Presentation on theme: "Hollie Shaner-McRae DNP RN FAAN"— Presentation transcript:
1 Hollie Shaner-McRae DNP RN FAAN EVIDENCE BASED PRACTICE COMMITTEE MODELING EVIDENCE BASED PRACTICE: SEQUENTIAL COMPRESSION DEVICESAnn Laramee APRN MSMartha Jo Hebert RNHollie Shaner-McRae DNP RN FAANLinda Gruppi RN MSN
2 Venous Thromboembolism Deep Vein Thrombosis – blood clot in the deep veins of legs that can travel to heart and lungs causing a Pulmonary EmbolismCan be fatal, cause disabilityAccounts for 10% of hospital deathsIncidence of hospital acquired is 10-40% for med and gen surg, 40-60% for major orthopedicPost operative VTE 9.3/1000 dischargesTo set the stage….The literature states…..
4 VTE The Most Common Preventable In-Hospital Death
5 Risk Factors for VTE Advancing age Family history Immobility Trauma ObesityPregnancy or post partumCentral Venous catheterEstrogen based therapySmokingFamily historyTraumaRecent surgeryMedical conditionsMI, CHF, strokeLung diseaseCancerSepsisHospitalizationIdentification and documentation of a pt’s risk for VTE is the initial step that a health care practitioner uses in minimizing and or preventing this disease.Surgery related risk factors include immobilization, infection, dehydration, vessel injury and duration and type of surgery.Minor surgeries have lower incidence but major surgeries such as GI, bariatric, orthopedic have greater risk.
6 Prevention of VTE Non-Pharmacological Pharmacological Graduated Compression StockingsIntermittent Pneumatic compression devices(SCDs)Foot pumpsIVC filtersPharmacologicalUnfractionated HeparinLow Molecular Weight HeparinFondaparinuxThere are 5 different IPC devices available and vary based on the patterns of compression, length of sleeve and cycle length.Despite the existence of VTE prevention guidelines and vast amount of evidence that prophylaxis prevents VTE, prevention strategies continue to be underused.
7 Fletcher Allen Health Care Observation audit October 2007: 38% use of SCD (n=20/53)SCD compression sleeves: averaged 1100 pairs/monthVTE diagnosis: July 2008 – June 2009- 195 cases- Incidence 8.9/1000 dischargesSCIP: VTE prophylaxis overall compliance July 2008 – July 2009- Ordered 95% (n=201/211)- Received 96% (n=200/209)IssuesVariation in practice with orderingFailure to follow policyKnowledge deficit of appropriate useLack of patient educationOther institutions in the same region and similar size have between cases of VTE/year.Fletcher Allen Health Care (FAHC) providers regularly order Sequential Compression Devices (SCD) to prevent Venous Thromboembolism (VTE). Random audits found wide variation in prescription, multiple order sets and poor compliance with SCDs use and adherence to the policy.Consequently the policy was inactivated.
8 FAHC Nursing Evidence-Based Practice Model State the problemForm a teamEvaluateoutcomesCheck researchAdopt practicechangeSynthesize EvidenceAs you know we have an EBP committee and this issue was brought to the committee’s attention.We have adopted the Iowa EBP model and made our own simplified version as well.ColleaguesHelpingAchieveModelPractice.Pilot the changeAdopted from:2001 Iowa Model
9 The Evidence Based Practice (EBP) Committee will use a structured approach and the Iowa Model of EBP to address this practice issueTrigger was audits and compliance with use and order appropriateness. In addition, Best practice as seen in practice guidelines was in the literature and multiple articles found on DVT screening tools and nurses role as part of health care team in identifying pts at riskInterestingly, there is a discussion on the NNE listserve regarding SCD use in CT pts and there is wide variation in this population in one region!!Review of literature
10 Stetler’s Levels of Evidence Level and Qualityof EvidenceType of EvidenceLevel I (strongest evidence)Meta-analysis or systematic review of multiple controlled studies or clinical trialsLevel IIIndividual experimental studies with randomizationLevel IIIQuasi-experimental studies such as nonrandomized controlled single-group pre-post, cohort, time series, or matched case-controlled studiesLevel IVNonexperimental studies, such as comparative and correlational descriptive research as well as qualitative studiesLevel VProgram evaluation, research utilization, quality improvement projects, case reportsLevel VI (weakest evidence)Opinions of respected authorities; or the opinions of expert committees, including their interpretation of non-research based informationAn additional aspect of learning and practicing nursing based on evidence is to understand the quality, validity, and applicability of evidence in research articles. The FAHC Evidence Based Practice Committee recommends the adoption of the Stetler model for a Level of Evidence hierarchy.The Stetler hierarchy model, adapted from the 1994 Agency For Health Care Policy And Research (AHCPR), hierarchy incorporates research types important to nurses and acknowledges the value of the nursing experience by placing qualitative studies in the middle of the hierarchy, and includes quality improvement and program evaluation data as well.
11 Summary of Literature Systematic Review General recommendations: Patients at high risk of bleedingPatients with multiple risk factors as adjunct therapyUsed properly!! Compliance!!Lack of evidence for specificsInitiation – when to start?DurationTypeThe systematic review includes studies found in major electronic sources that evaluated SCDs over the last 20 years. Each research article was critically appraised and summarized by a member of the EBP committee or local expert. All studies were categorized according to the Stetler levels of evidence. 28 research studies and guidelines were reviewed and summarized. There are numerous published research articles regarding use of anticoagulation for thromboprophylaxis but there is little research on mechanical devices.At the time of this writing, the review is in final draft form.Despite the existence of guidelines, prevention strategies continue to be underused.A number of studies addressing compliance which is a huge issue.Lack of evidence about specific use of SCDs, initiation, duration, type.
12 2nd half of the Iowa Model 2nd half of the Iowa Model. There is sufficient research so follow next steps of piloting the change in practice
13 Next Steps Multidisciplinary Team Agree on the Systematic Review Revise and Reinstall SCD PolicySelect Outcomes to be AchievedPilot the change on a Surgical and Medical UnitThe EBP Committee appraised the literature and systematically reviewed the best available evidence on the effectiveness of SCDs in preventing VTE in the adult medical and surgical hospital populations.Using this review the EBP committee will update the policy and procedures for SCD use.Over the next year, a selected group of multidisciplinary experts (nurses, physicians, and quality consultant) will champion this change in practice. The systematic review, updated policy and recommendations from the team of experts will be used to update processes, educate caregivers and improve the quality of care we provide.2 units have already volunteered to pilot this work.
14 Next StepsCollect Unit Baseline Data, Evaluate Process & Outcomes, Modify the PracticeInstitute the Change in Practice Hospital wide?Monitor and Analyze: Structure, Process, and Outcome DataDisseminate ResultsOn the pilot units, collect baseline data, evaluate the change process and modify practice as necessary.Determine if new policy and process be adopted permanently and widely throughout hospital.Ongoing Structure, process and outcome data will be monitored and analyzed to evaluate the change.This data will determine if the change in practice will be adopted permanently or require modifications.
15 Summary The Iowa EBP Model can be effective The EBP Committee is a resource and champion for quality changes in nursingSCDs are an effective prophylaxis for the appropriate patientsCompliance is essentialVariation in the prescription and poor compliance in practice with SCDs triggered the need for this EBP project. The EBP committee is leading this change in practice by using a structured process and an established EBP model. Implementing best practice and assuring compliance.This project can be a model for others who are about to incorporate a change in practice.