Evidence-based practice for hospital-acquired conditions

AORN Journal,  July, 2008  by Robin Chard

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QUESTION: I have been asked to take the lead in forming an evidence-based practice task force to deal with the hospital-acquired conditions for which the Centers for Medicare & Medicaid Services (CMS) will no longer provide payment to health care institutions. Could you suggest a method to assist me in starting this project?

ANSWER: Ideally, the task force should include members from various health care disciplines because a holistic approach to patient care requires a team effort. The intent of using evidence in practice is to provide care that is based on research. Accountability for one's own practice is necessary to establish the process. Social trends that are driving the need for research utilization include consumerism, cost implications, regulatory requirements, health policy, and Magnet status. (1)

The task force members should clearly understand how to apply evidence in practice. Evidence-based practice is the method through which perioperative nurses can identify which interventions result in the most positive patient outcomes, thus eliminating risks. In order to take action, changes or modifications in practice must occur at the point of care.

Task force members should develop a process for identifying which perioperative practice issues may directly contribute to hospital-acquired conditions. They should start by using an inductive approach through which a specific problem leads to a general interest. In other words, they should identify problems in practice via direct patient care, journals, colleagues, conferences, and professional organizations.

Knowing which questions to ask is a clinician's starting point. Two types of questions exist: background and foreground. Background questions address general, foundational information on the topic of interest, whereas foreground questions are more specific and result from the foundational knowledge generated from the background questions. The following is an evidence-based practice exercise for developing foreground clinical questions that uses a format known as PICO. (2) The exercise relates to the hospital-acquired condition of mediastinitis.

* P = Patient population of interest. One of the first steps in framing a question is to identify the population of interest. In this case, it would be patients undergoing coronary artery bypass surgery.

* I = Intervention of interest. Several of the interventions to prevent surgical site infections are listed in AORN's recommended practices (eg, those for maintaining a sterile field (3) and for preoperative patient skin antisepsis (4)). Hot topics such as double-gloving and skin preparation products may be chosen as interventions of interest. For example, nurses may elect to conduct a research project on whether a relationship exists between the practice of double-gloving and the incidence of mediastinitis.

* C = Comparison of interest. This step is optional, but in the example above, nurses could compare two different types of skin preparation solutions and determine whether either has an effect on the incidence of mediastinitis.

* O = Outcome of interest. The outcome is the desired effect, which will strengthen the evidence on which to base practice. If double-gloving leads to a statistical difference in reducing patients' risk of acquiring mediastinitis, it could be become an accepted, if not mandatory, practice.

One of the most important aspects of translating research into practice is to have management support. If one is not already established, a research committee provides a forum through which the task force members can discuss potential projects and solicit advice. Historically, there has been a disconnect between nursing research and practice, but a paradigm shift toward a more streamlined approach for translating research into practice is well underway. Perioperative nurses can be proactive leaders of their profession by developing evidence-based interventions.

The PICO format may be applied to any of the identified CMS hospital-acquired conditions, including

* falls and trauma such as burns, fractures, dislocations, and intracranial and crushing injuries;

* pressure ulcers;

* catheter-associated urinary tract and vascular infections; and

* mediastinitis from coronary artery bypass surgery.

In addition, a PICO format could be applied to the problems of objects left in a patient after surgery, air embolism, and blood incompatibility reactions, which have been listed by CMS as preventable events that should never occur. (5)

Editor's note: Magnet is a trademark of the American Nurses Credentialing Center, Silver Spring, MD.

REFERENCES

(1.) Houser J. Nursing Research: Reading, Using, and Creating Evidence. Boston, MA: Jones and Bartlett Publishers; 2008.

(2.) Nollan R, Fineout-Overholt E, Stephenson P. Asking compelling clinical questions. In: Melnyk BM, Fineout-Overholt E, eds. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:25-37.