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Nurse Gives Research a Forum at Conference

Thursday July 28, 2011
Elizabeth Bridges, RN
Elizabeth Bridges, RN
(Courtesy of AACN)
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CHICAGO — A nursing professor and researcher led an educational session about how nurses can apply evidence-based practice information they glean from journal articles into their own practices, and how they can spark discussions among critical care staff that may lead to improvements in patient safety and care.

The presentation, led by Elizabeth Bridges, RN, PhD, CCNS, FCCM, FAAN, associate professor at the University of Washington School of Nursing in Seattle, was titled “Critical Care Nursing Research Studies You Should Know About” and was given at the American Association of Critical-Care Nurses’ National Teaching Institute and Critical Care Exposition, which ran April 30 to May 5.

Practice versus evidence-based practice

During her session, Bridges discussed the time-honored practice of using central venous pressure to guide fluid resuscitation and the use of fluid boluses. “CVP is useful in diagnosis of pulmonary dysfunction, but it is not useful in predicting if your patient will respond to a fluid bolus,” she said.

Bridges, who also is the clinical nurse researcher at the University of Washington Medical Center, said nurses should be “smart consumers of evidence” when reading research articles and referred nurses to the article “Does Central Venous Pressure Predict Fluid Responsiveness? A Systematic Review of the Literature and the Tale of Seven Mares” by Paul E. Marik, MD, published in the journal Chest in 2008. The article posited that using CVP to guide IV fluid therapy may be a flawed approach.

Bridges said the article is a “must read” for critical care nurses. She asked her audience how many nurses still use CVP to monitor their patients, and the majority of nurses raised their hands. “My challenge is, if you take even one paper home from the NTI, take this home and start talking about it,” she said.

Bridges also delved into the topic of central line bundles. “Certainly, having a policy in place is a first step, but that, in and of itself, is not good enough,” she said.

To illustrate, she shared details of a study published at PlosOne.org in January that reviewed the central line-associated bloodstream infection rate at 250 National Healthcare Safety Network hospitals. The study found less than half of the ICUs had a written central line-bundle policy, and only 38% of the ICUs that monitored compliance adhered to the bundle more than 95% of the time. The results demonstrated that simply having a policy in place did not decrease the CLABSI rate.

Bridges said following barrier precautions, using chlorhexidine, adhering to optimal site selection and maintaining daily checks are steps that can help increase compliance. “If you’re in a hospital right now that’s struggling with compliance, if you will even do one of these things very, very well, you have the potential to decrease your CLABSI rate by 38%. But you’re not going to get sustained long-term benefits unless you do all of them.”

Bridges touched upon the role of biomarkers in sepsis, saying that while procalcitonin has not been found to be a useful marker for identifying patients with and without sepsis, it may be a guide for when to discontinue antibiotics. But further research is needed, she said.

Checklists — a mighty tool

Bridges also lauded the Keystone Project, which started in 2004 as a collaboration between Johns Hopkins and 103 hospitals in Michigan to reduce the CLABSI rate. The Keystone Project promoted staff education, creation of a catheter insertion cart, conferring with providers daily about whether catheters could be removed, implementation of a checklist to ensure adherence to evidence-based guidelines for preventing infections, and facility-sactioned empowerment of nurses to stop catheter insertion procedures if they observe a guideline violation.

“This [project] was about engaging everyone in a culture of safety,” she said. “The hospitals shared important data, which is of utmost importance.”

During the session, Bridges also stressed the importance of post-insertion checklists, and checklists in general, but said only a well-planned checklist can be of help to nurses. “There shouldn’t be more than eight items on [a checklist],” she said. “It is not meant to replace a protocol or a procedure. Those things need to be much more detailed. A checklist is to include critical items that you must do to ensure a safe outcome.”

Bridges discussed adverse events that occur during intrahospital transport of critically ill patients. A six-month study, published in the March issue of the American Journal of Critical Care, in which a dedicated team for intrahospital transports was used resulted in a clinically significant adverse events rate of 1.7% that, the report said, was well below the 8% rate for adverse events reported in other studies. Bridges pointed out that intrahospital transport of critically ill ventilated patients is a risk factor for VAP. “These studies demonstrate the importance of having skilled transport teams and dedicated equipment and also the importance of checklists to ensure safe transport,” she said.

Take-home message

Bridges’ take-home message for attendees was that keeping abreast of the latest research and bringing it to the table at unit meetings can help start a conversation about best practices and enhance care. “This is what we need to do,” she said. “We need to know the literature.”

Bridges, who also is a critical care Air Force nurse researcher on active duty for almost 22 years, plus six years in the Air Force Reserve, was honored by the AACN with the Flame of Excellence Award during the NTI conference.

For additional information on using research to promote best practices, and suggestions about journal articles for review, read the sidebar to this story at http://bit.ly/ljMqkj.

Sallie Jimenez is a regional editor.


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