Carol Rauen

Evidence-Based Practice Habits: Transforming Research Into Bedside Practice

ctions speak louder than words. If that statement is true clinically, it could be said that nursing practice is more connected to tradition than it is evidence based. Many common practices in critical care nursing continue today despite clear and reliable research that contradicts them. The barriers to research implementation that were identified 3 decades ago—lack of time, insufficient administrative support, and limited access to information—are still daunting clinicians today. The importance of basing practice on research is well understood. The barrier is the actual transformation Evidence-Based Practice Habits: Transforming Research Into Bedside Practice

Strategies for success: orienting to the role of a clinical nurse specialist in critical care.

Successful integration of a new clinical nurse specialist within an organization optimizes the safe, cost-effective implementation of evidence-based practice and research. This article provides strategies and information to support the clinical nurse specialist during his or her role transition, highlights opportunities and challenges to the role, and provides examples of orientation and performance tools that can assist in a successful orientation process.

Continuing to challenge practice to be evidence based.

Practice habits continue in clinical practice despite the availability of research and other forms of evidence that should be used to guide critical care practice interventions. This article is based on a presentation at the 2014 National Teaching Institute of the American Association of Critical-Care Nurses. The article is part of a series of articles that challenge critical care nurses to examine the evidence guiding nursing practice interventions. Four common practice interventions are reviewed: (1) weight-based medication administration, (2) chest tube patency maintenance, (3) daily interruption of sedation, and (4) use of chest physiotherapy in children. For weight-based administration of medication, the patients actual weight should be measured, rather than using an estimate. The therapeutic effectiveness and dosages of medications used in obese patients must be critically evaluated. Maintaining patency of chest tubes does not require stripping and milking, which probably do more harm than good. Daily interruption of sedation and judicious use of sedatives are appropriate in most patients receiving mechanical ventilation. Traditional chest physiotherapy does not help children with pneumonia, bronchiolitis, or asthma and does not prevent atelectasis after extubation. Critical care nurses are challenged to evaluate their individual practice and to adopt current evidence-based practice interventions into their daily practice.

Cardiac Contusion and the 12-Lead ECG.

T is the fifth leading cause of death in adults and the leading cause of death in children in the United States. It is surpassed only by heart disease, cancer, lower respiratory tract diseases, and stroke in the adult population. Trauma to the chest accounts for 25% of all injury-related deaths and is second to head and spinal cord injury as the leading cause of death due to trauma. Although the majority of trauma victims are between the ages of 14 and 40 years, 10% of patients with blunt chest trauma are older than 65 years. Cardiac injury resulting from thoracic blunt trauma is more common in patients with pre-existing cardiac disease. Seventy percent of motor vehicle collision victims sustain some type of thoracic injury, and 5% to 50% of these cases have cardiac contusion. These are usually caused by a cardiac deceleration process and full frontal impact and the transfer of energy to the myocardium, sternum, and spine. Patients with blunt chest trauma should have a 12-lead electrocardiogram (ECG) done as part of their trauma assessment.

Trauma and the elderly: the impact on critical care

The population older than age 65 is growing rapidly. This change in the demographics of our nation is impacting critical care in many ways. Most researchers have found that trauma patients older than 65 have a higher mortality rate, longer hospital stays, more complications, common mechanism of injuries, and poorer outcomes than their younger counterparts. These facts must be taken into consideration when planning care for the elderly trauma patient population. This paper will review the research literature on elderly trauma victims and the impact these patients are having on critical care practice.

Benefit Versus Burden: Should Advanced Practice Nurses Maintain Clinical Certifications?

is an independent clinical nurse specialist in The Outer Banks of North Carolina. Carol contributed the CCRN questions. She welcomes feedback from readers and practice questions from potential contributors at rauen.carol104@gmail.com. Elizabeth Katz Brock, RN, MS, CCRN, ACNP, an acute care nurse practitioner in the surgical critical care department at MedStar Washington Hospital Center in Washington, DC, contributed the introduction and the Cardiac Surgery Certification (CSC) questions. CCRN and CCRN-E Practice Questions 1. A hallucinating patient with a history of schizophrenia is admitted with diabetic ketoacidosis. A priority nursing action of the admission nurse would be to A. Review all preadmission medications B. Contact the patient’s counselor C. Withhold all psychiatric medications until blood glucose level is normal D. Place wrist restraints on the patient

The Power of Mentoring

The relationship between a mentor and a graduate st ud n is the most influential relationship in the student’s career. Effective me ntors are much more than advisors or teachers. They are a role models, cons ulta ts, problem solvers, and supporters. They provide timely and constructive f e dback, career guidance, professional contacts, sources of information about research grants and fellowship and job opportunities, and letters of recommendatio n throughout your professional career.

Maintaining Your Momentum: Moving Evidence Into Practice.

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. Ensuring that we provide safe, evidence-based, cost-effective care to all patients is an assumption of today’s health care system. All patients and health care providers should expect a health care system that is committed to preventing harm and improving patient care by having clinicians use evidence-based, safe practices.1 The Institute of Medicine’s report To Err Is Human clearly articulated the need for health care professionals to embrace evidence-based practice (EBP) to improve outcomes of patient care.2 Since that hallmark publication, efforts have been made by multiple organizations to encourage EBP. Several organizations are leading the way by providing EBP resources and toolkits to inform and improve practice: the Institute for Healthcare Improvement,3 The National Quality Forum,1 the Agency for Healthcare Research and Quality,4 the American Association of Critical-Care Nurses (AACN),5 and the Society of Critical Care Medicine,6 to name just a few. Yet practice outcomes and reviews suggest that barriers persist, preventing daily application of current best evidence in the care of patients.7-9 Barriers range from qualities of hospital systems and organizations, to leadership support, to individual health care professionals not fully embracing EBP interventions as a practice standard.7-11 In 2010, the Insititute of Medicine provided a vision that all clinical decisions would be evidence based by 2020.12 To meet this goal, we as critical care nurses have an opportunity to lead practice change by fully embracing EBP in our daily practice. Practice interventions wedded in tradition need to be retired, and evidence-based nursing interventions should be consistently implemented in the care of the critically ill patients and families we serve. Practice knowledge is not stagnant. Evidence supporting practice interventions is dynamic and continually evolving. To ensure that practice is based on the current best evidence, critical care nurses need to have a good understanding of what EBP is. Although multiple definitions of EBP can be found in the literature and it is beyond the scope of this article to provide an in-depth discussion of EBP, several key tenets are present in each definition. Essential elements of EBP include the integration of best research and other forms of evidence to guide practice, viewing clinical expertise as a component in care effectiveness, and considering patients’ preferences, values, and engagement in care decisions as essential to providing optimal evidence-based care to patients and their families. Embracing EBP as a practice standard requires critical care nurses to be active consumers of current evidence, critically applying evidencebased interventions in practice and retiring traditional ways of providing care.

We Do It for Our Patients

I was told by a nurse attending a CCRN/PCCN review course that he had no intention of sitting for the certification examination. His response when I asked why was, “I will not be paid any more, my hospital does not pay for the test, and frankly I just don’t see any reason to do it.” When asked why he had come to the review course, he answered “Oh, I like to learn, it was free, and I’m being paid to be here.” I asked the nurses attending the review who had raised their hands indicating their intent to take the examination, all of whom worked for the same health system, why they were going to sit for the examination. The enthusiastic response I got was split among 2 themes: “I’m doing it for myself ” and “I’m doing it for my patients.” One of the hallmarks of a professional is selflessness and lifelong learning. Striving for and achieving certification falls into both of these categories.

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Practice habits continue in clinical practice despite the availability of research and other forms of evidence that should be used to guide critical care practice interventions. This article is based on a presentation at the 2014 National Teaching Institute of the American Association of Critical-Care Nurses. The article is part of a series of articles that challenge critical care nurses to examine the evidence guiding nursing practice interventions. Four common practice interventions are reviewed: (1) weight-based medication administration, (2) chest tube patency maintenance, (3) daily interruption of sedation, and (4) use of chest physiotherapy in children. For weight-based administration of medication, the patients actual weight should be measured, rather than using an estimate. The therapeutic effectiveness and dosages of medications used in obese patients must be critically evaluated. Maintaining patency of chest tubes does not require stripping and milking, which probably do more harm than good. Daily interruption of sedation and judicious use of sedatives are appropriate in most patients receiving mechanical ventilation. Traditional chest physiotherapy does not help children with pneumonia, bronchiolitis, or asthma and does not prevent atelectasis after extubation. Critical care nurses are challenged to evaluate their individual practice and to adopt current evidence-based practice interventions into their daily practice.