| Learning Objective #1: Identify some of the factors used in introducing a successful evidence-based change in clinical practice | |||
| Learning Objective #2: Describe optimal evidence-based intervention for reducing and/or preventing back pain in patients undergoing invasive cardiac procedures |
Practice Problem
The most uncomfortable part of hospital admission for patients requiring coronary interventional and/or diagnostic procedures is the time required to lie flat after removal of the indwelling femoral arterial introducer sheath. Conventional practice required a minimum of 6 hours of supine bedrest following sheath removal, often resulting in the problem of back pain.
The Nurse Practitioner/Clinical Nurse Specialist (NP/CNS) for Interventional Cardiology targeted this problem for further investigation in 1994 and took the lead in determining the process and strategies to be used. A group of interested physicians and nurses was convened, reflecting the multi-disciplinary interest in addressing this clinical problem.
Type of Evidence Used
The basis for the practice of prolonged bedrest was a mix of ritual, research and expert opinion. The expert consensus was that prolonged bedrest was required to ensure adequate hemostasis at the femoral arterial puncture site. Research, much of it conducted by nurse researchers, had been gradually demonstrating the safety of reducing bedrest times from a high of 24 hours to a low of 6 hours following sheath removal.
Method used to obtain and Review Evidence
Electronic databases including Medline and CINAHL were reviewed for all entries matching target search terms. Relevant articles were identified, copies obtained and the findings were reviewed by the NP/CNS and the medical director of interventional cardiology.
The findings of the literature review revealed a split between patients undergoing diagnostic cardiac catheterization and percutaneous coronary intervention (PCI) procedures. It was agreed that, initially, the diagnostic and the PCI patients would be treated as two distinct groups of patients. Several research studies examined bedrest times less than 6 hours following diagnostic catheterization, while there were no studies published examining bedrest of less than 6 hrs following PCI at the time of the review.
Planned Strategy for Improvement
Diagnostic Catheterization Group At a meeting of the interest group in 1996, the results of the literature review were presented. It was decided that the published research supported making a change in practice from 6 hours to 2 hours of bedrest. A plan was developed for introducing the change using close monitoring and follow up for the first 50 inpatients. This would allow for the gradual introduction of the practice change in a controlled fashion.
PCI Group At this same meeting in 1996 it was decided to explore the possibility of conducting a research study to examine reducing bedrest to less than 6 hours following PCI.
How the Strategy was Implemented
Diagnostic Catheterization Group The first 50 inpatients were followed between March and May 1997.
PCI Group A research study proposal was developed and funding successfully applied for and obtained. Nursing staff from a variety of clinical areas were involved in the process of recruitment, data collection and patient care during the research process. Educational sessions were held to prepare them for their role and to introduce the concept of evidence based nursing practice.
A total of 354 patients were recruited into the BAC Trial between March 1997 and October of 1998. The start of data collection was timed to coincide with the implementation of the practice change for inpatients undergoing diagnostic cardiac catheterization. This streamlined the launch and recruitment efforts.
Method of Evaluation
Diagnostic Catheterization Group Follow up evaluation of the data from the first 50 patients demonstrated the safety of the practice change and the efficacy in reducing patient discomfort. A decision was made to continue with 2 hours of bedrest for this group.
PCI Group Data analysis verified that 2 hours of bedrest was safe and significantly effective in reducing back pain in patients undergoing PCI. The investigators reviewed the data and in March 1999, 2 years after data collection began, the findings were presented to the nursing and medical staff. The change in practice was implemented the next day. A process for ongoing evaluation of outcomes was initiated to ensure continued patient safety.
Outcomes/Results
(1) Clinical Practice Changes: In the end, the diagnostic cardiac catheterization group and the PCI group, initially divided by the research literature, had the same outcome. Reducing bedrest time from 6 hours to 2 hours following arterial sheath removal and promoting early mobilization is a safe and effective nursing intervention that prevents and/or reduces back pain, while potentially decreasing costs. Follow up has confirmed the safety and efficacy of this evidence based change in practice.
(2) Peer Communication: The process and findings of our experience were presented by means of 6 oral papers at local, national, international conferences between 1998 and 2000. A total of 3 poster presentations were made between 1997 and 1998. Audience members included both nursing and medical professionals.
A summary of the BAC trial results is available on-line in The Registry of Nursing Research, Sigma Theta Tau Website (www.nursingsociety.org). Two publications in peer reviewed journals, including one which is available on-line via Medscape, round out the communication strategy.
(3) Further study A meta-analysis of the existing research data on bedrest following cardiac diagnostic and interventional procedures is currently underway. Plans following completion of the analysis include conference presentation and submission to the Cochrane Collaboration for possible inclusion in the evidenced based practice database.
Lessons Learned
(1) Identify at least one person to champion the project from the beginning. This person must be intimately involved in the process and sustain momentum over time.
(2) Use all relevant members of the multi-disciplinary team. Clinical problems are patient focused, not discipline focused, and therefore usually require the efforts and expertise of different professionals to find appropriate solutions. Excluding other professionals from the process may result in opposition and blocking behaviors when it comes time to implement change.
(3) Have patience. The process of change takes a long time. It is now 9 years since the bedrest project was initiated and, while change in clinical practice has occurred in our institution, many other centres are still imposing prolonged bedrest on their patients. The meta-analysis currently underway will hopefully continue to add to the body of evidence that other institutions can utilize.
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