITIATIVE
MegaDyne Mega Soft® Return Electrode
BACKGROUND AND PURPOSE
In surgery, electrocautery is used to assist the surgeon with hemostasis. When utilizing monopolar cautery, the current enters through the active electrode (the Bovie pencil) and must leave through a grounding pad. Nurses at Homestead Hospital utilize the Association of Operating Room Nurses’ (AORN) Recommended Practices for Electrosurgery. In Homestead Hospital, the practice was to ground patients using disposable grounding pads. Improper placement of these pads can cause harm to patients such as burns or Bovie site reactions. Since these pads used conductive technology, they need to be positioned on clean, dry skin over a large muscle mass as close to the operative field as possible. Although return site burns have not been reported in the Operating Room (OR), nurses noted at the end of surgery some redness at the Bovie grounding pad site particularly with the adhesive removal. In 2012, Homestead Hospital had 2 occurrences of Bovie grounding pad site skin reactions.
Use of Evidence-Based Findings
In May 2013, Patient Care Manager Wanda Vargas-Rosado, RN attended the Surgical Services Director’s Meeting. At the meeting, a Surgical Services director of a sister hospital brought information regarding the Megadyne Mega Soft® 2000 Return Electrode, a capacitively coupled return electrode (as opposed to conductive return electrode). This meant that the electrode did not require patient contact. It could be placed as close to the patient as possible, but not touching the patient. This minimized the risk for return site burns or skin reactions. Vargas-Rosado gave this information to OR Clinical Nurses Maritza Colon, RN and Gloria Jaramillo, RN. Both nurses expressed interest in getting information on the product. Clinical Nurse Educator Jose Nazario, RN reviewed the literature and shared information with the nurses about the product. He also arranged for the Megadyne product representative to come in for product demonstration.
Revising an Existing Practice
As described above, Homestead Hospital utilized the Clinical Excellence through Evidence-based Practice (CETEP) model for evidence-based practice (EBP) implementation. Using the elaboration sheet as a guide and the check-off list, approved by the Evidence-based Practice and Research Council in September 2013, (NK3 05 CETEP Check-Off List) Nazario methodically went through the CETEP model steps described below and the appraisal process.
Clinical Practice Question:
Will using the Mega Dyne Mega Soft 2000 Return Electrode decrease Bovie grounding pad site reactions?
Assess (Critical Appraisal Components)
Evidence Based Factors
The team reviewed an article that described the evaluation conducted on the product. ECRI. (2000). MegaDyne Mega 2000 Return Electrode. Health Devices, 29(12),p.445-460. The team members also looked at the AORN electrocautery guidelines. Association of Preoperative Registered Nurses (2014). Standards, Recommended Practices, and Guidelines. Denver, Colorado.
Patient Factors
The OR nurses had found a product they felt would benefit the patients by decreasing grounding pad site reactions/burns and increase patient comfort.
Clinical Setting Factors
External Factors
Plan
After reviewing the literature; seeing the product; and speaking with the Clinical Nurses Colon and Jaramillo, the Surgical Services leadership team decided to trial the product. The product representative came and in-serviced the staff. (NK3 06 Product In-service Rosters and Product Evaluation by Surgical Staff) The trial started in October 2013. Majority of the staff and physicians gave positive feedback. However, a few staff members were concerned about the compatibility of the MegaDyne Mega Soft 2000 with the ValleyLab Force FX, the brand of electrocautery machine used in Homestead Hospital. The literature supported the use of the MegaDyne 2000 and the ValleyLab Force FX (ECRI, 2000). Nurses also saw the benefits of using the product on the elderly population. In this group, finding a disposable grounding pad site that was clear and over a large muscle mass was challenging. Additionally, this was the population that would tend to develop site reactions due to fragile skin being pulled with the adhesive upon electrode removal.
Implement
After a successful trial, the Surgical Services nursing leadership team decided to purchase 4 MegaDyne Mega Soft 2000 pads for use in the OR. (NK3 07 Paid Product Invoice) The nursing leadership team informed the staff during the January 2104 staff meeting that the MegaDyne 2000 grounding pads have arrived. The OR staff started using them in the OR in the same month. Additionally, Vargas-Rosado revised the policy (NK3 08 HH-400-3600-600-011 Electrosurgical Equipment) in January 2014 to reflect the revised practice.
PARTICIPANTS
Clinical Nurses Involvement
Name/Credentials |
Title |
Department |
Role in the Team |
Gloria Jaramillo, BSN, RN, CNOR |
Clinical Nurse |
Surgical Services |
Member; provided input for the project |
Maritza Colon, RN, CNOR |
Clinical Nurse |
Surgical Services |
Member; provided input for the project |
OR Nurses |
Clinical Nurses |
Surgical Services |
Participated in product trial |
Jose Nazario, MSN, RN, CGRN |
Clinical Nurse Educator |
Surgical Services |
Project lead; reviewed the literature; coordinated staff training on product use |
Carmen Bouchard, MSN, RN, CNOR |
Director |
Surgical Services |
Provided fiscal support |
Wanda Vargas-Rosado, BSN, RN, CNOR |
Patient Care Manager |
Surgical Services |
Provided administrative support |
Lamberto Hernandez MSN, RN, CNOR |
Patient Care Supervisor |
Surgical Services |
Member |
OUTCOME(S)
Each of the 4 OR rooms has a MegaDyne Mega Soft 2000 for use in adults and 1 for use in pediatric cases. The nurses have not reported any more grounding pad site reactions since they began using it.
Exhibit NK3b: OR Grounding Pad Site Reaction Incident Report
Analysis: There were no reports of Bovie site redness in FY14 since after implementation of the MegaDyne Mega Soft 2000.
Summary Attachments/Hyperlinks/Evidences
NK3 05 CETEP Check-Off List
NK3 06 Product In-service Rosters and Product Evaluation by Surgical Staff
NK3 07 Paid Product Invoice
NK3 08 HH-400-3600-600-011 Electrosurgical Equipment
Exhibit NK3b: OR Grounding Pad Site Reaction Incident Report