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Evidence-based practice in a clinical setting
By Steve Risch, MSN, RN, CCRN, CCNS
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This course is 1 contact hour
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Course must be completed by October 15, 2018
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Goals and objectives: The goal of this evidence-based practice continuing education program is to introduce critical care nurses to EBP and review the differences among evidence-based practice, research, and quality improvement. After studying the information presented here, you will be able to:
  1. Describe EBP
  2. Differentiate among EBP, research, and quality improvement
  3. Recall EBP evidence related to common critical care practices
  4. Review the steps of starting an EBP project
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Evidence-based practice is a vital part of enhancing critical care nursing practice, which is essential for providing quality care to patients. Adopting EBP to your culture improves patient outcomes and patient, family, and healthcare provider satisfaction. It can also reduce costs and the risk of harm by decreasing unnecessary tests and procedures.1,2
The first step in the EBP process is creating a culture to incorporate EBP into the organization. Translating evidence into practice has become important to healthcare with the increased focus on lowering costs through reduced lengths of stay and prevention of hospital-acquired infection.

Critical care nurses provide vital care to very sick patients, and even more crucial, nurses are providing care that is proven to be effective. One researcher’s findings suggest that establishing EBP leads to higher quality of care and reduces costs.3 Creating such a culture helps organizations to obtain high reliability. To help nurses effectively apply EBP at the bedside, this module explains the rigorous process of EBP implementation. It ends with a summary of key EBP practices you should incorporate into your critical care nursing practice.
Integrating EBP into clinical practice
Developing an institutional culture of EBP is essential to support effective change in practice. The first step to integrate EBP in an institution is selecting a framework in which decisions are made. Implementation science has moved toward a systematic approach, using theoretical frameworks to guide the process of integrating research into practice. Several frameworks exist with differences in each model and framework. Nurses must understand those differences to identify the best model for the specific process being implemented.4
The next step is to ask the clinical question. Developing a PICOT question is crucial to ensure you are identifying the clinical problem. The P includes types of patients/patient population. Consideration should include sex, ethnicity, and patients with particular healthcare problems. The I includes interventions or specific methods or treatments of interest. C is comparison or alternatives in treatment or interventions to the problem. This may also include new or alternative ways to achieve the same outcome. The O is looking at the desired outcome. This must be precise and brief when developing your question. The T is for timing. This can be optional but may be relevant to the particular clinical question.1
Select team members
If the topic is a priority for the organization, the next step is to establish teams. An emphasis on interprofessional collaboration continues to be the key strategy to successful implementation of EBP and performance outcomes. Advanced practice nurses and professional development educators are key stakeholders and experts in implementing EBP. They are also ideal professionals to provide leadership in implementing EBP.
Search for the best evidence
Once a PICOT question is developed, a systematic review will need to be completed to answer the clinical question. Systematic review and meta-analysis generate a rigorous process to summarize data, critically appraise data, and make recommendations for practice.
Medical librarians are invaluable to help translate the PICOT terms to key search words that will ensure you acquire the best literature to answer your clinical question. Below is a list of databases often used to do extensive literature searches.
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How to earn continuing education
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THIS COURSE IS 1 CONTACT HOUR
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Read the Continuing Education article.
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This course is FREE of charge courtesy of OnCourse Learning and Capella University until July 17, 2017.
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If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
4.
Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
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All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
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OnCourse Learning is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team.

OnCourse Learning is also accredited by the Florida Board of Nursing and the District of Columbia Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.
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editors-noteEDITOR’S NOTE: Victoria A. Kark, MSN, RN, CCRN, CCNS, CSC, past author, has not had the opportunity to influence the content of this version. Steve Risch, MSN, RN, CCRN, CCNS, is a board certified clinical nurse specialist for the surgical/neuro ICU-neuro acute care unit at Holy Cross Hospital in Silver Spring, Maryland.
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Sources for nursing research include both publically available and those requiring a subscription or membership to access:
Partners in improved care
Nursing research, evidence-based practice, and quality improvement (QI) each play an important, and complementary, role in improving patient outcomes.
Nursing research is a systematic investigation that includes development, testing, and evaluation. Research is the generation of new knowledge, which can be generalized to the population. An example to critical care nurses might be: What is the effect of therapeutic hypothermia on the patient’s skin? If no literature is found on this topic, the critical care nurse should consult a nurse scientist to help design an institutional review board-approved study to address this clinical topic.
Evidence-based practice is defined as a problem-solving approach to the delivery of healthcare that incorporates the best available evidence, clinicians’ expertise, and patient values and preferences.4
An example of an evidence-based project might include investigating the use of pharmacological venous thromboembolism (VTE) prophylaxis for patients who underwent a craniotomy and are recovering in the neuro ICU. A problem-focused trigger was identified because these patients were developing hospital-acquired VTEs. Nurses developed a PICOT question and researched the literature. A PICOT question is a four-part method of building a question that identifies the problem, intervention, comparison, outcome, and timing.

Nurses critiqued the literature to ensure it answered the PICOT question and rated it for strength and quality. They monitored the pharmacological prophylaxis application and VTE rate. A protocol was implemented: pharmacological prophylaxis initially was 20% and increased to more than 90%. Due to this increase, the VTE rate in this patient population fell below the benchmark.
QI is the continual process of using data-guided investigations to produce improvement in nursing care delivery. For instance, a QI project might be collecting and analyzing data to determine the rate of complications for sheath removal after cardiac catheterization. Systematic assessment of an identified problem occurs through a set of related activities that are designed to measure improvement in processes and outcomes of patient care. Examples of QI activities include implementing nurse-sensitive indicators, checking compliance with established standards, and examining the effects of a change in medication administration to reduce medication errors.
Understanding the differences among research, EBP, and QI provides clarity relative to these three concepts. Understanding key concepts helps integrate and use QI, EBP, and research. Achieving clarity can enhance interprofessional collaboration to improve patient care and obtain better outcomes.2
An example of a PICOT question may be: Problem: family presence Intervention: multidisciplinary ICU rounds Comparison: not being present Outcome: improves patient satisfaction scores in that the nurse and physician kept the patient informed
Evidence resources
1. SORT (Strength of Recommendation Taxonomy) 2. Grade Working Group (Grading of Recommendations Assessment Development, and Evaluation) 3. AGREE II (Appraisal of Guidelines for Research and Evaluation 2)
This third step is time consuming and may seem overwhelming to a direct care bedside nurse. Even though it is a rigorous process, studies must be evaluated for their validity, reliability, and applicability to answer the clinical question.
The team members need to examine how much high-quality evidence was found during the literature search. The strength of clinical evidence can be noted by assigning each study an evidence level. Most level hierarchies designate randomized control trials, meta-analyzes, or systematic reviews as the highest level of evidence for making clinical judgements.2
The next step is determining a grade to guide recommendations for incorporating findings into practice. Recommendation grades are based on how the team gauges the strength of evidence for implementing a treatment or intervention. Grades are often stated as Grade A, B, or C, or with plus signs. Grading the evidence provides the strength of the recommendation arising from the evidence. Grading is an important part of the process, yet is not standardized across health professions. Fortunately, only a small number of grading systems exist. Below are some examples:2
The key next step is applying your evidence into practice. After critically appraising the literature, you will have to make a decision whether to move forward to implement the evidence into practice. This requires a structured plan and solid process to implement best evidence into patient care.
Critical evidence appraisal
Once an EBP protocol has been implemented, the next step is to evaluate outcomes. Did it make a difference? Did it answer the clinical question? Clinicians must evaluate the expected outcomes from the implementation strategies. The evaluation of your project may have to include a QI process to identify gaps in procedure and process. From these identified gaps, the nurse will have the opportunity to make adjustments to the process to achieve the desired outcome.
The last step is to disseminate the results. You can communicate these results by using podium and poster presentations at professional conferences or at grand rounds at your organization.
Barriers to implementing EBP include lack of education about EBP and inadequate leadership support to integrate EBP fully into organizations. That is why it is important for an organization’s leaders to remove these barriers in support of the spirit of inquiry. To be successful in the implementation of EBP, hospitals must create structure and processes, and increase access to databases by staff to promote EBP.2 A study in 2016 found that despite nurses’ positive attitudes about EBP, nurses feel their ability to implement EBP practices remains low. The researchers recommend organizations and healthcare systems take a three-prong approach to cultivating EBP, focusing on leadership, education, and mentoring.4
Below are examples of established evidence-based guidelines that are common nursing practices in the critical care area.
Ventilator-associated pneumonia
Central line-associated bloodstream infections
The Centers for Disease Control and Prevention estimates that 41,000 bloodstream infections occur each year in the U.S., costing between $3,700 and $3,900 per episode.7 Most of the progress toward eliminating these infections has occurred in ICUs; however, more work needs to be done.
Independent risk factors for catheter-associated central line infections include:7
  • Prolonged hospitalization
  • Prolonged duration of catheterization
  • Heavy colonization at insertion site
  • Heavy colonization of the catheter hub
  • Internal jugular catheterization
  • Femoral catheterization in adults
  • Neutropenia
  • Reduced nurse-to-patient ratio in the ICU
  • Use of the catheter for total parental nutrition
  • Substandard catheter care
Best practices and recommendations with regard to prevention of and monitoring for catheter-associated central line infections include the following.7
Before insertion:
  • Receive from your institution an evidence-based list of indications for central-line insertion
  • Provide education for healthcare providers on insertion, care, and maintenance of catheter care
  • Ensure that providers who insert central lines go through a credentialing process
  • Bathe patients with chlorhexidine before insertion

At insertion:7
  • A checklist will need to be developed to ensure the procedure is completed in a sterile fashion.
  • A nurse or other trained healthcare personnel must observe insertion practices.
  • A nurse or other healthcare personnel should be empowered to stop the procedure if sterility is broken.
  • Hand hygiene must be practiced before the procedure.
  • Maximal barrier precautions must be used.
After insertion:7
  • Adequate nurse-to-patient ratios in the ICU
  • Disinfection of the hubs before accessing the port
  • Daily assessment by the interprofessional team regarding the continued need for the central line
Catheter-associated UTIs
Worldwide, catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection and is associated with increased patient morbidity, mortality, length of stay, and hospital costs.8 Urinary tract infections are the most common type of healthcare-associated infection reported by acute care facilities, with nearly all associated with introduction of a urinary catheter.9 The most effective way to reduce the incidence of CAUTI is to restrict urinary catheterization to patients who have clear indications for it and remove the catheter as soon as it is no longer needed.
Key components of the CDC’s CAUTI guidelines include:9
  • Perform a daily review of the need for the urinary catheter
  • Check that the catheter remains connected to the drainage system
  • Perform routine daily hygiene, including perineal care
  • Regularly empty urinary drainage bags at the end of the shift
  • Perform hand hygiene and don gloves before each catheter care procedure10
Minimizing alarm fatigue
Alarm fatigue occurs when a person is exposed to excessive number of sounds. This may result in sensory overload and desensitization to sounds. Patient safety can be compromised when alarm fatigue results in failure to recognize and respond to alarms.11
Several strategies exist for reducing alarm fatigue related to telemetry alarms:11
  • Provide adequate skin preparation for ECG electrode placement. Adequate cleansing of the skin before electrode placement can decrease impedance, enhance conductivity, and minimize signal noise. Washing the skin with soap and water and clipping excessive hair can reduce artifact and increase the skin-electrode interface.
  • Change electrodes daily. Evidence from quality improvement projects indicates that changing ECG electrodes daily can avoid unnecessary alarms.
  • Customize alarms based on patient need. More than a 40% reduction in alarms has been achieved when alarm ranges are customized to specific patient need. For example, when adjusting heart rate alarms, if a patient’s heart rate is 80, the nurse can adjust the low parameter alarm to 60 and high to 80.
Other evidence-based strategies include placing delays on SpO2 monitors, establishing interprofessional teams to develop policies and procedures, and using monitors only for clinically appropriate patient needs.10
Prevention of ICU-acquired delirium
Delirium is brain organ dysfunction that is exacerbated in critically ill patients, especially those who require mechanical ventilation. Delirium leads to increased mortality for ICU patients. A set of evidence-based practice guidelines has been established that incorporates prevention of delirium, early mobilization, and management of pain and sedation.10 The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle provides a standardized approach to care that enhances interprofessional communication among care providers and a nurse-driven program to manage analgesia and sedation.
The A, B, and C of the ABCDE bundle include protocols to assess for a spontaneous breathing trial or “wake-up and breathe” protocol. This process has guidelines for nurses and respiratory therapists working together to determine if it is safe to lower the sedation to perform the breathing trial.

If patients meet a safety screen, the nurse will turn off sedation agents and assess physiological parameters. If the patient meets the safety checks, the respiratory therapist will proceed with the spontaneous breathing trial. If the patient can tolerate the spontaneous breathing trial, he or she should be considered for extubation.

The C indicates that it takes coordinated protocols to achieve complete compliance with the bundle. It takes effective communication among care providers with an organized approach to the bundle. D is to assess for delirium; the most common tool used is the CAM-ICU, a series of focused cognitive questions to assess disorganized thinking.

Patients at risk for delirium include those with prolonged use of prodeliriogenic medications and mechanical ventilation, those who have been immobilized, and patients with catheters and restraints. Evidence-based strategies to prevent delirium are early extubation, avoidance of drug interactions and prodeliriogenic drugs, and timely removal of all catheters.10
Early mobilization of hospitalized patients
The adverse effects of prolonged bed rest are many and all too frequent for hospitalized patients. Pressure wounds, muscle atrophy, cardiopulmonary weakness, and immune-compromised complications are common adverse effects when patients are unable to maintain mobility. A newer trend, supported by research findings, is earlier mobilization of patients who once were deemed “too sick” to get out of bed. Early mobilization not only improves the patient’s functional status, but also reduces length of hospital stay.10
Mobility efforts should begin as soon as the patient has stabilized hemodynamically and in respiratory status, often within the patient’s first 48 hours in the unit.12 Even patients receiving ventilatory support can exercise. To obtain the most benefit from mobilization:
  • Plan sessions to optimize patient comfort
  • Evaluate the patient’s tolerance to activity
  • Ensure adequate personnel are available for patient safety
Mobilization activities may not be appropriate for patients who require a high level of ventilator support or those who have unstable hemodynamic parameters.
Venous thromboembolism prevention
Future of evidence-based practice
Evidence-based practice is the keystone of nursing, but marketplace changes call for more collaboration to implement EBP. Current staff can become EBP champions and role models for newer nurses to implement a shared vision for implanting EBP across disciplines.4 As nurses, we cannot answer these practice questions without examining the literature and researching the key components necessary to help us — and our patients and patient families — make sound decisions.
Patients in the critical care area are at risk for developing deep vein thrombosis (DVT) due to many factors. According to national clearinghouse guidelines, hospitalized patients should be assessed for risk factors for developing DVT at the time of admission, upon change in level of care, and at discharge.

They should be educated about risk, prevention, and signs and symptoms. Patients should mobilize as soon as possible to prevent DVT, and those who are at higher risk should be considered for pharmacological prophylaxis. A combination of intermittent sequential devices and pharmacological therapy is recommended for higher-risk patients who have low risk for bleeding.

Organizations should have a structured process to evaluate patient risk factors for preventing venous thromboembolism.13
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To support EBP, several critical care and government organizations, including the American Association of Critical-Care Nurses, the Society of Critical Care Medicine, the American College of Chest Physicians, the American Heart Association and the Agency for Healthcare Research and Quality, have developed position statements and clinical practice guidelines. These national guidelines are already critically analyzed and provide recommendations for practice. Nurses should be aware that some guidelines do not always answer certain clinical questions.
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Ventilator-associated pneumonia (VAP) is the leading cause of death from hospital-acquired infections and affects 10% to 20% of mechanically ventilated patients in the U.S. each year.5 In response to this preventable complication of mechanical ventilation, the Institute for Healthcare Improvement (IHI) developed a “bundle” of measures designed to prevent VAP.6 In addition, American, Canadian, and European scientific societies have developed evidence-based guidelines to prevent VAP.5

The key components of a ventilator bundle are:5
  • Elevate the head of the bed to 30 to 45 degrees to prevent aspiration of oral secretions
  • Perform daily “sedation interruption” from medications given to sedate or calm the patient
  • Assess the patient’s readiness to be extubated per hospital protocol
  • Use peptic ulcer disease prophylaxis to prevent development of stress ulcers as a result of critical illness or mechanical ventilation
  • Use deep venous thrombosis (DVT) prophylaxis to prevent formation of thrombi in the patient on bed rest
  • Provide daily oral care with chlorhexidine to reduce the risk for aspiration of potentially infectious oral secretions
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While Mitchell is on the ventilator, the head of his bed should be elevated at 30 to 45 degrees to:
1
Prevent aspiration of oral secretions
Decrease pressure in the brain
Prevent the development of pressure wounds
a.
b.
c.
d.
Keep the nasogastric tube in place
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Part of the plan of care for Mitchell includes a “wake up and breathe” each day. Which statement about sedation interruption is CORRECT?
2
a.
It reduces the amount of suctioning needed.
b.
It reduces the rate of ventilator-associated pneumonia.
c.
It is not required for patients on the ventilator.
d.
It increases the length of time a patient will spend on the ventilator.
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Which patient is at greater risk for acquiring delirium?
3
a.
A 24-year-old admitted with a mild traumatic brain injury
b.
A 45-year-old who was extubated two hours ago
c.
A 65-year-old admitted with congestive heart failure who has a Foley catheter
d.
A 55-year-old who underwent a coronary artery bypass graft
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When can the nurse begin mobilizing Mitchell?
4
a.
When he is weaned from the ventilator and extubated
b.
When he is hemodynamically stable
c.
When the physician orders it
d.
When Mitchell requests it
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Answers
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c.
ANSWERS:
a.
Elevating the head of the bed 30 to 45 degrees prevents ventilator-associated pneumonia by decreasing the risk of aspiration of GI contents or oropharyngeal and nasopharyngeal secretions.
b.
Using daily “wake up and breathe” has been correlated with reduction in the rate of ventilator-associated pneumonia.
1
Older adults and patients who have catheters are at greater risk for developing delirium.
b.
Mobilization can begin as soon as hemodynamic and respiratory problems have stabilized, frequently within the first 48 hours after ICU admission.
2
3
4
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Clinical vignette
Scenario:
Mitchell, age 58, arrives in the ED complaining of severe chest pain. He is diaphoretic and says his pain is radiating down his left arm and up into his jaw, and adds that he is nauseated. A few minutes after admission, Mitchell suffers a cardiac arrest. He is resuscitated and transferred to the ICU. He is intubated, is on a ventilator, and has a central-line catheter in place.
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Evidence-based practice in a clinical setting
Earn 1 credit hour with this continuing education course
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