Evidence-Based Practice Change Champion Program Improves Quality Care.

Nurses need training and mentoring to lead evidence-based practice (EBP) improvements. An array of roles have been reported to have a positive impact on EBP adoption. A training program was created to assist point-of-care nurses and nurse leader partners in operationalizing the EBP Change Champion role to address priority quality indicators. The program, a case exemplar, and lessons learned are described with implications for leaders responsible for promoting EBP to improve quality care.

CE: Original Research: Are Milk and Molasses Enemas Safe for Hospitalized Adults? A Retrospective Electronic Health Record Review.

: Background: Constipation in hospitalized patients is common. As a treatment of last resort for unresolved constipation, a milk and molasses enema is often used by nursing staff. But there has been little research investigating the safety and efficacy of this approach. PURPOSE: The purpose of this retrospective study was to evaluate the safety of milk and molasses enemas for hospitalized adults with constipation that remained unresolved after standard treatment options were exhausted. METHODS: Data were extracted from the electronic health records (EHRs) of 615 adult patients who had received a milk and molasses enema between July 2009 and July 2013 at a large midwestern academic medical center. Data analysis occurred for a random subset of this group.Participant characteristic variables included age, sex, admitting diagnosis, diet orders, medications, laxatives and enemas administered before the milk and molasses enema, and laboratory values. Serious complication variables included bacteremia, bowel perforation, electrolyte abnormalities, allergic reaction, abdominal compartment syndrome, cardiac arrhythmia, dehydration, and death. FINDINGS: The final sample of 196 adults had a mean age of 56 years; 61.2% were female and 38.8% were male. Of 105 admitting diagnoses, the most frequent (9.7%) was abdominal pain, unspecified site. Of the 14 discharge dispositions, the most frequent was home or self-care (50.5%). A laxative order was present for 97.4% of patients and a stool softener order was present for 86.2%. Sodium and potassium levels remained within normal limits during hospitalization. For the subset of patients who had these values measured within 48 hours before and after milk and molasses enema administration, no significant changes were found. No cases of nontraumatic abdominal compartment syndrome or other serious adverse enema-related events were documented in the EHR. CONCLUSIONS: No safety concerns were identified from this retrospective EHR review of hospitalized adults who received a milk and molasses enema for constipation relief. The findings indicate that this treatment is safe, although further study examining its efficacy in this population is needed.

Patient, Nurse, and Organizational Factors That Influence Evidence-Based Fall Prevention for Hospitalized Oncology Patients: An Exploratory Study.

BACKGROUND: Hospital falls remain common despite decades of studies and guidelines to reduce their rate. Research evidence alone is insufficient, and integration of patient values and preferences, clinician expertise and experiences, and organizational culture is needed to ensure sustainable practice changes. Little is known about the best strategies for integrating these constructs to sustain effective fall prevention programs. AIMS: Guided by the Comprehensive Framework for Implementation Research (CFIR), this study aimed to identify patient, nursing staff, and organizational-level factors that influence effective and sustainable fall prevention strategies with the goal of identifying variables amenable to targeted interventions. METHODS: A descriptive research design engaged four oncology units in a Midwestern academic medical center and included patients (N = 39) and nursing staff (N = 70). Questionnaire data were collected from patients with interview assistance, and nursing staff completed a demographic form and two standardized instruments adapted for the study. Data were analyzed using descriptive statistics and narrative summaries. RESULTS: Findings indicated two-thirds of patients did not see themselves at risk for falling, despite nearly half having a fall history. Nursing staff indicated knowledge gaps related to specific known risks and interventions, and confidence in fall prevention management was lowest for team communication about patient risks and engaging patients and families in preventing falls. LINKING EVIDENCE TO ACTION: Engagement of patients in fall risk assessment and management, clear and routine communication among team members, and creating a culture of true engagement with appropriate leadership and resources can potentially improve the sustainability of successful fall prevention programs. The CFIR can guide the planning of fall prevention and other evidence-based practice changes to become hardwired and sustainable over time even with the ongoing introduction of new initiatives.

CE: Original Research: Exploring Clinicians' Perceptions About Sustaining an Evidence-Based Fall Prevention Program.

: Purpose: This study aimed to address the knowledge gap between implementing and sustaining evidence-based fall prevention practices for hospitalized patients by exploring perspectives of the interprofessional health care team. DESIGN: A qualitative design was used to capture insights from clinicians across disciplines in a large midwestern academic medical center. METHODS: Four homogenous semistructured focus groups and three individual interviews involving a total of 20 clinicians were conducted between October 2013 and March 2014. Audio-recorded data were transcribed and analyzed using inductive qualitative analysis. FINDINGS: Two primary themes emerged from participants regarding the sustainability of an evidence-based fall prevention program: communication patterns within the interprofessional health care team and influences of hospital organizational practices and elements. Several subthemes also emerged. Participants gave nursing staff primary responsibility for fall risk assessment and prevention. CONCLUSIONS: Individual professional perceptions and practices, as well as organizational characteristics, affect the sustainability of evidence-based fall prevention practices. While all team members recognized patient falls as a significant quality and safety issue, most believed that direct care nurses hold primary responsibility for leading fall prevention efforts. The data support the importance of effective interprofessional team communication and organizational practices in sustaining an evidence-based fall prevention program across inpatient units. Furthermore, the data call into question the wisdom in labeling quality indicators as "nursing sensitive"; the evidence indicates that a team approach is best.

CE: Oral Care for Head and Neck Cancer Symptom Management.

: An evidence-based practice change at a radiation oncology center in a large academic medical center was designed to reduce the severity of oral mucositis in adults receiving radiation treatment for head and neck cancer. In the intervention described, patients were given newly created oral care kits and educational materials to improve their oral hygiene. Evaluations were conducted at three points during the project (before radiation treatment, during week 4 to 5 of treatment, and one month after treatment). At week 4 to 5-when the severity of oral mucositis is expected to peak-patients reported improved oral hygiene practices and reduced oral mucositis severity. The authors conclude that the use of these oral care kits and educational materials lessened the effects of oral mucositis during and after radiation treatment.

Pain Management Interventions for Needle Stick Procedures: An Ambulatory EBP Project.

Pain is a prevalent global health concern, and pain assessment and treatment is a patient right. This evidence-based practice project targeted translating pain management interventions into practice for adult and pediatric patients undergoing needle stick procedures in ambulatory settings. Evidence-based interventions should consistently be offered to patients who often experience procedural pain or discomfort. Implementation of the practice change included multiple interactive, reinforcing strategies. Pre/post-implementation evaluation measures included clinician knowledge, perceptions, and current practices. A pain-related question was added to the institution's ambulatory patient satisfaction survey. Ongoing reinfusion efforts are aimed at promoting sustainability and integration of the practice change.

Worksite Physical Activity Intervention for Ambulatory Clinic Nursing Staff.

Health behaviors, including physical activity (PA), of registered nurses (RNs) and medical assistants (MAs) are suboptimal but may improve with worksite programs. Using a repeated-measures crossover design, the authors explored if integrating a 6-month worksite non-exercise activity thermogenesis (NEAT) intervention, with and without personalized health coaching via text messaging into workflow could positively affect sedentary time, PA, and body composition of nursing staff without jeopardizing work productivity. Two ambulatory clinics were randomly assigned to an environmental NEAT intervention plus a mobile text message coaching for either the first 3 months (early texting group, n = 27) or the last 3 months (delayed texting group, n = 13), with baseline 3-month and 6-month measurements. Sedentary and PA levels, fat mass, and weight improved for both groups, significantly only for the early text group. Productivity did not decline for either group. This worksite intervention is feasible and may benefit nursing staff.

American Academy of Otolaryngology-Head and Neck Surgery Foundation Clinical Practice Guidelines.

All health care professionals want to provide their patients with the best care possible. In order to accomplish this, the most current research must be incorporated into their daily practice. Many medical specialty societies have developed clinical practice guidelines to help facilitate achievement of safe, high quality patient care. This manuscript highlights the recommendations from the clinical practice guidelines developed and published through the American Academy of Otolaryngology-Head and Neck Surgery Foundation. Dissemination of clinical practice guidelines, to a broad audience, is essential to ensure implementation and adoption into practice. The key action statements and recommendation strength of each from the clinical practice guidelines are highlighted to help achieve these goals.

Pain management prior to nasogastric tube placement: atomized lidocaine.

Nasogastric tube (NGT) insertion is often painful for patients of all ages. Randomized clinical trials in adult patients support the use of some form of topical lidocaine in reducing pain associated with NGT insertion. A review of pediatric evidence also confirms that NGT insertion is painful and provides guidance in determining lidocaine concentrations, dosages, and administration methods. The Iowa Model of Evidence-Based-Practice to Promote Quality Care provided the framework for development of a weight-based standard of practice (SOP) for administration of atomized lidocaine prior to NGT insertion for all patients. To facilitate usage, the orders for NGT placement and atomized lidocaine administration were linked in the electronic health record (EHR). Atomized lidocaine was administered via a patient-specific intranasal mucosal delivery device. Evaluation measures included pre- and post-implementation questionnaires which measured discomfort with NGT insertion in pediatric patients (0-10 scale; pre-implementation mean = 7.4; post-implementation mean = 6.5), monitoring utilization of atomized lidocaine via automated dispensing cabinet reports, soliciting comments from families and users, and monitoring institutional patient safety (incident) and adverse drug reaction reports. No patient safety or adverse drug reactions related to atomized lidocaine were identified post-implementation. Patients of all ages have benefited from administration of weight-based intranasal atomized lidocaine to decrease pain caused by NGT insertion. Ongoing safety evaluation and research is warranted since this is the first known report in the literature describing implementation of a weight-based dosing SOP.

Clinical consensus statement: tracheostomy care-putting statements into action!

A clinical consensus statement (CCS) on tracheostomy care for adults and children was developed to improve care for this patient population. Statements were identified using a modified Delphi method with the goal to reduce practice variations among tracheostomy patients. Integration of these statements into daily practice in the care setting is the next step for information dissemination. The CCS affected current policies, procedures, protocols, staff education, and patient education. The process of updating practice at a large tertiary care center is described using evidence-based implementation strategies.

Monitoring sedation in patients receiving opioids for pain management.

Excessive sedation precedes opioid-induced respiratory depression. An evidence-based practice project standardized systematic sedation monitoring by nurses using an opioid sedation scale and respiratory assessment when opioids are administered for pain management. Nurses were educated and documentation updated. Nurses demonstrated increased ability to identify at-risk patients (3.2 pre-implementation; 3.6 post-implementation; 1-4 Likert scale) and reported understanding the tool to assess for oversedation (2.6 pre-implementation; 3.2 post-implementation). Documentation compliance improved, and patient safety was maintained.

Evidence-based oral care for oral mucositis.

Nurses must intervene to provide evidence-based supportive care and symptom management for cancer patients. Oral mucositis, a distressing side effect of cancer treatment, is both a research and clinical priority. Nurses can lead improvements with evidence-based oral mucositis interventions. This article describes application of evidence-based clinical recommendations for oral mucositis across diverse patient populations.

High level disinfection of flexible nasopharyngoscopes, videolaryngoscopes, and rigid nasal endoscopes: an evidence-based approach.

In 2008, the Center for Disease Control (CDC) issued new guidelines for the cleaning of nasopharyngoscope (flexible fiberoptic), videolaryngoscopes, and rigid nasal endoscopes (Rutala et al., 2008). The guidelines outlined the basic process steps and requirements including staff training, competency testing, approved products, personal protective equipment, and appropriate storage. To date, published occurrences of pathogen transmission related to procedures requiring the use of a scope have been associated with failure to follow established cleaning and disinfection guidelines or use of defective equipment (Rutala, 2011). The University of Iowa Hospitals and Clinics (UIHC) established a multi-disciplinary team to review and revise the current policy and to generate implementation recommendations. The team used a systematic evidence-based approach to initiate the changes in practice. The initial project focus was in the Otolaryngology Department due to high scope usage in that patient care area.