Purpose: The purpose of this EBP project is to explore the literature for evidence on the administration of Inotropic and Vasopressor agents as treatment for cardiovascular syndromes on the telemetry med-surg unit, (1) what is the nurse to patient ratio, (2) what assessment is warranted, and (3) how frequently.
Setting: A 30-bed telemetry medical-surgical unit within an acute care urban teaching hospital. There are 400 plus beds with multiple care settings. The population is diverse in terms or ethnicity, age, gender and geographic location. Care team include, physicians, residents/fellows, nurses and ancillary staff.
Design/Methodology: Clinical Question is: “For adult patients admitted to telemetry medical-surgical units with terminal illness requiring vasopressors/inotropes, what is the nurse to patient ratio, assessment and frequency?” IOWA model will be used.
Problem: Problem focused trigger (An adult patient with hypotension, DNR/DNI, spouse wanted everything to be done; patient had EKG changes on Norepinephrine (Levophed); ordered for Neosynephrine; no education/competency; no change in staffing ratio; no guidelines from administration on assessment and frequency).
The literature review was conducted according to the PICO question.
P = adults, 18 years and older, who are DNR/DNI and needed vasopressor/s
I = titration versus no titration (capped); frequency of assessment
C = no titration on med-surg & every 4 hours assessment (med-surg)
O = Expected outcome: which vasopressors can be administered safely on telemetry units? What is the nurse to patient ratio? What assessment is needed and how frequently?
T = n/a
- Search strategy: Searched electronic databases: PubMed, Cochrane, CINHALL,
- Inclusion Criteria: human, English, randomized controlled trial, meta-analysis, case reports, popular literature, literature reviews, adults, DNR/DNI, medical-surgical, Intensive Care Unit, Vasopressors
- Exclusion Criteria: no abstract present, abstract without manuscript, animal studies
- Evidence appraisal: articles were reviewed, levels classified according to the John Hopkins Nursing Evidence-Based Practice (EBP) and summary tool.
Results: retrieved 287 articles for review, with 8 selected to fit the inclusion criteria. Seven were Systematic Reviews/RCT/meta-analysis; 1- opinion of respected authority.
After review categorization:
- Outcomes comparing Vasopressor to placebo
- Outcomes comparing vasopressin to other vasoactive drugs, alone or combination with epinephrine or Neosynephrine, or oral Midodrine
- Outcomes comparing high doses of drug therapy to standard dosing
Summary of findings:
- Setting for vasoactive drugs – ICU/Stepdown
- Wide variability on outcomes, survival and mortality
- Monitoring – ICU, arterial pressure, frequent monitoring of blood pressure
- Limited data: on assessment frequency in medical-surgical units, DNR/DNI requiring Vasopressors, patient to nurse ratio
Recommendation: Current practice – expert opinion; need for research in this area.
Conclusion: Current practice in this acute care urban academic medical center is based on expert opinion, thus, front line nurses must advocate for themselves and their patients when patient situation cross the safety and quality boundaries of care delivery. There is a gap in the research on the use of vasopressors in the medical-surgical settings for patients who signed DNR/DNI, the frequency of assessment and the patient to nurse ratio.