Evidence-Based Pain Assessment in Nonverbal Palliative Care Patients.

BACKGROUND: Central to palliative care is the early assessment and treatment of pain, whether physical, psychosocial, or spiritual. Nonverbal palliative care patients are at risk for inadequate pain assessment leading to prolonged suffering. AIMS: The purpose of this project was to implement and evaluate an evidence-based pain assessment tool for nonverbal palliative care patients. DESIGN: The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Healthcare and the Implementation Strategies for Evidence-Based Practice Guide provided the guiding frameworks. SETTINGS: On a six-bed adult inpatient Palliative Care Unit (PCU). PARTICIPANTS/SUBJECTS: Nonverbal palliative care patients. METHODS: Evidence supported use of the Multidimensional Objective Pain Assessment Tool (MOPAT) for nonverbal patients receiving palliative care. During an eight-week pilot, nurses recorded pain assessments on a paper form and trended pain scores over a 24-hour period. Evaluation included knowledge, attitudes, and behaviors pre- and post-pilot and was subsequently used in a Precision Implementation Approach to promote adoption. RESULTS: Nurses' attitudes toward palliative care pain assessment improved in all items on the evaluation tools. Pain was assessed using MOPAT for 74% of nonverbal palliative care patients and 88% of patients had linked pain interventions to MOPAT scores. CONCLUSIONS: MOPAT is the only valid evidence-based pain assessment tool for nonverbal patients receiving palliative care. This project led to successful adoption of the MOPAT within the PCU.

Sacred cow gone to pasture: a systematic evaluation and integration of evidence-based practice.

BACKGROUND: Sacred cows (SC) are old habits in practice, considered routine and above dispute, regardless of evidence to the contrary. PURPOSE: This is the first known report that aims to conduct a systematic evaluation of practices that have been described in the literature as SC and strategies for planned implementation of evidence-based practices (EBP). METHODS: A large, complex, academic medical center department of nursing compared SC to EBP. Nurses systematically reviewed and rated the degree to which current practices adhered to best-evidence versus SC. This initiative, "Sacred Cow: Gone to Pasture," was developed, structured, and implemented according to the Iowa Model of Evidence-Based Practice to Promote Quality Care, as well as Everett Rogers' Diffusions of Innovations Theory. Implementation of EBP followed a phase plan using the Implementation Strategies for Evidence-Based Practice to help to support adoption and integration. RESULTS: Review of organization-specific policies and procedures and reports of actual practices revealed that SC persist, even in a center internationally recognized as a leader in EBP. The SC initiative caught the attention of busy clinicians, and raised awareness of SC and the importance of adherence to EBP. The SC initiative resulted in policy and practice changes and sparked new EBP and research, resulting in numerous improvements, including a significant decline in catheter-associated urinary tract infections and shifting from basins to commercially prepared cloths for patient bathing. LINKING EVIDENCE TO ACTION: A strategic approach is crucial to eliminating SC and integrating EBP. This report calls nurses globally to action, to identify and abandon ineffective healthcare practices. Further research should compare and test the efficacy of implementation strategies, in particular how to sustain EBP in clinical settings.

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.

Iowa Implementation for Sustainability Framework.

BACKGROUND: An application-oriented implementation framework designed for clinicians and based on the Diffusion of Innovations theory included 81 implementation strategies with suggested timing for use within four implementation phases. The purpose of this research was to evaluate and strengthen the framework for clinician use and propose its usefulness in implementation research. METHODS: A multi-step, iterative approach guided framework revisions. Individuals requesting the use of the framework over the previous 7 years were sent an electronic questionnaire. Evaluation captured framework usability, generalizability, accuracy, and implementation phases for each strategy. Next, nurse leaders who use the framework pile sorted strategies for cultural domain analysis. Last, a panel of five EBP/implementation experts used these data and built consensus to strengthen the framework. RESULTS: Participants (n = 127/1578; 8% response) were predominately nurses (94%), highly educated (94% Master's or higher), and from across healthcare (52% hospital/system, 31% academia, and 7% community) in the USA (84%). Most (96%) reported at least some experience using the framework and 88% would use the framework again. A 4-point scale (1 = not/disagree to 4 = very/agree) was used. The framework was deemed useful (92%, rating 3-4), easy to use (72%), intuitive (67%), generalizable (100%), flexible and adaptive (100%), with accurate phases (96%), and accurate targets (100%). Participants (n = 51) identified implementation strategy timing within four phases (Cochran's Q); 54 of 81 strategies (66.7%, p < 0.05) were significantly linked to a specific phase; of these, 30 (55.6%) matched the original framework. Next, nurse leaders (n = 23) completed a pile sorting activity. Anthropac software was used to analyze the data and visualize it as a domain map and hierarchical clusters with 10 domains. Lastly, experts used these data and implementation science to refine and specify each of the 75 strategies, identifying phase, domain, actors, and function. Strategy usability, timing, and groupings were used to refine the framework. CONCLUSION: The Iowa Implementation for Sustainability Framework offers a typology to guide implementation for evidence-based healthcare. This study specifies 75 implementation strategies within four phases and 10 domains and begins to validate the framework. Standard use of strategy names is foundational to compare and understand when implementation strategies are effective, in what dose, for which topics, by whom, and in what context.

Unruptured intracranial aneurysms: using evidence and outcomes to guide patient teaching.

It is estimated that approximately 10 to 15 million Americans have intracranial aneurysms. Intracranial aneurysms are classified as either unruptured or ruptured. Advances in knowledge and technology are enhancing diagnosis, management, and outcomes associated with unruptured intracranial aneurysms. Optimal outcomes are achieved when aneurysms are treated before they rupture. If the aneurysm ruptures, the mortality rate ranges from 30% to 60%. A review of evidence regarding aneurysms, including the pathogenesis, risk factors, treatment options, and outcomes, is presented. Treatment options addressed include surgical clipping, endovascular coiling, or watchful waiting. Current evidence supports aggressive treatment for patients with previously ruptured aneurysms, large or symptomatic aneurysms, a family history of aneurysm rupture, a long life expectancy, and aneurysms demonstrating growth. Factors that favor watchful waiting include aneurysms that are small or located in the anterior circulation and in patients with a short life expectancy or comorbid medical conditions. Nurses are in an ideal position to use evidence and outcomes to provide accurate and current information on how to reduce the risks for rupture and evaluate treatment options.