Nursing Research Council
Mount Auburn Hospital
Nursing Research Council (NRC)
Selected Project Summaries
Prepared for Nursing Grand Rounds 5/5/2011
Research Question: Should Lidocaine be used prior to IV cannulation to minimize patient discomfort. Requested by Deb Baker, Chief Nurse Executive.
Findings: After reviewingthe literature and consulting withMAH experts, no evidence was foundto supportwidespread routine use ofintradermallidocaine prior to an IV start.
Outcome: The recommendation was to assessthe patient, their individual needs, thesituation and to select theappropriate interventionsonanindividualizedbasis.
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Research Question: Are Heparin flushes necessary to maintain patency of Central Lines Requested by Critical Care Committee based on inconsistent practice.
Discussion: Staff noticed inconsistent practice regarding central lines flushing. The floors were flushing with Heparin but the Units were not using Heparin flushes due to increased incidence of Heparin Induced Thrombocytopenia (HIT).
Findings: We reviewed the recent literature and practices at MAH and other local teaching hospitals, and noted a trend to eliminate Heparin flushes for central lines due to the risk of the patient developing HIT. Additionally using a neutral displacement connector on our IV lines reduces the risk of reflux and clotting.
Outcome: Based on our findings a recommendation to the medical staff and quality/safety department was made to eliminate the use of heparin flushes in all units. This resulted in a hospital wide change in practice regarding Heparin flushing. Proper flushing techniques were reviewed at the Med.Surg. competency day.
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Research Question: Is "laboring down" adequate and efficient for descent of fetal vertex in second stage of labor versus active pushing? Requested by Pat Callahan, RN, Labor and Delivery
Discussion: Traditional standards of care promote immediate active pushing once full cervical dilitationis present regardless of maternal urge to push down. This can lead to longer pushing periods, often resulting in maternal distress and exhaustion, fetal distress and sometimes Cesarean sections.
Additionally, because of prolonged pushing many L&D nurses have reported shoulder pain, injury after years of holding legs and possibly a career change.
Findings: Strong evidence clearly supports laboring down.
Outcome: As a result of our study, the NRC recommended allowing a woman to rest until maternal urges are presentto bear down, benefiting not only the patient but nurses. The evidence was presented at a Department Meeting and a practice change is evolving.
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Research Question: Straight Needle versus Butterfly Needle Phlebotomy Study
What equipment is currently being used at MAH for collecting bloodspecimens? Requested by the Nursing Leadership Council
Findings: The literature supported the belief that the butterfly needle is easierto manipulate and obtain blood for multiple specimens, and more successful in obtaining specimens from patient with fragile veins. A survey of MAH staff found thebutterfly needle was preferred dueto the perception of theease of use, better results for patient with poor access, patient request, and safety. Presently, there is extensive phlebotomy education of PCA’s but no competency review. However, there is no educational requirement or competencies for RNs who perform phlebotomy.
Outcome: Recommend the establishment ofinitial training for RNs, annual competency evaluation for PCAs and RNs who perform phlebotomy. Provide support to the PCA educator.
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TPN
Research Question: Is a patient receiving TPN via a violated line vs. a non-violated line at an increased risk for infection? Request by Joan Spinosa, IV Therapy
Finding: We did not find evidence supporting the practice of a dedicated line for TPN use. The policy at five surrounding hospitals revealed that only one hospital allows use of a violated linefor TPN, all others use a non-violated line.
Outcome: Continue with the current MAH policy with the use of a dedicated line when administering TPN,along withNational Institutes of Health guidelinesof insertion and care of central lines.
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IV Fluid Order Renewal
Research Question: Is there evidence to supportthe MAH nursing policy that IV orders be written every 24 hours? Requested by: Deb Baker, The Practice Council, & IV Therapy.
Findings: No evidence was found in a literature review. Policies vary among local andBoston hospitals.
It was determined that assessing fluid status is a shared responsibility to ensure good patient care.
Outcome: Both nursing and medicine needto assess a patient's fluid andelectrolyte status to determine the appropriateadministration and duration of IV fluids.
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Use of Sheepskin to Prevent Friction and Shearing
Research Question:Does the use of sheepskin prevent friction and shearing. Requested by Dottie Devanna, Clinical Educator.
Findings: The evidence found in the literature review, did not support the use of man made sheepskin. However, the use of natural sheepskin reduced skin breakdown by 60%, although natural sheepskin is cost prohibitive.
Outcome: The Council recommended ongoing staff education in the prevention of sheering and friction.
Although the council acknowledged the benefit of natural sheepskin but recognized the acquisition and maintenance would be cost prohibited.
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C-Diff Precautions in the Out-Patient Setting
Research Question:Does the hospital policy for C-Diff precautions apply in the out-patient setting?
Requested by Paula Falzone, from the Hematology-Oncology Clinic
Findings: The council conducted a literature review, a survey of 5 Boston hospitals and heard evidence from the nursing director of the MAH ID department. The evidence did support maintaining the current MAH guidelines as recommended by the Centers for Disease Control.
Outcome: No change required in current practice.
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Pre-Medication for Cardiac Catheterization
Research Question: What is the current evidence and practice in cath labs regarding pre-medication with Benadryl to prevent adverse reactions to contrast media? Requested by Meg Morris, RN, Clinical Mentor, Cardiac Cath Lab.
Findings: The contrast media used in the cath lab has improved over the years and is associated with decreased adverse reactions. According to the British Medical Journal, premedication is not necessary.
Outcome: After reviewing the evidence in the literature, expert opinion, survey of local hospital practices, in-house review of practices and expert opinion the committee determined that routine administration of Benadryl to cath lab patients is not necessary.
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Amiodarone
Research Question: Should Amiodarone be given only through a Central Line?
Requested by Peg Sullivan, RN, Step Down Unit
Discussion: The staff noticed a very high rate of phlebitis with patients receiving IV Amiodarone through a peripheral line. The MAH pharmacy and manufacturer’s guidelines recommend a central line.
Findings: A review of nursing practices revealed inconsistencies in practice. A literature review revealed a phlebitis rate of 7-23% using varying doses. The NRC designed and executed a research study to evaluate the rate and severity of phlebitis in this population. Data was collected on 12 patients who had multiple IV’s. It was found that 8/12 or 66% of the patients developed a phlebitis and 50% of the total number of peripheral IV’s developed phlebitis.
Outcome: Based on this data, multiple practice changes were initiated and in-services were conducted. The cardiac surgical patients have their central lines kept in longer in case amiodarone therapy is needed. Nursing and pharmacy practice regarding amiodarone administration was revised. A manuscript was developed and accepted for publication in the journal, Critical Care Nurse.
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Safe Lifting Project
Research Question: Do we have appropriate resources available to decrease work place injuries to staff? Requested by Colette Taylor, RN, Assistant Manager, Needham 8
Findings: Research included a review of the literature, inventory of available equipment at MAH, consultation with employee health, PT, administration and a review of MAH employee injuries. The committee concluded that a safe lifting program at MAH would reduce employee injuries, reduce costs,
enhance retention and recruitment, and maintain a safer environment for patient care.
Outcome: The NRC recommended that a hospital wide multidisciplinary committee be established and identified 7 initiatives for their consideration.
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NG Tube Placement
Research Question: What is the evidence based method of confirming correct placement of NG tubes and checking residuals? Requested by: Becky Logiudice, RN, and Nancy Butters, RN,
Findings: MAH does not have a policy on NG tubes placement and checking residuals. The best evidence of tube placement is by radiographic confirmation, which visualizes the entire course of the tube. DO NOT rely on the ausculatory method for assessing tube location. There is no evidence to support this method. Aspirate gastric contents and determine the pH: - If pH <5 begin feedings or instill medications. - If pH >6 DO NOT FEED or instill medications. Recheck gastric aspirate in 1 hour and if >6 consider radiographic confirmation of placement.
Outcome: Develop a policy/procedure based on evidence. Our findings and recommendations were forwarded to the Practice Council for implementation.
Pain Evaluation for Non-verbal Patients
Research Question: Is there an effective pain evaluation tool for non-verbal patients?
Requested by Dottie Devanna, Clinical Educator
Discussion: There is no pain evaluation tool for non-verbal patients at MAH. NRC conducted a comparative study of four pain scales. Two were selected for additional trials. Evidence was collected by consulting with a Pain expert, JCAHO and University of Virginia expert.
Findings: From a literature review, four pain scales were identified and trialed on the nursing units. The FRACC scale was selected since it was the most inclusive for evaluation for non-verbal pain.
Outcome: A modified FRACC scale was recommended to the Nursing Practice Council (NPC) for implementation.
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Project Summaries 5/5/2011