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									    College of Nursing

6th Annual Evidence Based
    Practice Symposium
       Proceedings Booklet




       Friday, May 1, 2009
         9:00 – 3:00 PM
  University of Oklahoma - Tulsa
  Schusterman Learning Center
        2009 EVIDENCE-BASED PRACTICE SYMPOSIUM
                        AGENDA

                 University of Oklahoma College of Nursing – Tulsa
                           Schusterman Learning Center
                                    May 1, 2009
9:00          Welcome and Overview (Auditorium)

               Shelly Wells, PhD(c), MBA, CNS, BC, Assistant Dean, OUCN-Tulsa
               Cindy M. Lyons, MS, RN, CNE, Faculty, OUCN-Tulsa

9:30           Keynote Address: ―A Case for Utilizing Evidence-Based Practice
                     in Nursing Leadership and Community Practice”

                Shelly Wells, PhD(c), MBA, A-CNS, BC & Su An Arnn, Phipps, PhD, RN, CNE

10:30         Break

10:45         AM Concurrent Sessions: Tracks 1-4
Track 1 | Critical care issues - Auditorium

 In neurotrauma patients, do early tracheotomies performed within seven days, versus, 28 days, result in earlier
  weaning from the ventilator, decreased rates of pneumonia and shorter length of stay in the intensive care unit?
 What is the most effective intervention to decrease VAP in adult ICU patients; performing oral care through the use
  of toothbrushes or Toothettes vs. the use of an antiseptic agent chlorhexidine gluconate?
 In critically ill patients does the instillation of normal saline in comparison to not instilling normal saline prior to
  endotracheal suctioning increase negative outcomes?

Track 2 | Skin and infection issues – Room 222

 For patients at risk for developing pressure ulcers, does a static pressure-relieving device compared to dynamic
  pressure-relieving surfaces provide improved protection against pressure ulcer development?
 For adult surgical patients who have a non-draining surgical incision, what is the best practice for incision dressing
  removal to prevent surgical site infection?
 In the clinical practice setting, is there a relationship in the prevention of peripheral intravenous catheter related
  infection when preparing the insertion site using friction versus a circular motion?

Track 3 | Clotting issues – Room 137
 Which arterial closure method is safer, more effective, and causes less vascular complications following cardiac
  catheterization in adults—the use of manual compression or the use of arterial puncture closing devices (APCDs)?
 For adults 18 and older receiving subcutaneous heparin therapy, does rotating sites, duration of injection, pre and
  post application of ice reduce the side effects of bruising, pain, and hematomas at the injection site compared with
  the standard technique?
 In bedridden patients in hospital settings, is subcutaneous Lovenox/Heparin or pneumatic compression stockings
  most effective in preventing venous thromboembolism?




                                                                                                                             2
Track 4 | Family centered care – Room 138

    What is the efficacy of a computer-assisted emergency department triage system compared to traditional memory-
     led triage systems?
    In hospital patients aged one day to eighteen years, does family-centered care, when compared to conventional
     patient centered care, improve hospital satisfaction scores and decrease length of hospital stay?
    Can having family present during cardiopulmonary resuscitation have positive benefits to both family members and
     nurses?

12:15          Lunch and Poster Presentations (Founders Hall)

1:30           PM Concurrent Sessions: Tracks 5-8
    Track 5 | Public health issues - Auditorium

     Would early education, by nurses, on MRSA prevention and transmission reduce the number of patients under 18
      years of age from contracting Community Acquired MRSA?
     In adults age 18 years and older is the use of non-pharmacological agents (such as guided imagery, quitlines, and
      exercise) as compared to pharmacological agents more effective in smoking cessation?
     For children with obesity, are diet and exercise alone as effective for weight loss as diet and exercise with
      medication as an adjunct treatment?


    Track 6 | Pain and nutrition issues – Room 138

     Is Demerol or Fentanyl the safest medication for adequate pain control for postoperative clients older than 65?
     In adult patients with acute pancreatitis, which nutritional intervention, enteral or parenteral feeding, improves
      dietary intake, results in fewer treatment complications, and decreases length of hospitalization?
     What is the best pain management practice for post op patients: patient controlled analgesia (PCA) or
      conventional opioid analgesia?


    Track 7 | Older adult patient issues – Room 137

     In the hospitalized patient age 65 years or older, what is the effect of the NICHE model of care on patient
      outcomes compared with a non-NICHE model of care?
     In the community dwelling elderly population, ages 60 years and older, does purposeful cardiovascular exercise
      at least two times a week, compared to no exercise at all, result in a constant or increase of mental and physical
      health?

    Track 8 | Newborn and infant issues – Room 222

     What are the negative health effects of infants when exposed to bottles that contain varying concentrations of
      Bisphenol-A?
     Is a urine specimen from a urethral catheter compared to a sterile bag equally effective for accurate diagnosis of a
      UTI in a symptomatic child under 5 years?


    3:00          Evaluation and Adjournment




                                                                                                                           3
        “Special Thanks”



We wish to thank our event sponsors:




  St. John Health System

Saint Francis Health System

  Hillcrest Medical Center




                                       4
                 THE UNIVERSITY OF OKLAHOMA – TULSA


                                    COLLEGE OF NURSING
                      Sixth Annual Evidence Based Practice Symposium
                                        May 1, 2009

                                                ABSTRACTS


TRACK 1

In neurotrauma patients, do early tracheotomies performed within seven days, versus, 28 days,
result in earlier weaning from the ventilator, decreased rates of pneumonia and shorter length of
stay in the intensive care unit? (Matrix, p. 15-17)

Student Presenters: Meghan Blair, Lacey Penrod, Victoria Pierce, Gabriel Speth
Faculty Consultant: Lisa Lee, MS, RN

For decades, tracheostomy placement has been commonly performed on neurological patients in the intensive care
unit. Healthcare providers have been discussing how timing of this procedure affects patient outcomes. This
includes ventilator weaning times, rates of pneumonia and length of stay in intensive care. The question then arises;
do patients benefit more from early or late tracheostomy? In 1989, a consensus conference recognized that too little
research existed to establish when tracheostomies should be performed. The group recommended that a
tracheostomy be performed if the patient is expected to require mechanical ventilation for over three weeks or if an
endotracheal tube has been in place for over ten days. Since this is merely a recommendation, the decision of, if and
when a tracheostomy is performed are often at the discretion of the physician. The primary objective of this
literature review is to determine the best evidence-based practice regarding tracheostomy timing. Through an
extensive literature review it was concluded that early tracheostomies have no significant effect on rates of
pneumonia although may reduce the length of stay in the intensive care unit and duration of mechanical ventilation
in patients with severe head trauma. Nonetheless more reliable and consistent research is required in order to
recommend a change in practice.


What is the most effective intervention to decrease VAP in adult ICU patients; performing oral
care through the use of toothbrushes or Toothettes vs. the use of an antiseptic agent chlorhexidine
gluconate? (Matrix, p. 18-20)

Student Presenters: Jennifer Crawford, Ashley Grey, Krista Keuchel, Stephanie Yates
Faculty Consultant: Tonya Ballone-Walton, MS, RN, CNE

Oral care performed on mechanically ventilated patients in intensive care units greatly influences patient‘s survival
and quality of life. Ventilator-associated pneumonia (VAP) occurs in 20% to 25% of mechanically-ventilated
patients and is associated with a mortality rate of 50% to 80%. Past research has shown a correlation in initiating
interventions of oral care and a decrease in the occurrences of VAP. Without the crucial steps of proper oral care,
dental plaque builds up on teeth within 72 hours of intubating a patient. This plaque leads to colonization in the
oropharynx and if left untreated, leads to VAP. Adequate oral decontamination plays a pivotal role in preventing the
spread of this dental plaque from the oral cavity to the respiratory tract. A standardized evidence based oral care
routine has yet to be implemented into practice. However, the results of our studies support and suggest that an oral
care protocol including mechanical cleaning with a tooth brush and use of the antiseptic agent, chlorhexidine,
reduced the number of cases of VAP and should be implemented.




                                                                                                                    5
In critically ill patients does the instillation of normal saline in comparison to not instilling normal
saline prior to endotracheal suctioning increase negative outcomes? (Matrix, p. 20-22)

Student Presenters: Christina Campbell, Yuri Casasola, Leslie Ireland, Amanda Kramer
Faculty Consultant: Jenny Barnhouse, MS, RN, CNE

The instillation of normal saline prior to endotracheal suctioning of critically ill patients has been a widespread
practice in hospitals for many years. Passed on by tradition this procedure is generally believed to help break up
tenacious respiratory secretions and aid in their removal during suctioning. However research has shown that not
only is this procedure practiced inconsistently, there is currently no solid evidence supporting its usefulness in the
removal of secretions. Furthermore the evidence suggests that its use may be detrimental to the patient as measured
by decreases in oxygen saturation and increases in heart rates, pH, anxiety and potential for infection. While more
research on this subject is necessary the current body of evidence suggests that the current practice of routinely
instilling normal saline during endotracheal suctioning should be discontinued.


TRACK 2

For patients at risk for developing pressure ulcers, does a static pressure-relieving device
compared to dynamic pressure-relieving surfaces provide improved protection against pressure
ulcer development? (Matrix, p. 23-27)

Student Presenters: John Bloomer, Livia Phillips, Justin Sword, Lance Wheeler
Faculty Consultant: Carol Stewart, MS, RN, GCNS

The issue of pressure ulcers will continue to be an ongoing concern within the health care industry. Treatment for
pressure ulcers represent $11 Billion in annual expenses, and are responsible for approximately 60,000 deaths each
year (Duncan, 2007). Advancements within the development and improvement of various support surfaces have left
a void in determining a consensus for effective prevention. Clients at risk for the development of pressure ulcers
include individuals who are stationary, or have limited mobility for extended periods of time. The researchable data
provided in comparing the various static and dynamic surfaces provides questionable results and indicates the need
for additional information.


For adult surgical patients who have a non-draining surgical incision, what is the best practice for
incision dressing removal to prevent surgical site infection? (Matrix, p. 27-29)

Student Presenters: Meagan Ward, Katie Huff, Jessica Honeycutt, Arlene Williams
Faculty Consultant: Gerri Ellison, PhD, RN

The Centers for Medicare & Medicaid Services (CMS) announced new Medicare and Medicaid payment and
coverage policies to improve safety for hospitalized patients. These guidelines included certain surgical site
infections as a ―never event‖ and will not reimburse for the care involved. Surgical sites account for approximately
40% of hospital acquired infections. Cost containment issues are very high with the current state of the US
economy. The resources needed to support frequent dressing changes impact hospital budgets. Therefore, the length
of time a non-draining surgical incisions should be dressed to prevent infection in adult patients is both a quality of
life issue for patients and families as well as a significant cost of care consideration for the health care system. A
review of relevant literature yielded scant research and little current research (one within the last 10 years) on this
question. National Clearinghouse guidelines recommend that patients who have had repair of surgical wounds
should keep the incision site covered and dry for 24-48 hours. There is no research-based recommendation regarding
the use of dressings to cover a closed incision beyond 48 hours. Current practice for incision coverage beyond 48
hours is determined by physician preference and varies greatly between individual physicians, hospitals and states.
Clearly, there is a need for additional research to determine practice on this timely and costly issue.




                                                                                                                     6
In the clinical practice setting, is there a relationship in the prevention of peripheral intravenous
catheter related infection when preparing the insertion site using friction versus a circular
motion? (Matrix, p. 30-35)

Student Presenters: Marsha Cleaver, Carolyn Loper, Sandra Thomas
Faculty Consultant: Allen Nottingham, MS, RN

Nurses have been taught for years to use a circular motion when preparing the skin for intravenous catheter
insertion. In this technique, circular motion is used working from the inside to the outside using an antiseptic agent.
The belief is that this will produce antisepsis and reduce the risk of catheter-related infection. But is there scientific
research to support this technique? With the emphasis on shorter hospital stays and reduction of hospital related
complications, evidence is needed to support the best method for skin antisepsis in the hospital setting. Studies
found that chlorhexidine gluconate reduces the risk of catheter-related infections, but the technique for application
was non-specific. After an extensive review of the literature, it was the conclusion of this group that the application
of an antiseptic product with friction in a back-and-forth motion for approximately 20 seconds may provide adequate
skin antisepsis prior to intravenous catheter insertion. Due to the lack of scientific evidence related to the method of
application of antiseptic products to support this hypothesis, further study is critically needed.


TRACK 3

Which arterial closure method is safer, more effective, and causes less vascular complications
following cardiac catheterization in adults—the use of manual compression or the use of arterial
puncture closing devices (APCDs)? (Matrix, p. 36-40)

Student Presenters: Stephanie Ford, Michelle Giddens, Brenna Johnson, Rachel Wilkinson
Faculty Consultant: Bobbie Carpenter, MS, RN, CNE

Following cardiac catheterization, the method chosen to close the femoral artery comes with risks of vascular
complications such as hematomas, pseudoaneurysms, blood clots, loss of pulse, hemorrhaging, and much more.
Two main methods are used by doctors to stem the flow of blood from the femoral artery after being accessed for
cardiac catheterization: arterial puncture closing devices (APCDs) or manual compression. This work investigates
whether arterial puncture closing devices or manual compression is safer, more effective, and causes fewer vascular
complications. Some literature found that using APCDs resulted in slightly less risk of vascular complications than
using manual compression. But, most literature stated that both manual compression and APCDs are similar in their
safety and effectiveness. Despite the similarity in their safety and effectiveness, the practice recommendation
appears to support the use of APCDs because they lead to a decrease in time to hemostasis, ambulation, and a
reduced length of stay in the hospital. Therefore, nurses working in the cardiac catheter labs should become
advocates for the use of compression devices on their patients.


For adults 18 and older receiving subcutaneous heparin therapy, does rotating sites, duration of
injection, pre and post application of ice reduce the side effects of bruising, pain, and hematomas
at the injection site compared with the standard technique? (Matrix, p. 41-44)

Student Presenters: Amalia Floyd, Ashley Hill, Meagan Inouye, Kristen Monroe
Faculty Consultant: Brenda Nance, MS, RN

Heparin, an anticoagulant, is being used on a daily basis by thousands of patients for a variety of medical conditions
resulting in positive effects. However, there have been complications resulting from non-standardized
administration of subcutaneous heparin injections such as bruising, pain and hematomas at the injection site.
Question: For adults 18 and older receiving subcutaneous heparin therapy, does rotating sites, duration of injection,
pre and post application of ice reduce the side effects of bruising, pain, and hematomas at the injection site
compared with the standard technique? Method: A review of literature to determine best practice of administration
of subcutaneous heparin to reduce side effects of bruising, pain and hematomas at the injection site. Results: The
literature reviewed indicated by rotating sites within the abdomen and applying ice for two minutes pre and post
injection reduced duration and perception of pain. By increasing injection duration to thirty seconds pain and
bruising associated with the injection were significantly reduced. Conclusion: From the evidenced obtained, we
feel a change in the standard technique is warranted. Best practice for subcutaneous injections for heparin should
include rotating sites within the abdomen, pre and post administration of ice at injection site, and increasing
injection duration up to thirty seconds. However, we do feel more research needs to be conducted including, needle
size and angle of insertion.
                                                                                                                      7
In bedridden patients in hospital settings, is subcutaneous Lovenox/Heparin or pneumatic
compression stockings most effective in preventing venous thromboembolism? (Matrix, p. 45-46)

Student Presenters: Temequah Breckenridge, Nancy Hancin, Shannon Rials, Dana Stipes
Faculty Consultant: Jamie Morris, MS, RN

Venous thromboembolism (VTE) is a serious risk and frequent complication for patients on bedrest. VTE is
composed of deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE has a hospitalization rate of
approximately 250,000 per year with a population affected rate of 2 million annually. Patients having a diagnosis of
DVT have an estimated 30% chance of developing a symptomatic PE, with a resulting mortality rate of 17%.
The purpose of studying this question is to evaluate whether subcutaneous Lovenox/Heparin is superior to
pneumatic compression stockings in prevention of VTE. The results reveal a conclusion that Lovenox is superior to
other forms of VTE prevention, however, it also reveals that a combination of Lovenox along with compression
stocking significantly reduces the incidence of VTE.


TRACK 4

What is the efficacy of a computer-assisted emergency department triage system compared to
traditional memory-led triage systems? (Matrix, p. 46-53)

Student Presenters: Erika Bartee, Julie Chenoweth, Deborah Graves, Hannelore Hager
Faculty Consultant: Vanessa Johnson, PhD, MS, RN, BC

BACKGROUND: Emergency department (ED) overcrowding is a growing problem worldwide. The number
of EDs decreased nine percent, putting an even heavier load on the remaining emergency service facilities, while
numbers of ED visits increased twenty percent from 1995 to 2005 in the United States. Consequently, a growing
number of hospitals are implementing computer-assisted triage systems in an effort to improve the ED triaging
process. PICO QUESTION: What is the effect of a computer-assisted emergency department triage system
compared to a traditional memory-led triage system on patient outcomes, staff satisfaction, and hospital cost among
adult patients? METHOD: A team of reviewers searched various electronic databases using the key terms,
―computer-assisted triage‖ and ―nurse led triage‖ for articles published within the past four years. RESULTS:
Studies have shown positive effects on patient outcomes, staff satisfaction, and cost with the use of computer-
assisted triaging. CONCLUSIONS: Computer-assisted triage systems are likely to significantly improve the
effectiveness of emergency departments and merit consideration for widespread implementation.


In hospital patients aged one day to eighteen years, does family-centered care, when compared to
conventional patient centered care, improve hospital satisfaction scores and decrease length of
hospital stay? (Matrix, p. 53-59)

Student Presenters: Meg Dick, Kala Gaydos, Hannah Hudgins, Melody Jacobson
Faculty Consultant: Evelyn Acheson, PhD, RN

Parents want to be involved in providing care, monitoring symptoms, and decision making with healthcare providers
caring for their child. Nursing staff are beginning to see the advantages to family involvement. Hospitals are
beginning to realize that family-centered care helps to improve family and staff satisfaction. This review defines
what would be included in the family-centered care guidelines. Guidelines would include the physical setup of a
unit, facilities for families, education for families, training for staff, and an evaluation of the implementation of
protocol is proposed. The literature reviewed supported that families and healthcare team satisfaction increased with
the implementation of these guidelines but there is little evidence supporting that the implementation of family-
centered care decreased length of hospital stay.




                                                                                                                    8
Can having family present during cardiopulmonary resuscitation have positive benefits to both
family members and nurses? (Matrix, p. 59-65)

Student Presenters: Roland Harrison, Brant Mahan, David McAllister, Jeff Struttmann
Faculty Consultant: Jackie Lamb, MS, RN

Family witnessed resuscitation (FWR) is the act of allowing family members to be present during cardiopulmonary
resuscitation of a loved one. FWR has become significantly more relevant due to the increase of family members
expressing a desire to be present during their loved ones last moments. Although our research indicates there are
benefits of FWR, only 5% of hospitals have implemented a written protocol/guideline. Our presentation utilizes a
systematic review of literature which includes research and personal testimonies to determine if having family
present during cardiopulmonary resuscitation can have positive benefits to both family members and nurses. It is
our recommendation that healthcare organizations adopt a FWR policy and a FWR education program to improve
outcomes for families and nurses during cardiopulmonary resuscitation.


TRACK 5

Would early education, by nurses on MRSA prevention and transmission reduce the number of
patients’ under18 years of age from contracting Community Acquired MRSA? (Matrix, p. 66-71)

Student Presenters: Stephanie Bilby, Briley Fogleman, Jennifer Geiger, Brook Oney
Faculty Consultant: Cathy Lovelace, MSN, RN

Community-acquired strains of methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as an
epidemic across the United States. While once thought as primarily a skin infection, CA-MRSA is now often seen in
serious infections such as necrotizing pneumonia, sepsis syndrome, osteomyelitis, and necrotizing fasciitis. The
incidence of CA-MRSA varies throughout the United States, affecting the young, old, rich and poor. In the last ten
years the United States has seen a drastic increase of new cases of CA-MRSA, especially in children. The increase
in incidence is attributed to the lack of education on transmission, poor hygiene practices, and the misuse of
antibiotics. The objective of our research was to find the best treatment and preventative strategies for the
transmission of CA-MRSA. Recommended interventions from the literature includes covering wounds, performing
hand hygiene, taking antibiotics as prescribed, and not sharing personal equipment. More research needs to be done
to determine the most common methods of transmission and the best prevention techniques.


In adults age 18 years and older is the use of non-pharmacological agents (such as guided imagery,
quitlines, and exercise) as compared to pharmacological agents more effective in smoking
cessation? (Matrix, p. 72-77)

Student Presenters: Brandi Fuselier, Courtney Garner, Rachael Robison, Katy Stewart
Faculty Consultant: Emma Kientz, MS, RN, CNE

Despite a steady decline in cigarette smoking in the United States, Oklahoma continues to rank 5 th in the nation for
cigarette use. Among national health promotion initiatives, the goal is to reduce tobacco consumption by 12% by the
year 2010. Smoking cessation prevents many health-related complications including heart and lung disease. Often
times, those seeking smoking cessation are not provided with adequate treatment options and physicians tend to only
consider pharmacological interventions. Healthcare providers need to be well-versed in the various treatment
options for smoking cessation and be able to present this information to their clients. The clinical question we
formulated in response to this problem is: In adults 18 years and over, is the use of pharmacological agents in
comparison to non-pharmacological agents (such as exercise, guided imagery, and quit-lines) more effective in
smoking cessation? After reviewing the current literature regarding this topic, results reveal neither pharmacological
nor non-pharmacological methods alone are best in sustaining abstinence rates. Instead, both interventional methods
should be combined and tailored to each individual client.




                                                                                                                    9
For children with obesity, are diet and exercise alone as effective for weight loss as diet and
exercise with medication as an adjunct treatment? (Matrix, p. 77-80)

Student Presenters: Teresa Wooten, Julie Hanselman, Melinda Rose, Brina Boyle, Julie Nevins
Faculty Consultant: Bev Ruskjer, MS, RN, CNE

According to the Centers for Disease Control and Prevention, over 9 million (16%) children ages 13-19 in the
United States are overweight or obese. This is a number that has tripled since 1980. In addition, another 15% of
children in this age group are at risk of becoming overweight or obese. If these statistics are ignored, these children
will quickly develop life-altering illnesses at an early age. This not only is a crisis for the health of the United States,
but also for the economy. Many clinicians are prescribing weight loss medications to initiate the weight loss in this
age group. Research has shown that using weight loss medications in conjunction with total lifestyle changes such
as diet and exercise, is a more effective way to increase the rate of weight loss. However, the side effects and lack
of research for long-term use may not be worth it.


TRACK 6

Is Demerol or Fentanyl the safest medication for adequate pain control for postoperative clients
older than 65? (Matrix, p. 80-86)

Student Presenters: Stacy Garrett, Cathi Hampton, Elizabeth Martin, Lily Pina, Tana Vogele
Faculty Consultant: Mary Ann Pascucci, PhD, GCNS, BC

Inadequate treatment of pain in the postoperative older patient continues to be a common problem. Many factors
contribute to this widespread issue. The majority of the aging population has at least one chronic condition, takes
multiple prescription medications, and has ongoing physiological changes. Therefore, their pain tends to be under
managed or treated with medications not safe for this population. Despite the numerous literature discouraging the
use of Demerol (meperidine) in the older adult, it continues to be used for these patients. Due to the physiological
changes in older adults, Demerol (meperidine) frequently leads to delirium, neurotoxicity, respiratory depression,
and even seizures. It is metabolized and excreted mainly by the liver and kidneys, which work at decreased
efficiency in the older adult. Other medications have been used for this population with proven efficacy and
decreased side effects. One such medication is Fentanyl. According to recent studies, when tailored according to
the patient‘s age, weight, clinical status and desired effect, Fentanyl can be used in the postoperative older clients
with minimal adverse reactions. It is less sedating and disorienting and can be used safely in the aging population.
After reviewing the EBP findings, the following recommendations will assist healthcare professionals administer
pain medications safely and effectively to the post operative older patient: increased awareness and education on the
adverse effects of Demerol (meperidine); interdisciplinary committees should be formed that monitor the use of
medications with severe adverse reactions; proper monitoring of patients taking these medications; and medication
doses need to be individualized and titrated as appropriate for each patient.


In adult patients with acute pancreatitis, which nutritional intervention, enteral or parenteral
feeding, improves dietary intake, results in fewer treatment complications, and decreases length of
hospitalization? (Matrix, p. 87-89)

Student Presenters: Michelle Mann, Erika Rumble, Mary Sawyer, Chanda Vlanich, Paul Vlanich
Faculty Consultant: Su An Phipps, PhD, RN, CNE

Background: The incidence of new acute severe pancreatitis cases is 17/100,000 persons in the United States.
Initial management of these patients requires intensive patient care and nutritional support. Early nutritional support
plays an important role in preventing serious complications and ensuring optimal recovery, while decreasing the
burden of the disease. The optimal route of nutritional therapy in patients with acute severe pancreatitis remains
controversial. Methods: Literature was reviewed by searching databases including Ovid MEDLINE, CINAHL,
and Cochrane Systematic Reviews. Randomized control trials and 3 meta-analysis were reviewed to compare
outcomes in patients with acute severe pancreatitis who received either parenteral or enteral nutrition therapy.
Results: In all the reviewed studies, the researchers found that the patients receiving enteral nutrition therapy had
fewer treatment complications, experienced dietary improvement, had a shorter length of hospitalization, and a
lower cost of care. Conclusion: The reviewed studies provided evidence that the use of enteral nutrition is the best
practice for nutritional therapy for patients with acute severe pancreatitis. Nurses can play an important role in the
healthcare team by influencing team members to use the appropriate nutritional intervention in patients with acute
severe pancreatitis.
                                                                                                                         10
What is the best pain management practice for post-operative patients; patient controlled
analgesia (P.C.A.) or conventional opioid analgesia? (Matrix, p. 89-91)

Student Presenters: Fran Trujillo, Mary Woods, Edgar Paul, Jeff Jeter
Faculty Consultant: Jamie Morris MS, RN

There are multiple variables to consider during the pain phenomena. Some variables are unpredictable and
individualized such as attitudes and beliefs. Some parameters to consider when determining individualized pain are
subjectivity and pain quality and frequency. Variables affecting clinical outcomes may include the following:
patient experiences and physician preferences for a particular pain control method, dose, and delivery route; type of
surgery and surgical outcomes; pre-operative teachings; pain scales; and patient issues such as disease processes.
Other patient issues may include history of substance use, side effects and/or allergies, degree of autonomy,
attitudes, motivation, and culture. Post-operative pain control depends on effective independent interventions given
such variables. Effective pain control methods are vital for post-operative physical comfort. Ineffective pain
management and results in physiological and mental instability. When there is effective pain control there is a
reduction of complications which promotes timely wound healing, and a faster recovery and discharge from the
hospital. The purpose of this review of literature is to research what the best pain control method is for post-
operative patients: P.C.A. or conventional pain control methods.


TRACK 7

In the hospitalized patient age 65 years or older, what is the effect of the NICHE model of care on
patient outcomes compared with a non-NICHE model of care? (Matrix, p. 91-95)

Student Presenters: Veronica Armas, Janet Knappier, Candace McNeese, Sara Ralph
Faculty Consultant: Stephanie R. Moore, MS, APRN-BC CNS

Over 50 percent of the care provided in the hospital/acute care setting is to patients that are ages 65 and older. In
order to address the needs of this growing population, units specific to geriatric care are necessary. In 1992, the
John A. Harford Foundation Institute for Geriatric Nursing, implemented nationwide, the Nurses Improving Care for
Health System Elders (NICHE) program. The NICHE program offers four practice models to increase the
knowledge of staff nurses. These include: the Geriatric Resource Nurse model (GRN); the Geriatric Syndrome
Management model (GSM); the Acute Care of the Elderly Nursing Unit model (ACE); and the Quality Cost Model
of Transitional Care. Adaptation of these programs to a particular hospital‘s needs can provide them with the
necessary tools to assess and improve patient outcomes for the geriatric population.


In the community dwelling elderly population, ages 60 years and older, does purposeful
cardiovascular exercise at least two times a week, compared to no exercise at all, result in a
constant or increase of mental and physical health? (Matrix, p. 95-100)

Student Presenters: Sarah Glenn, Laurel Hadsell, Candice Harper, Whitney Kindell
Faculty Consultant: Carol Stewart, MS, RN, GCNS

The aging adult population is the largest growing population in the world. Functional decline is associated with a
sedentary lifestyle, and the elderly population is a major group at risk for inactivity and displaying decreased motor
strength, flexibility, and cognitive impairment due to the aging process. Mobility, cognitive functioning, and
functioning daily activity are at a steady decline throughout the life span. Due to this, a desire for increased quality
of life in advanced years has prompted research into possible improvements in physical and mental functioning for
community based aging adults in relation to physical exercise. The purpose of the literature review was to determine
if purposeful cardiovascular exercise was mentally and physically beneficial to the community dwelling population,
aged 60 and over, when compared to no exercise at all. According to the current literature review and the growing
body of evidence, regular exercise at least twice a week can improve the functional and cognitive abilities of older
adults, thus contributing to a better quality of life. The literature provides evidence that providing exercise is crucial
to the future of functioning and independence of older adults. Some challenges to reducing sedentary lifestyles in
the elderly population include 1.) issues related to measuring free-living physical activity, 2.) determining the
amount of physical activity required to make a change in health, 3.) strategies for assessing and modifying the
physical activity level of the elderly population, and 4.) increasing awareness among health care providers as to the
importance of physical activity to the health of the elderly population.


                                                                                                                       11
TRACK 8

What are the negative health effects on infants when exposed to bottles that contain varying
concentrations of Bisphenol-A? (Matrix, p. 101-106)

Student Presenters: Kim Pritchard, Leslie Oakes, Rachel Schupp, Margaret Y. Smith, Tracie
Summers
Faculty Consultant: Juli Martini, MS, RN

Bisphenol A is a chemical that can be found in plastic materials commonly used to manufacture baby bottles. This
chemical is also present in a variety of consumer products used by individuals of all ages. Bisphenol A poses a risk
to multiple consumers, however infants are a vulnerable population because of the risk of Bisphenol A
exposure during critical stages of development. It is standard practice to warm infant bottles and this causes
Bisphenol A to leach into the contents of the bottle. Research findings indicate that there is a correlation between
Bisphenol A and diseases such as diabetes, heart disease, impaired immune function and neurodevelopmental
problems. Current research involves laboratory animals and their exposures and effects from Bisphenol A. Minimal
research has been conducted regarding exposure and effects to infants due to the obvious ethical dilemma. More
research is needed, however, there is enough evidence to support a change. The use of Bisphenol A products should
be discontinued, especially in relation to infants and children.


Is a urine specimen from a urethral catheter compared to a sterile bag equally effective for
accurate diagnosis of a UTI in a symptomatic child under 5 years? (Matrix, p. 106-110)

Student Presenters: Kristina Hammon, Jenna Noland, Amanda Wells, Jennifer York
Faculty Consultant: Evelyn Acheson, PhD, RN

Undiagnosed or misdiagnosed urinary tract infection in children less than five years of age can lead to complications
such as septicemia, renal scarring, and antibiotic resistance making the prompt and accurate diagnosis of UTI
essential to management and treatment. Contamination during urine collection further complicates accurate
diagnosis. The gold-standard for urine collection remains suprapubic needle aspiration; however this is traumatic,
not always successful, and not without potential complication leaving physicians and nurses to debate over the
contamination rates of clean-catch versus catheter obtained specimens as well as taking into consideration whether
the child is symptomatic versus asymptomatic for urinary tract infection.




                                                                                                                  12
TRACK 1             EBP Team 2: Megan Blair, Lacy Penrod, Victoria Pierce, Gabriel Speth

Clinical Question: In neurotrauma patients, do early tracheotomies performed within seven days, versus, 28 days, result in earlier weaning from the ventilator,
decreased rates of pneumonia and shorter length of stay in the intensive care unit?
              Citation                         Population Studied                        Results of Study                   Threats to Validity of Study                      Implications of Study
          (in APA format)                  (Who was studied? How many             (What were the variables? What          (Where there significant problems           (How can results help in caring for
                                               where in the study)                  did the researchers find?)              with the study? Where there                    patients? Is more research
                                                                                                                             reasons to doubt findings?)                  required before we can draw
                                                                                                                                                                                   conclusions?)
Barquist, E., Amortegui, J., & Hallal,   Patient older than 15 years. They       Variables:                               The testers know who is in what             Unless there are over-riding factors,
A., et al. (2006). Tracheostomy in       have either a Glasgow Coma Scale        Early tracheostomy and the effect on     group. The group of patients                there does not appear to be a clear
ventilator dependent trauma patients:    (GSC) >4 with a negative brain CT,      reduced number of days of                undergoing ―late‖ tracheostomy had          benefit in terms of ventilator use to
a prospective, randomized intention-     or a GSC>9 with a positive head CT.     mechanical ventilation, frequency of     longer periods of ventilation before        tracheostomy before day 10 in the
to-treat study. The Journal of           Ventilator dependence due to            pneumonia and ICU length of stay.        entry in the retrospectively analyzed       non head injured critically ill trauma
Trauma. Injury, Infection, and           traumatic injury was a requirement.                                              group.                                      patient. More research should be
Critical Care, 60(1), 91-97.             The subjects must be intubated at       Findings:                                                                            done, because other studies have
                                         least 3 days when they were 7 days      There was no significant difference                                                  conflicting results.
                                         after admission to Ryder Trauma         between groups (early and late
                                         Center. There were 60 enrolled          tracheotomies) in any outcome
                                         patients.                               variable including length of
                                                                                 ventilator support, pneumonia rate, or
                                                                                 death.
Griffiths, J., Barber, V.S., Morgan,     Five randomized and quasi-              The risk of pneumonia was unaltered      Excluded studies without either an          In critically ill adult patients who
L., & Young, D.J. (2005). Systematic     randomized controlled studies that      by the timing of tracheostomy. Early     English title or abstract. Limited          require prolonged mechanical
review and meta-analysis of studies      compared early tracheostomy with        tracheostomy significantly reduced       amount of studies (5). Each of the          ventilation, performing a
of the timing of tracheostomy in         either late tracheostomy or prolonged   duration of artificial ventilation and   studies examined different                  tracheostomy at an early stage may
adult patients undergoing artificial     endotracheal intubation. A total of     length of stay in intensive care.        populations of critically ill patients in   shorten the duration of artificial
ventilation. BMJ, 330. doi:              406 participants were in the five                                                critical care units for surgical,           ventilation and length of stay in
10.1136/bmj.38467.485671.E0.             studies.                                                                         trauma, burn patients, and one              intensive care.
                                                                                                                          multicentre study in 3 medical
                                                                                                                          critical care units. (patients available
                                                                                                                          for study)
Ahmed, N., & Kuo, Y. (2007). Early       Fifty-five patients admitted to the     Variables: This study investigated       The limited size of the sample and           Due to the inconclusiveness, the
versus Late Tracheostomy in Patients     surgical ICU with severe traumatic      effects the early tracheostomy versus    study is restricted to patients in one      results of this study would not affect
with Severe Traumatic Brain Injury.      brain injuries, requiring mechanical    late tracheostomy had on length of       hospital; therefore, it is not certain      current nursing practice.
Surgical Infections, 8(3), 343-347.      ventilation, with a GCS score < 8       stay in ICU, length of time on the       that outcomes were not due to
                                         who had an expected survival for        ventilator, overall mortality,           differences in quality of nursing care      Further studies should be conducted
                                         longer than 3 days upon admission.      incidence of pneumonia, median total     or variance in interventions i.e. oral      to help determine the conclusiveness
                                                                                 length of hospital stay, median total    care kits.                                  of the results, in order to direct
                                                                                 hospital cost, and length of time                                                    proper evidence based practice.
                                                                                 before being discharged to
                                                                                 rehabilitation.




                                                                                                                                                                                                               13
             Citation                        Population Studied                         Results of Study                  Threats to Validity of Study                   Implications of Study
         (in APA format)                 (Who was studied? How many              (What were the variables? What         (Where there significant problems          (How can results help in caring for
                                             where in the study)                   did the researchers find?)             with the study? Where there                 patients? Is more research
                                                                                                                           reasons to doubt findings?)               required before we can draw
                                                                                                                                                                             conclusions?)

                                                                                Findings: Early tracheostomy were
                                                                                beneficial in significantly reducing
                                                                                length of ICU stay; however, did not
                                                                                show significant effect on days of
                                                                                ventilation, overall mortality,
                                                                                incidence of pneumonia, median total
                                                                                length of hospital stay, discharge to
                                                                                rehabilitation, or median total
                                                                                hospital cost.

Bouderka, M., Fakhir, B., Bouaggad,    Patients were included in the study if   Independent variables:                  The sample size is small and the           Early tracheostomy decreases the
A., Hmamouchi, B., Hamoudi, D., &      they met the following criteria:         Tracheostomy on day 5 or 6 after        research occurred in only one              total days of the ventilator and
Harti, A. (2004, August). Early        Isolated severe head injury              admission versus prolonged              hospital. Nursing care is not              mechanical ventilator time after
tracheostomy versus prolonged          (admission GCS score ≤ 8); cerebral      endotracheal intubation                 described in detail. Nursing care may      pneumonia is isolated severe head
endotracheal intubation in severe      contusion on CT scan; GCS score <8       Dependent variables:                    have varied and affected outcomes.         injury. More research would be
head injury. Journal of Trauma         on the fifth day without any sedation.   Time of mechanical ventilator           The type of bacteria isolated during       required before a conclusion can be
Injury Infection and Critical Care,    On the fifth day of hospitalization if   support, rate of nosocomial             nosocomial pneumonia may have              drawn.
57(2), 251-254.                        these criteria were present, patients    pneumonia, day pneumonia was            affected the time of mechanical
                                       were randomized to: early                diagnosed, number of mechanically       ventilator support.
                                       tracheostomy (T, n=31) or prolonged      ventilated days after nosocomial
                                       endotracheal intubation (I, n=31).       pneumonia was diagnosed, and rate
                                                                                of mortality

                                                                                Results:
                                                                                The mean time of mechanical
                                                                                ventilator support was shorter in T
                                                                                group than in I group. Nosocomial
                                                                                pneumonia was not more frequent in
                                                                                T group than in I group; however, the
                                                                                day pneumonia was diagnosed was
                                                                                later for T group than for I group.
                                                                                After nosocomial pneumonia has
                                                                                been acquired, the number of
                                                                                mechanically ventilated days was
                                                                                greater in I group than in T group.

Dunham, C., Ransom, K. (2006).         Thirteen peer-reviewed studies that      The systematic analysis suggested        A threat to validity is the possibility   Early tracheotomies lower the
Assessment of early tracheostomy in    compared early tracheostomy (ET)         that ET is correlated with a decrease   of using articles in the search that are   number of ICU and ventilator days in
trauma patients: a systematic review   and no ET or ET and late                 in ventilator and ICU days for          not valid. Since the research was not      a head trauma patient, which would




                                                                                                                                                                                                          14
             Citation                        Population Studied                         Results of Study                    Threats to Validity of Study                     Implications of Study
         (in APA format)                 (Who was studied? How many              (What were the variables? What           (Where there significant problems          (How can results help in caring for
                                             where in the study)                   did the researchers find?)               with the study? Where there                   patients? Is more research
                                                                                                                             reasons to doubt findings?)                 required before we can draw
                                                                                                                                                                                 conclusions?)
and meta-analysis. The American        tracheostomy (LT) were reviewed.         patients with a severe brain injury.      performed themselves, that poses a         indicate a quicker recovery. More
Surgeon (57)3, pp.27-281.              Using Pub Med, the National Library      Also, they found no advantage or          risk to the validity of their search       research is needed to determine the
                                       of Medicine database was explored        detriment with ET in association with     results.                                   appropriate time to change from
                                       using the text words ―tracheostomy‖      pneumonia rates and laryngotracheal                                                  translaryngeal intubation to a
                                       and ―trauma.‖                            pathology in trauma patients.                                                        tracheostomy.


Lindgren, V., & Ames, N. (2005).       Patients requiring mechanical            Clinically suspected nosocomial           A threat to validity is the possibility    This article looks at the possible
Caring for patients on mechanical      ventilation in the ICU. This article     pneumonia (VAP) occurred less             of using articles in the search that are   variables that could create doubt
ventilation. American Journal of       sited 60 articles/ studies referencing   often in patients in a semi recumbent     not valid to begin with. Since the         about the validity of the studies done
Nursing , 105 (5), 50-60.              the care of patients on mechanical       position (45 degree angle), the risk of   research was not performed                 concerning tracheotomies. Nursing
                                       ventilation.                             VAP increased with long-duration          themselves that poses a risk to the        care is an important variable to
                                                                                mechanical ventilation and decreased      validity of their search results.          consider when researching the affects
                                                                                consciousness. Recent study found                                                    of early versus late tracheotomies. If
                                                                                that toot brushing, which is effective                                               nursing practices such as oral care
                                                                                in removing plaque, was not                                                          were not sufficient then the rates of
                                                                                performed routinely, and that sponge                                                 VAP could easily be skewed in all
                                                                                toothettes, which are ineffective for                                                research results.
                                                                                plaque removal, were used instead.
Augustyn, D. (2007). Ventilator-       This peer-reviewed article cited 42      Nursing activities such as proper oral    A threat to the validity is the            Regardless of the time at which
associated pneumonia: Risk factors     research studies concerning              care, hand washing, and suctioning        possibility of using articles in the       tracheostomies are placed, nursing
and prevention. Critical Care Nurse,   ventilator-associated pneumonia          techniques decrease the rate of VAP.      review that are not valid to begin         care must be correct and consistent if
27(4), 32-39.                          (VAP) risk factors and nursing care.     Nurse education on the prevention of      with. Since the research was not           VAP is to be prevented. Further
                                                                                VAP is essential.                         performed by the authors themselves        research on the timing of
                                                                                                                          a risk to the validity of their search     tracheostomy placement must
                                                                                                                          results is presented.                      include correct and consistent
                                                                                                                                                                     nursing care of the subjects in order
                                                                                                                                                                     to produce valid results that can be
                                                                                                                                                                     applied to practice.




                                                                                                                                                                                                              15
TRACK 1            EBP Team 5: Jennifer Crawford, Ashley Grey, Krista Keuchel, Stephanie Yates

Clinical Question: What is the most effective intervention to decrease VAP in adult ICU patients; performing oral care through the use of toothbrushes or Toothettes
vs. the use of an antiseptic agent chlorhexidine gluconate?
              Citation                      Population Studied                         Results of Study                   Threats to Validity of Study                   Implications of Study
          (in APA format)               (Who was studied? How many              (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                            where in the study)                   did the researchers find?)              with the study? Where there                 patients? Is more research
                                                                                                                           reasons to doubt findings?)               required before we can draw
                                                                                                                                                                              conclusions?)
Cutler, C., & Davis, N. (2005).       This was an observational study          The independent variable was the         The major limitation of this study       This study establishes the need for a
Improving oral care in patients       conducted at five Chicago are acute      oral cleansing protocol. The             was that observations where done in      more comprehensive protocol to
receiving mechanical ventilation.     care hospitals, which included two       researchers found that use of a          4 hour blocks. This may have biased      prevent VAP. More research is
American Journal of Critical Care,    community teaching hospitals and 3       standardized oral care protocol          the results because of each block did    needed to determine the ideal
14(5), 389-395.                       community hospitals. A total of 523      increases the frequency in               not encompass an entire day and          frequency of oral care administration
                                      patients were observed for a total of    comprehensiveness of oral care           therefore the true hourly frequency of   and the relationship of frequency of
                                      172 observation hours.                   provided to patients.                    oral could not be determined.            oral care in VAP prevention.
                                                                                                                        Another limitation was that no
                                                                                                                        observations were done from 11pm -
                                                                                                                        5am as to not disturb sleeping
                                                                                                                        patients.
                                                                                                                        The experience was not able to
                                                                                                                        establish inner reliability among the
                                                                                                                        observers. The observers were
                                                                                                                        trained to identify all types of oral
                                                                                                                        care provided.
Fields, L. B. (2008). Oral care       The population was a 24 bed ICU          The independent variable was the         Limitations included accuracy of         The results of the study showed the
intervention to reduce incidence of   with stroke patients. The study          following oral care protocol;            documentation on the worksheets,         need for more frequent and thorough
ventilator-associated pneumonia in    consisted of 345 patients with a total   Brushing of patient‘s teeth, tongue,     which showed different numbers of        oral care. With the emphasis on the
the neurologic intensive care unit.   of 2,000 ventilator days.                and hard palate with a tooth brush       ventilated days recorded by the          importance of tooth brushing.
American Association of                                                        and tooth paste for at least 1 minute,   respiratory therapists and the nurses.
Neuroscience Nurses, 2008, 40(5),                                              3 times a day, the use of Toothettes     The other limitation was lack of
291-298.                                                                       to swab the teeth, tongue and hard       funding.
                                                                               palate for 1 minute and to apply
                                                                               moisturizer to lips every 4 hours. An    No limitations were significant
                                                                               oral assessment was performed every      enough to doubt the findings.
                                                                               12 hours.
                                                                               The control group was the usual oral
                                                                               care. Usual oral care consisted of
                                                                               daily toothbrush along with Toothette
                                                                               mouth care PRN.

                                                                               The researchers found that the VAP
                                                                               rate dropped to 0 % within one week




                                                                                                                                                                                                         16
              Citation                         Population Studied                          Results of Study                   Threats to Validity of Study                Implications of Study
          (in APA format)                  (Who was studied? How many               (What were the variables? What          (Where there significant problems       (How can results help in caring for
                                               where in the study)                    did the researchers find?)              with the study? Where there              patients? Is more research
                                                                                                                               reasons to doubt findings?)            required before we can draw
                                                                                                                                                                              conclusions?)
                                                                                   of the implementation of the oral care
                                                                                   protocol.




Koeman, M., Van der Ven, A., Hak,        The population was conducted in two       Patients were randomized per             The limitations were that the           Oral pharyngeal decontamination
E., Joore, H., Kaasjager, K., De         university hospitals in mixed ICU‘s.      hospital. The independent group had      recruitment depended on the             with chlorhexidine delayed the
Smet, A., et al. (2006) Oral             The study was a randomized double         two cm of paste, which was               willingness of the physicians.          development of VAP. Daily risk of
decontamination with chlorhexidine       blind placebo controlled trial which      approximately 0.5 g of chlorhexidine,                                            VAP decreased by 55% with the use
reduces the incidence of ventilator-     consisted of 385 patients.                administered to each side of the         The discretion to keep a patient        of chlorhexidine.
associated pneumonia. Critical Care                                                buccal cavity.                           ventilated more than 48 hours was
Medicine, 173, 1348-1355.                                                                                                   also dependent on the physician.

                                                                                                                            The criteria for VAP microbiology
                                                                                                                            specificity was low, as a result VAP
                                                                                                                            may have been overestimated.
Mori, H., Hirasawa, H., Oda, S.,         This was a nonrandomized trial with       Independent variable: Use of oral        This research was gathered in a long    When this study was completed the
Hidetoshi, S., Matsuda, K., &            historical controls. The population       care protocol, specifically use of a     study period and during the 8-year      researchers claimed it was the first
Nakamura, M (2006). Oral care            included 1,252 patients who were          toothbrush.                              study period advances in treatment of   study of VAP prevention by oral care
reduces incidence of ventilator-         admitted to the ICU during period         Dependent variable: decreased            underlying conditions and surgical      and that its findings warrant a large
associated pneumonia in ICU              between January 1997 and December         incidence of ventilator-associated       techniques may have influenced the      scale multi-center trail on the
populations. Intensive Care Med, 32,     2002 (oral care group), while 414         pneumonia in mechanically                duration of mechanical ventilation      efficacy of oral care of VAP
230-236.                                 patients who were admitted to the         ventilated patients.                     and length of ICU stay. Furthermore,    prevention. However , these results
                                         ICU during period between January         Findings: This study found that oral     the nursing staff changed during the    would suggest that an oral care
                                         1995 and December 1996 and who            care consisting of tooth brushing and    study period, but the supervising       routine including mechanical
                                         did not receive oral care served as       washing reduced the incidence and        dentist and main ICU staff did not      cleaning with tooth brushing and
                                         historical controls (non-oral care        risk of VAP in ICU patients, and that    change. In order to maintain            washing be implemented
                                         group).                                   it delayed the onset of VAP.             consistent and adequate oral care
                                                                                                                            technique, the nurses had to undergo
                                                                                                                            periodic education and guidance by
                                                                                                                            the supervising dentist.

Tantipong, H.Morckchareonpong, C.,       The population consisted of adult age     The independent group received oral      Limitations to the study included:      The results from the study highlight
Jaiyindee, S., & Thamlikitkul, V.        18 years or older that was                care 4 times per day that involved       patients who had pneumonia at time      the need to add 2% chlorhexidine
(2008). Randomized controlledtrial       hospitalized in intensive care units at   brushing the teeth, suctioning any       of enrollment, and patient that were    solution to oral care in preventing the
and meta-analysis of oral                Sirirag Hospital with a total of 36       oral secretions, and rubbing the         allergic to chlorhexidine solution      occurrence of VAP.
decontamination with 2 %                 beds. The study consisted of 207          oropharyngeal mucosa with 15 ml          were excluded.
chlorhexidine solution for               eligible patients                         with of a 2% chlorhexidine solution.                                             Although oral decontamination with
theprevention of ventilator-associated                                                                                      Unable to perform a blind study due     chlorhexidine reduced the risk of




                                                                                                                                                                                                              17
             Citation                        Population Studied                      Results of Study                   Threats to Validity of Study                 Implications of Study
         (in APA format)                 (Who was studied? How many           (What were the variables? What          (Where there significant problems      (How can results help in caring for
                                             where in the study)                did the researchers find?)              with the study? Where there               patients? Is more research
                                                                                                                         reasons to doubt findings?)             required before we can draw
                                                                                                                                                                         conclusions?)
pneumonia. Infection Control and                                             The control group consisted of the       to the taste and odor of the           VAP in patients who received
Hospital Epidemiology , 29(2), 131-                                          same oral care procedure, except         chlorhexidine were quite different     mechanical, no differences in
136.                                                                         their procedure used normal saline       from those of the normal saline.       duration of length of stay or mortality
                                                                             instead of chlorhexidine.                                                       rate could be demonstrated; therefore
                                                                                                                                                             more research needs to be completed.
                                                                             The researchers found that 20% of
                                                                             the patients in the chlorhexidine
                                                                             group converted from being
                                                                             colonized with gram negative bacilli
                                                                             to not being colonized. This resulted
                                                                             in a significant reduction in the rate
                                                                             of VAP in the chlorhexidine group
                                                                             by 53%.




TRACK 1            EBP Team 15: Christina Campbell, Yuri Casasola, Leslie Ireland, Amanda Kramer
Clinical Question: In critically ill patients does the instillation of normal saline in comparison to not instilling normal saline prior to endotracheal suctioning increase
negative outcomes?
             Citation                        Population Studied                      Results of Study                   Threats to Validity of Study                 Implications of Study
         (in APA format)                 (Who was studied? How many           (What were the variables? What          (Where there significant problems      (How can results help in caring for
                                             where in the study)                did the researchers find?)              with the study? Where there               patients? Is more research
                                                                                                                         reasons to doubt findings?)             required before we can draw
                                                                                                                                                                          conclusions?)
Akgul, S., &Akyolcu, N. (2002,         20 ICU patients who were intubated    Variables: Patients were suctioned at    It was unknown whether patients        This study concluded that saline
November). Effects of normal saline    and mechanically ventilated because   two-hour intervals by the same           consented to be part of this study.    solution with suctioning resulted in
on endotracheal suctioning. Journal    of pulmonary or cardiovascular        technician once with saline and once     There is no indication that the        undesirable but not significant
of Critical Nursing, 11(6), 826-830.   problems or trauma. The majority of   without using saline. The patients       researcher who performed the           alterations in oxygen saturation or
Retrieved March 1, 2009, from          patients in the study were between    were connected to an EKG monitor at      suctioning was blinded to the study.   blood gas levels. The author
CINAHL Plus with Full Text             60 and 69 years of age.               the time of suctioning and blood         There is no indication which           suggested an alternative to the use of
database.                                                                    gases were taken at 1 and 5 minutes      suctioning was done first or whether   saline during suctioning would be to
                                       The study was carried out on an       after the procedure.                     this would affect the results.         ensure adequate humidification in the
                                       experimental basis in the Intensive   Results: Partial decreases in pO2,       The study population was small and     mechanical ventilation system. More




                                                                                                                                                                                                       18
              Citation                          Population Studied                        Results of Study                     Threats to Validity of Study                  Implications of Study
          (in APA format)                   (Who was studied? How many             (What were the variables? What            (Where there significant problems        (How can results help in caring for
                                                where in the study)                  did the researchers find?)                with the study? Where there                 patients? Is more research
                                                                                                                                reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                  conclusions?)
                                          Care Unit of a university hospital in   pCO2, HCO3, and SaO2 with and              my not accurately reflect results.       research is needed with larger
                                          Turkey.                                 with out the use of saline did not         The author does not address the          populations in order to fully
                                                                                  reach a statistically significant level.   significant increase of heart rate in    determine if the use of saline during
                                                                                  Patients suctioned using saline            patients suctioned using saline or the   suctioning has detrimental affects on
                                                                                  instillation exhibited significantly       effects of this stress on the patient.   the health of the patient.
                                                                                  increased heart rate in the fourth and
                                                                                  fifth minutes with no increase noted
                                                                                  in patients suctioned without saline.
                                                                                  A significant increase in pH was seen
                                                                                  in patients following suction with
                                                                                  saline.

Ridling, D., Martin, L., & Bratton, S.    24 critically ill, endotracheally       Variables: Instillation of normal          Most of the children in the study had    The results show that the instillation
                                          intubated children aged newborn to      saline before endotracheal suctioning      congenital cardiac disease, so the       of normal saline before endotracheal
(2003, May). Endotracheal
suctioning with or without instillation   18 years. Population consisted of       was performed, and no use of normal        findings may not be applicable to        suctioning in children does decrease
of isotonic sodium chloride solution      children with obtained consent from     saline before endotracheal suctioning      children with other illnesses. The       oxygen saturation.
                                          parents before initiation of            was performed.                             study was limited by the variety of
in critically ill children. American                                                                                                                                  More research is needed in the area
Journal of Critical Care, 12(3), 212-     suctioning.                                                                        ages and endotracheal tube sizes.
                                                                                  Results: Oxygen saturation was                                                      of pediatrics with the regards to the
219. Retrieved March 9, 2009, from                                                                                           Although the suctioning procedure
                                                                                  significantly lower in subjects who                                                 instillation of normal saline before
                                                                                                                             was pre-established in the ICU and
CINAHL Plus with Full Text                                                        had normal saline instilled during                                                  suctioning because this was one of
database.                                                                                                                    by the standard of care, the number
                                                                                  suctioning than in patients who did                                                 the first studies done with pediatric
                                                                                                                             of care providers performing the
                                                                                  not. The difference in oxygen                                                       patients. Further studies should
                                                                                                                             procedure was not limited. The
                                                                                  saturation was significant at 1 and 2                                               include a larger sample size and
                                                                                                                             number of patients enrolled was
                                                                                  minutes after suctioning. By 10                                                     should assess for any other negative
                                                                                                                             insufficient to achieve statistical
                                                                                  minutes after suctioning, the                                                       outcomes as a result of the
                                                                                                                             significance.
                                                                                  difference in oxygen saturation                                                     instillation of normal saline before
                                                                                  between the 2 study groups was not                                                  endotracheal suctioning in children.
                                                                                  significant.
Young-Ra, Ji, Hee-Seu K., Jeong-          16 pneumonic adult patients with a      Variables: Instillation of 2 mL or 5       The number of patients enrolled was      The research study indicated the
Hwan, P. (2002, August). Instillation     tracheotomy tube, who where             mL of normal saline before                 insufficient to achieve statistical      instillation of normal saline before
of Normal Saline before Suctioning        admitted into a neuro-surgical          endotracheal suctioning was                significance.                            suctioning could have adverse effects
in Patients with Pneumonia. Yonsei        intensive care unit.                    performed, and no use of normal                                                     on oxygen saturation. Further
Medical Journal, 43(5), 607-612.                                                  saline before endotracheal suctioning                                               research is required due to the limited
Retrieved March 1, 2009, from                                                     was performed.                                                                      number of participants studied.
CINAHL Plus with Full Text                                                                                                                                            However, the evidence found in the
                                                                                  Results: The recovery time for
database.                                                                                                                                                             study should be able to help the
                                                                                  oxygen saturation to return to
                                                                                                                                                                      patients by making health care
                                                                                  baseline levels following suctioning
                                                                                                                                                                      providers aware of the risk of using
                                                                                  was; just after suctioning, 45 seconds
                                                                                                                                                                      normal saline prior to suctioning.




                                                                                                                                                                                                                19
              Citation                        Population Studied                     Results of Study                      Threats to Validity of Study                 Implications of Study
          (in APA format)                 (Who was studied? How many          (What were the variables? What             (Where there significant problems        (How can results help in caring for
                                              where in the study)               did the researchers find?)                 with the study? Where there               patients? Is more research
                                                                                                                            reasons to doubt findings?)             required before we can draw
                                                                                                                                                                            conclusions?)
                                                                             and no return of the oxygen saturation
                                                                             to baseline levels at 5 minutes
                                                                             following suctioning, for 0, 2 and 5
                                                                             mL saline instillations with p-values=
                                                                             0.54, 0.06 and 0.003, respectively.

Halm, M & Krisko-Hagel, K. (2008,       Review of 28 studies, articles,      Variables: Effects of the use of            No details were provided regarding       Standardized research would yield
September). Instilling Normal Saline    guidelines and reviews dating from   normal saline during suctioning on          the selection of articles for this       more definitive findings. However
With Suctioning: Beneficial             1978 to 2007.                        sputum recovery and various                 review other then the databases          the bulk of the evidence does point to
Technique or Potentially Harmful                                             physiological parameters                    searched and key words used to           the potential for adverse effects with
Sacred Cow? American Journal of                                              (oxygenation, hemodynamic                   search. Unknowns include:                the use of NS during suctioning with
Critical Care, 17(5), 469-472.                                               alterations, infection and subjective       populations studied, settings. Also      no discernible benefits in terms of
Retrieved March 1, 2009, from                                                symptoms )                                  variables were not strictly defined      breaking up and removing secretions
CINAHL Plus with Full Text                                                   Results: Collectively these studies         and outcomes were not standardized.      which is why NS is ostensibly used
database.                                                                    provided evidence of the adverse            Some of the studies used are 30 years    in this procedure.
                                                                             effects of instillation of NS during        old.
                                                                             suctioning. No solid scientifically
                                                                             based evidence of benefits from use
                                                                             of NS was found.



Thompson, L (2000). Suctioning          Review of 95 studies including       Variables: Variety of interventions         The review uncovered a wide range        While the final conclusions of the
Adults with an Artificial Airway. The   RCTs, other studies, literature      currently employed in the nursing           of research. The variety of designs      systematic review are not definitive
Joanna Briggs Institute for Evidence    reviews, surveys and guidelines      management of patients with an              and the lack of consistency in the       due to the previously mentioned
Based Nursing and Midwifery.                                                 artificial airway. Of specific interest     studies meant that the results could     methodological concerns, the
Systematic Review No. 9. Retrieved                                           were: methods used for tracheal             not be combined statistically. The       evidence suggests a change is needed
April 1, 2009 from                                                           suctioning; the instillation of saline      authors of the review identified many    in the practice of routinely installing
http://www.joannabriggs.edu.au                                               prior to suctioning; The following          issues relating to quality or study      normal saline prior to suctioning
/pubs/systematic_reviews.php                                                 outcome measures were included:             design leading them to suggest a         patients with artificial airways.
                                                                             changes to arterial blood gases, i.e.       careful interpretation of the results.
                                                                             oxygen pressure (PaO2), carbon
                                                                             dioxide pressure (PaCO2) and
                                                                             saturated oxygen (SaO2) levels;
                                                                             Results: Various adverse effects
                                                                             were noted from using normal saline
                                                                             when suctioning and no significant
                                                                             research based data was found to
                                                                             indicate that instilling saline increases
                                                                             removal of respiratory secretions.




                                                                                                                                                                                                            20
 TRACK 2              EBP Team 12: John Bloomer, Livia Phillips, Lanson Wheeler, Justin Sword

 Clinical Question: For patients at risk for developing pressure ulcers, does a static pressure relieving device compared to dynamic pressure relieving surfaces provide
 improved protection against pressure ulcer development?
             Citation                         Population Studied                         Results of Study                  Threats to Validity of Study                   Implications of Study
         (in APA format)                  (Who was studied? How many              (What were the variables? What         (Where there significant problems        (How can results help in caring for
                                              where in the study)                   did the researchers find?)             with the study? Where there                 patients? Is more research
                                                                                                                            reasons to doubt findings?)              required before we can draw
                                                                                                                                                                               conclusions?)
Bansal, C., Scott, R., Steward, D., &   Patients at risk for decubitis ulcers:   Independent Variables: N/A              Threats: The article is a review of      Implications: More care to eliminate
Cockrell C. (2005). Decubitis ulcers:   aged, incontinent, debilitated,                                                  literature spanning 67 years. As it      occurrences‘ of pressure decubitis
A review of the literature.             paralyzed unconscious patients as        Dependent Variables: N/A                reports data gleaned from varied         ulcers is indicated.
International Journal of                well as those with neurologic or                                                 sources, it is a sound as the sum of
Dermatology, 44(10). 805-810.           cardiovascular disease, under                                                    those sources.
Retrieved Feburary, 19, 2009 from       prolonged anesthesia, who are            Findings: ―Two thirds of decubitis
EBSCOhost.                              dehydrated or malnourished, who          ulcers occur in patients>70 years.
                                        have hypotension or have undergone       Eighty-three percent of hospitalized
                                        surgery.                                 patients with decubitis ulcers
                                                                                 developed them in the first five days
                                                                                 of hospitalization. Hospitalized
                                                                                 patients have a 3-17% incidence rate;
                                                                                 surgical patients, 12-66%.
                                                                                 Immobilized patients in long-term
                                                                                 care facilities have a 33% incidence
                                                                                 rate. Recurrence rates for decubitis
                                                                                 ulcers may be as high as 90%.
                                                                                 Present treatment costs for decubitis
                                                                                 ulcers in the US is estimated in
                                                                                 excess of $1 billion per year‖
 Duncan, K. (2007 October). 5           Healthcare patients who developed        Independent Variables: N/A              Threats: There are no glaring            Implications: Risk and ongoing
 Million Lives Campaign.                pressure ulcers in various healthcare                                            weaknesses evident in the article. It    patient assessment as well as
 Preventing pressure ulcers: the        facilities.                              Dependent Variables: N/A                focuses on a strategy of prevention of   measures to maintain skin integrity,
 goal is zero. Joint Commission                                                                                          pressure ulcers based on continuous      nutrition and use of pressure
 Journal of Quality and Patient                                                                                          patient assessment for pressure ulcer    relieving surfaces can help reduce
 Safety, 33(10), 605-610. Retrieved                                              Findings: ―An estimated 60,000          from admission to release, with          rates of pressure ulcer development.
 March 8, 2009 from CINHAL Plus                                                  patients die each year from             special attention extended to
 with Full Text database.                                                        complications due to hospital-          optimized nutrition and hydration,
                                                                                 acquired pressure ulcers.‖              skin moisture management and
                                                                                                                         pressure minimization.
                                                                                 (Duncan, 2007)




                                                                                                                                                                                                         21
               Citation                         Population Studied                          Results of Study                    Threats to Validity of Study                     Implications of Study
           (in APA format)                  (Who was studied? How many               (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                                where in the study)                    did the researchers find?)               with the study? Where there                  patients? Is more research
                                                                                                                                 reasons to doubt findings?)                required before we can draw
                                                                                                                                                                                    conclusions?)
 McInnes, E., Bell-Syer,                  Median sample size was 100 and            Independent Variables: Alternating        Threats: Small sample sizes were a        Implications: AP mattresses were
 SEM, Dumville, JC, Legood, R., &         included patients within intensive        pressure                                  major limitation of many of the           associated with a high probability of
 Cullum, NA. (2008). Support              care, orthopedic, emergency, ward,                                                  studies. In addition, high attrition      reducing costs, resulting from a delay
 surfaces for pressure ulcer prevention   and medical/surgical settings.            Dependent Variables: Constant low         rates and lack of an attention-to-treat   in the formation of pressure ulcers,
 (Review). Cochrane Database of                                                     pressure/foam mattress                    analysis was a common theme               and a reduction in the patient‘s length
 Systematic Reviews, 4(3).                                                                                                    among studies. Baseline risk/data         of stay.
                                                                                    Findings: The researchers found           through rating tools (i.e. Braden,
                                                                                    that foam alternatives to the standard    Norton, Waterlow, Gosnell) was not
                                                                                    hospital foam mattress can reduce the     provided in several of the studies.
                                                                                    incidence of pressure ulcers.             comparability
  On October 1, 2008, Medicare            N/A                                       Independent Variables: N/A                Threats: N/A                              Implications: Prevention of pressure
  stopped paying hospitals (2009).                                                                                                                                      ulcers decreases the cost of hospital
  American Journal of Nursing,                                                      Dependent Variables: N/A                                                            operations. Pressure ulcer rates will
  Retrieved March 8, 2009 from                                                                                                                                          decrease.
  CINHAL Plus with Full Text                                                        Findings: Medicare stopped paying
  database.                                                                         hospitals for treating preventable
                                                                                    pressure ulcers
  Pappas, S. (2008, May). The cost        Congestive heart failure, joint           Independent Variables: N/A                Threats: The article does not             Implications: Adequate staffing
  of nurse-sensitive adverse events.      replacement and major bowel                                                         indicate how well the financial and       probably does play a role in
  Journal of Nursing Administration,      surgical patients—2495 patients           Dependent Variables: N/A                  staffing data and retrospective data      complication of patient recovery,
  38(5), 230-236. Retrieved March         total.                                                                              (collected from quality control)          which increases the cost of care per
  8, 2009, from CINHAL Plus with                                                    Findings: Pressure ulcer                  which were combined to produce the        case.
  Full Text database.                                                               development added an extra                afore mentioned figure were bundled
                                                                                    $2384.00 to the cost of care per          and unbundled to produce increased
                                                                                    case.—The ability to determine the        cost of care.
                                                                                    cost of adverse events from hospital
                                                                                    accounting systems was established.
Reddy, M., Gill, S., & Rochon, P.         Meta-analysis of 59 randomized,           Independent Variables:                    Threats: Methodological quality for       Implications: In caring for patients
(2006). Preventing pressure ulcers: A     controlled trials (n=13,845) that         Dynamic support surfaces                  the randomized controlled trials was      identified as being at risk for pressure
systematic review. The Journal of the     evaluated interventions for                                                         variable and generally suboptimal.        ulcer development, preventive
American Medical Association, 296,        preventing pressure ulcers and            Dependent Variables:                                                                interventions should be instituted that
974-948.                                  reported objective, clinically relevant   Static support surfaces                   The review summarized the studies         address pressure reduction and
                                          outcomes. Trials had anywhere from                                                  that found a significant reduction in     repositioning needs, because
                                          12 to 1,971 participants. Six trials      Findings: The following were              pressure ulcer incidence, but it did      reducing or eliminating risk factors
                                          had less than 50. Of the 59 trials,       identified as appropriate strategies to   not report the size of the benefits,      can prevent pressure ulcer formation.
                                          67.9% were in acute care settings,        prevent pressure ulcers: using            which is important when deciding
                                          17.1% were in LTC, 2.4% in                support surfaces, repositioning the       whether to implement an                   There is a need for well-designed
                                          rehabilitation, and 12.6% in mixed        patient, optimizing nutritional status,   intervention.                             RCTs that follow standard criteria for
                                          settings.                                 and moisturizing sacral skin.                                                       reporting nonpharmacological
                                                                                                                              There was inadequate blinding of          interventions and that provide data




                                                                                                                                                                                                                   22
              Citation                         Population Studied                        Results of Study                    Threats to Validity of Study                 Implications of Study
          (in APA format)                  (Who was studied? How many             (What were the variables? What           (Where there significant problems       (How can results help in caring for
                                               where in the study)                  did the researchers find?)               with the study? Where there                patients? Is more research
                                                                                                                              reasons to doubt findings?)              required before we can draw
                                                                                                                                                                               conclusions?)
                                                                                 Only 3 trials found that dynamic          patients, and small sample size was a   on cost-effectiveness for these
                                                                                 support surfaces were better than         potential limitation of many studies.   interventions.
                                                                                 static support surfaces, and 1 of these
                                                                                 trials did not report statistical
                                                                                 evidence.

Russell, L., Reynolds, T., Park, C.,     1168 Pts aged 65 or older, with a       Independent Variables: 562 Pts on         Threats: ―One possible limitation of    Implications: This study
Rithalia, S., Gonsalkorale, M., Birch,   score or 15-20 on the Waterlow          a Visco-elastic foam mattress             this study was the use of the           ―demonstrates conclusively that
J., et al. (2003). Randomized Clincial   assessment, who consented to regular    (CONFOR-Med) and seating                  Waterlow score for assessing risk of    replacing standard equipment with
Trial Comparing 2 Support Surfaces       examination of pressure areas.          cushions                                  developing PrUs‖ and ―its use could     the experimental equipment results in
Results of the Prevention of Pressure    (Relatives of Pts who were                                                        be seen as a limitation to the          a statistically significant reduction in
Ulcers Study. Advances in Skin &         ―clinically confused‖ provided          Dependent Variables: 604 Pts on           applicability of the PPUS-1 data.‖      blanching erythema.‖
Wound Care , 317-327.                    consent for participation)              Standard hospital mattresses (King‘s
                                                                                 fund, Linknurse, Softfoam,                Identifying blanching and               ―It should be noted that statistical
                                         Three settings were used for this       Transfoam, or a King‘s Fund               nonblanching erythema is difficult,     significance is not the same as
Prevention of Pressure Ulcers Study      study:                                  mattress with a Spenco or Propad          and this may be another limitation of   clinical significance; further work is
(PPUS-1)                                 -Hospital 1: acute elderly care &       mattress overlay) & seating cushions      the study. The technique for            needed to determine whether the
                                         orthopedic wards                                                                  identifying blanching erythema is not   effect demonstrated in this study
                                         -Hospital 2: elderly rehabilitation     Findings: *2 participants that were       generally standardized.‖                results in clinical benefit.‖
                                         wards                                   allocated to the experimental group
                                         -Hospital 3: acute elderly care wards   were incorrectly placed on a standard     ―Eliminating the risk of bias is        (Russell, et al., 2003)
                                                                                 mattress and thus excluded from the       impossible because it was impossible
                                                                                 trial.                                    to blind the research nurses to
                                                                                 *The seat cushion use was going to        mattress assignment‖
                                                                                 be examined but not enough ischial
                                                                                 ulcers developed to allow for
                                                                                 analysis.                                 (Russell, et al., 2003)

                                                                                 ―The experimental equipment
                                                                                 showed statistical significance to
                                                                                 standard equipment for prevention of
                                                                                 blanching erythema; significance was
                                                                                 not achieved for nonblanching
                                                                                 erythema.‖

                                                                                 ―A larger study is required to
                                                                                 determine whether this no significant
                                                                                 difference is genuine.‖




                                                                                                                                                                                                              23
              Citation                         Population Studied                         Results of Study                    Threats to Validity of Study                     Implications of Study
          (in APA format)                  (Who was studied? How many              (What were the variables? What           (Where there significant problems            (How can results help in caring for
                                               where in the study)                   did the researchers find?)               with the study? Where there                   patients? Is more research
                                                                                                                               reasons to doubt findings?)                 required before we can draw
                                                                                                                                                                                   conclusions?)
                                                                                  (Russell, et al., 2003)




Theaker, C., Kuper, M., & Soni, N.       62 ―high risk‖ patients, over 18 y/o     Independent Variables: 30 Pts on          Threats: The researchers state, ―with        Implications: As stated by the
(2005). Pressure ulcer prevention in     admitted to the ICU without current      KCI TheraPulse bed (low air loss or       the documented low incidence of              researchers the actual number of
intensive care-a randomised control      pressure sores                           optional pulsation)                       pressure sores it is possible that           participants may have skewed the
trial of two pressure-relieving                                                                                             significance might have been                 results. A study using a greater
devices. Anaethesia , 395-399.                                                    Dependent Variable: 32 Pts on             achieved had more patients been              number of participants may possibly
                                                                                  Hill-Rom Duo mattress                     recruited.‖                                  yield a significant difference.
                                                                                  (continuous or alternating pressure)                                                   In which case, additional research
                                                                                                                            ―Given the numbers actually                  would be needed to say for certain if
                                                                                  Findings: 6 pts on Hill-Rom Duo           available, a type 2 statistical error        one of the two pressure relieving
                                                                                  developed a PU and 3 pts on KCI           cannot be ruled out.‖                        devices is better at preventing
                                                                                  TheraPulse                                                                             pressure ulcer.
                                                                                  developed a PU                            ―It is also possible that the trial itself
                                                                                                                            may have influenced nursing care,            Currently, these results do not have a
                                                                                  Using chi-square analysis there was       although overall it took 2 years to          significant implication for practice.
                                                                                  no significant difference. p=0.35         perform and it seems unlikely that
                                                                                                                            the ‗novelty‘ aspects of the trial
                                                                                                                            would have been sustained.‖

                                                                                                                            (Theaker, Kuper, & Soni, 2005)

 Vanderwee, K., Grypdonck,M.,            447 patients admitted to 19 surgical,    Independent Variables:                    Threats: The researcher states, ―The         Implications: The only significant
Defloor, T. (2005). Effectiveness of     internal, or geriatric wards in seven    An experimental group of 222              sitting protocol was standardized and        finding was fewer patients developed
an alternating pressure air mattress     Belgian hospitals: Aged 18 or older;     patients lying on an APAM                 identical in both groups. However,           heel pressure ulcers on an APAM.
for the prevention of pressure ulcers.   No grade 2, 3, or 4 pressure ulcer       (Alternating Pressure Air Mattress)       the duration of the sitting was not          More research is needed before we
Nursing Science , 261-267.               lesions on admission; Body weight                                                  standardized.‖                               can draw definite conclusions.
                                         less than 140kg; No contraindications    Dependent Variables:
                                         for turning due to medical reasons;      Control group of 225 patients lying       ―Patients in the APAM group seemed           As stated by the researcher, Caution
                                         Expected hospitalization stay at least   on a visco-elastic foam mattress.         to develop more severe pressure              is required in interpreting the results
                                         3 days                                                                             ulcers than those in the control             of the subgroups. If the data are split
                                                                                  Findings: Fewer patients developed        group. Due to the limited numbers of         up into the Braden and NBE groups,
                                                                                  heel pressure ulcers on an APAM.          patients, we must be careful in              the number of patients becomes too
                                                                                  Patients identified as being in need of   generalizing this finding.‖                  small. Therefore, we can only
                                                                                  prevention based on the presence of                                                    discover tendencies.‖
                                                                                  Non-Blanchable Erythema had a             ―Caution is required in interpreting




                                                                                                                                                                                                                   24
            Citation                      Population Studied                        Results of Study                      Threats to Validity of Study                Implications of Study
        (in APA format)               (Who was studied? How many             (What were the variables? What             (Where there significant problems       (How can results help in caring for
                                          where in the study)                  did the researchers find?)                 with the study? Where there              patients? Is more research
                                                                                                                           reasons to doubt findings?)            required before we can draw
                                                                                                                                                                          conclusions?)
                                                                            tendency to develop fewer pressure          the results of the subgroups. If the
                                                                            ulcers on an APAM. Patients                 data are split up into the Braden and
                                                                            identified as being in need of              NBE groups, the numbers of patients
                                                                            prevention, based on the Braden             become too small. Therefore, we can
                                                                            Scale, appeared to develop more             only discover tendencies.‖
                                                                            sacral pressure ulcers on an APAM.
                                                                                                                        (Vanderwee ,2005)




TRACK 2             EBP Team 19: Jessica Honeycutt, Katie Huff, Arlene Williams, Meagan Ward

Clinical Question: For adult surgical patients who have a non-draining surgical incision, what is the best practice for incision dressing removal to prevent surgical site
infection?
              Citation                      Population Studied                       Results of Study                       Threats to Validity of Study                 Implications of Study
          (in APA format)               (Who was studied? How many            (What were the variables? What              (Where there significant problems      (How can results help in caring for
                                            where in the study)                 did the researchers find?)                  with the study? Where there               patients? Is more research
                                                                                                                             reasons to doubt findings?)             required before we can draw
                                                                                                                                                                              conclusions?)
Chrintz, H. Vibitz, H., Cordtz, T.,   1202 randomized surgical patients      633 patients had their wounds               No significant threats to validity      Implications for patient benefits are
Harreby, J., Waaddegaard, P.,         above the age of 3 years old in the    dressed until suture removal. 569 had       were identified. The study was          many:
Larsen, S. (1989). Need for           surgical wards of Kalundborg           their wounds treated without                randomized. An appropriate and          1. The method reduces number of
surgical wound dressing. British      General Hospital and Saeby General     dressings after the first operative day.    large sample size was used.             nursing hours and cost of bandages.
Journal of Surgery (76)               Hospital from November 1984 to         In the group with dressings, the            Proper consents were received.          2. Wounds can be examined more
2, 204-205.                           December 1987. 629 men and 573         infection rate was 4.9%. In the group       Patients with even birth-date           easily and any infection noted earlier.
                                      women                                  with short dressing time the infection      numbers received sterile dressings      3. Patients can carry out personal
                                      721 <50 years of age 481 > 50 years    rate was 4.7%.                              from the end of surgery to the time     hygiene more easily.
                                      old 1070 not overweight and 89                                                     sutures were removed. Patients with
                                      overweight.                                                                        odd number birthdates had sterile
                                                                                                                         dressings for the first 24 hrs post
                                                                                                                         surgery.




                                                                                                                                                                                                           25
              Citation                         Population Studied                       Results of Study                  Threats to Validity of Study                  Implications of Study
          (in APA format)                  (Who was studied? How many            (What were the variables? What         (Where there significant problems        (How can results help in caring for
                                               where in the study)                 did the researchers find?)             with the study? Where there                 patients? Is more research
                                                                                                                           reasons to doubt findings?)              required before we can draw
                                                                                                                                                                             conclusions?)
Dosseh Ekoue, D., Doleaglenou, A.,       102 randomized patients over a four    Equally divided into two groups of      The study group was relatively small     Removing dressings at 48 hours
Fortey, Y-K., Ayite, A.-E.,              month period undergoing intra-         ―with dressing‖ and ―without            at only 102 patients.                    would decrease expenses of
(2008). Randomized trial                 abdominal surgery in a tropical        dressing‖. The dressings of the ―with                                            dressings, nursing care, and
comparing dressing to no dressing        setting                                dressing‖ group were changed every                                               additional hospital days. Patients
of surgical wounds in a tropical                                                two days. The dressings of the                                                   would have more freedom post
setting. Journal of Chirugie                                                    ―without dressing‖ group were left                                               surgery not having to change
145(2) 143-6. Retrieved from                                                    off after the first 48 hours post                                                dressings often.
Ovid.                                                                           surgery. Results showed no
                                                                                difference in post op wound                                                      Because of the limited number of
                                                                                infection. In the ―without dressing‖                                             trials more research on this subject is
                                                                                group sutures were removed 2 days                                                needed.
                                                                                earlier and the hospital stay
                                                                                decreased by 2 days.


Holm, C., Petersen, J. S., Groenboek,    73 patients over 18 years of age who   Independent variable: Dressing          While the 5cm incision rule was in       Patients pain level was also assessed
F., & Gottrup, F. (1998). Effects of     were to undergo abdominal              type- Comfeel (occlusive) dressing      place, the way the incision was cut or   which found they liked the incision
occlusive and conventional gauze         operations that required an incision   left on until sutures were removed      closed was not standardized.             covered until the sutures were
dressings in incisional healing after    of more than 5cm were included in      (10 days) and Medpore (gauze)           Interrater reliability could also be a   removed better than two days post-
abdominal operations. Eur J Surg,        this study.                            dressing removed 2 days post-op         factor. Inspection of the wound after    op. Cost of these supplies are the
164, 179-183.                                                                                                           surgery did not follow a specific        same but cost effectiveness can come
                                                                                Dependent variable: Infection rate      protocol- only what the evaluator‘s      into play when the amount of
                                                                                                                        perception of scarring, pain, exudate,   dressings are involved.
                                                                                The rate of wound infection is not      leaking and transparency meant to
                                                                                increased when occlusive dressings      them.
                                                                                are used on surgical incisions. There
                                                                                was actually a trend to towards an
                                                                                increased infection rate in the gauze
                                                                                group even though it was not
                                                                                significant.
Sticha R.S., Swiriduk, D., &             This study included 100 patients who   Independent Variable: Early             Threats to the validity of the study.        This study demonstrated that
Wertheimer, S.J. (1998).                 underwent forefoot, rear-foot, or      exposure method)                                                                      early exposure does no harm.
 Prospective analysis of postoperative   ankle surgery in which incisions had                                           There were no significant problems           Infection rates did not increase.
wound infections using an early          been made on a non-weight bearing      Dependent Variable: Infection free      with the study.                              The benefits would be the
exposure method of wound care.           surface.                               incisions.                                                                            money saved with fewer
Journal of Foot and Ankle Surgery.                                                                                      The study did not show any                    dressing supplies, nurses‘ time,
37(4),286-91.                                                                   Findings: Wounds were inspected on      advantages as far as improved                 and more friendly/easier post-
                                                                                the 10-14 POD when sutures were         healing with early exposure.                  op care for the patient when
                                                                                removed and the incidence of                                                          discharged.
                                                                                infection was 1%.                       There was no indication of what they




                                                                                                                                                                                                           26
              Citation                        Population Studied                      Results of Study                    Threats to Validity of Study                  Implications of Study
          (in APA format)                 (Who was studied? How many           (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                              where in the study)                did the researchers find?)               with the study? Where there                patients? Is more research
                                                                                                                           reasons to doubt findings?)              required before we can draw
                                                                                                                                                                            conclusions?)
                                                                              (Wound infection was defined as one       patients were told as far as caring for
                                                                              with the presence of purulence,           their incisions after early exposure.
                                                                              cellulites, or lyhphangitis.)             (Were they more careful and               More research should be done to
                                                                                                                        fastidious with care for fear of          determine advantages to early
                                                                                                                        infection with the early exposure?)       exposure and study other time
                                                                                                                                                                  intervals such as POD #1 or POD#2.
Cruse, P. J., & Foord, R. (1980). The    This was a ten year prospective      Independent variable: patient skin,       Definition of infection not clearly       This study is referenced in most as
epidemiology of wound infection: A      study involving all surgical wounds   skin draped, skin preparation, preop.     stated. No interview conducted, just      the ―gold standard‖ of wound
10- year prospective study of 62, 939   from Foothills Hospital in Calgary    Hospitalization and exogenous             patient medical record information.       infection studies. Information is old
wounds. Surgical Clinics of North       from 1967-1977 which involved 62,     contamination                             Exact percentages not given on            but many standards are still used
America, 60(1), 27-40.                  939 patients.                                                                   results.                                  today. Of particular interest to our
                                                                              Dependent variable: wound                                                           topic is that surgical incisions were
                                                                              infection                                                                           exposed to air after 48 hours,
                                                                                                                                                                  meaning dressings were removed,
                                                                              The results showed that the following                                               and this was not associated with any
                                                                              actions will lead to reduced infection                                              increase in the infection rate. This
                                                                              rate to surgical wounds: short                                                      can be of great benefit to the patient
                                                                              preoperative stay, hexachlorophene                                                  who finds dressings bulky and
                                                                              shower before operation, shaving                                                    bothersome.
                                                                              kept to minimum, contamination
                                                                              eschewed, punctilious surgical
                                                                              technique, expeditious surgery as is
                                                                              safe, scrupulous care in operations
                                                                              performed on elderly, obese,
                                                                              malnourished and diabetic patients,
                                                                              no drains brought out through the
                                                                              operative wound, meticulous
                                                                              coagulation technique using the
                                                                              electrosurgical unit, and information
                                                                              to each surgeon regarding their
                                                                              infection rate and that of their peers.




                                                                                                                                                                                                           27
 TRACK 2              EBP Team 22: Marsha Cleaver, Carolyn Loper, Sandra Thomas

 Clinical Question: In the clinical practice setting, is there a relationship in the prevention of peripheral intravenous catheter related infection when preparing the
 insertion site using friction versus a circular motion?
 Citation                                Population Studied                        Results of Study                                 Threats to Validity of Study                           Implications of Study
 (in APA format)                         (Who was studied? How many were           (What were the variables? What did the           (Were there significant problems with the study?       (How can results help in caring for
                                          in the study)                            researchers find?)                               Were there reasons to doubt findings?)                 patients? Is more research required
                                                                                                                                                                                           before we can draw conclusions?)

Barenfanger, J., Drake, C., Lawhorn,     The study was conducted at Memorial       Findings:                                        Different time periods for each product in which       Chlorhexidine had comparable
J., Verhulst, S. J. (2004). Comparison   Medical Center in Springfield, Illinois   Chlorhexidine has comparable effectiveness       the population and season changed. A chart review      effectiveness and was noted to be less
of chlorhexidine and tincture of         - 11,738 blood cultures studied over      to tincture of iodine.                           was not done to determine if the isolate was true      expensive and easier to use.
iodine for skin antisepsis in            two time periods. First period, six                                                        contaminant. The blood cultures were collected by      There needs to be more study in regards
preparation for blood sample             months, using tincture of iodine and                                                       various staff which could lead to more varied          to the technique used regarding time,
collection. Journal of Clinical          second period, seven months, using        Variables:                                       technique. Two in-services were given in each time     friction, or simple application.
Microbiology, 42(5), 2216-2217           chlorhexidine for skin antisepsis         0.41% difference between the two products        period to instruct in skin antisepsis. Products were
                                                                                   was considered insignificant.                    applied per package inserts. Even though there
                                                                                                                                    were some variables the findings are significant.
Chalyakunapruk, N., Veenstra, D.L.,      A meta-analysis of 8 different            Variables:                                       Threats:                                               The use of chlorhexidine gluconate can
Lipsky, B.A., Saint, S. (2002).          randomized, controlled trials which       -Underestimation of the standard of error        Publication bias, smaller trial size                   reduce the risk of catheter related blood
Chlorhexidine compared with              compared chlorhexidine gluconate          related to multiple catheters per patient        The studies included various types of catheters and    stream infections. But more research is
povidone-iodine solution for vascular    with povidone-iodine solutions for        -Several types of chlorhexidine gluconate        insertions, but no mention of technique used to        recommended that would include the
catheter-site care: A meta-analysis.     catheter site care. Reported incidence    solutions were used                              apply the product.                                     method of application.
Annals of Internal Medicine,136 (11)     of catheter colonization or catheter      -catheter related bloodstream infections were
                                         related bloodstream infection with        defined differently
                                         sufficient data was used to calculate     -did not distinguish true bacteremia from
                                         the risk ratio. The studies involved a    blood culture contamination
                                         total of 4143 various catheters.
                                         Review by two investigators, no           Findings:
                                         discrepancies were found in the data      Significant reduction of central vascular line
                                                                                   blood stream infections in those who
                                                                                   received chlorhexidine gluconate versus
                                                                                   povidone-iodine for insertion-site skin
                                                                                   disinfection.




                                                                                                                                                                                                                             28
Citation                              Population Studied                         Results
                                                                         Results of Studyof Study               (What Threats were the Threats to Validity of Study
                                                                                                                         (What to Validity of Study                            Threats to of Study of
                                                                                                                                                                                          Validity
                                                                                                                                                                            Implications(Were there Study Implications of Study(W
(in APA format)                                                          (What were the variables?did the researchers (Were
                                                                                  variables? What
                                      (Who was studied? How many were in were thevariables? What did the researchers find?) there significant problems with the study?
                                                                                                                                         significant problems with the study? (How there reasons to in caring for help in caring for
                                                                                                                                                                            (How can results help in caring for
                                                                                                                                                                              Were canto doubt findings?)
                                                                                                                                                                               reasons results help       results
                                      in study)
                                      thethe study)                      What
                                                                         find?)did the researchers find?)                                doubt findings?)
                                                                                                                        Were there reasons to doubt findings?)                                            research
                                                                                                                                                                            patients? Is more research required required before
                                                                                                                                                                             before we can draw conclusions?)
                                                                                                                                                                                                          conclusions?)
                                                                                                                                                                            before we can draw conclusions?)


Danks, L. A. (2006). Central           Review of the literature with five         Chlorhexidine showed a strong trend toward       This review is limited to products used to prevent    Skin preparation prior to intravenous
venous catheters: a review of skin    research articles chosen to compare        a significant benefit in prevention of catheter   or reduce the risk of intravenous catheter site       catheter insertion is essential to reduce
cleansing and dressings. British      dressings and cleansing agents used in     related bacteremia and was superior to            infections. There is no mention as to the method of   infections. Further study is needed to
Journal of Nursing, 15(12), 650-      disinfection of insertion site and site    preventing staph infection.                       application of products.                              include the method of application of
654.                                  care thereafter.                           Transparent dressing is the most appropriate                                                            products for skin antisepsis.
                                      One of the five articles was reviewed      choice to reduce the risk of catheter site
                                      separately related to skin antisepsis.     infection.
                                      The other articles were combined and
                                      related to the dressings for central
                                      venous catheters

Hibbard, J. S., Mulberry, G. K.,      A randomized, parallel-group, active-      2% CHG and 70% IPA each alone showed          Small sampling size. Skin areas tested (groin and         Evidence that bacteria from patients‘
Brady, A. R., (2002). A clinical      control, open label clinical trial which   immediate (10 minute) antimicrobial activity. abdomen) were not the usual intravenous site              own skin are a primary factor in the
study comparing the skin antisepsis   included prescreening, screening and       CHG + IPA had the same result but was also locations.                                                   development of nosocomial infections.
and safety of Chloraprep, 70%         testing phases comparing the               more persistent lasting 24 hours on the                                                                 Effective skin antisepsis is of
isopropyl alcohol, and 2% aqueous     immediate and persistent antimicrobial     abdomen, however was not as significant on                                                              paramount importance.
chlorhexidine. Journal of Infusion    efficacy and safety of Chloraprep          the groin areas.                                                                                        This study made a point to describe how
Nursing, 25(4), 244-249               (CHG + IPA) with 70% isopropyl             Chloraprep was found to have less skin                                                                  the product was applied with a back and
                                      alcohol (IPA) alone and 2% aqueous         irritation and no evidence of skin toxicity.                                                            forth motion for 2 minutes on the groin
                                      chlorhexidine (CHG) alone.                                                                                                                         and 30 seconds on the abdomen with a
                                       Subjects:                                                                                                                                         drying time of 1 minute on the groin
                                      Healthy 18 – 70 year olds                                                                                                                          and 30 seconds on the abdomen
                                      Informed consent
                                      190 recruited, 153 were screened, 130
                                      met inclusion criteria, 106 received
                                      treatment, 85 completed the study




                                                                                                                                                                                                                            29
Citation                              Population Studied                           Results                               (What to Validity ofwas Threats How many were in the study) of Study
                                                                                                                                      (Who Study Validity of Study
                                                                                                                                                  to                                             (Were Implications of Study
                                                                           Results of Studyof Study Population Studied Threats were the Threats studied?to Validity of StudyImplications(Were there there significant problems
(in APA format)                                                            (What were the variables? the researchers find?)
                                      (Who was studied? How many were in the       variables? What did                                   significant problems with the study? Were to resultsfindings?) results
                                                                                                                                                  with the study? study?    (How can doubt help in
                                                                                                                        (Were there significant problems with theWere there reasons there reasons to caring for help in caring for
                                      study)                               What did the researchers find?)                               doubt findings?)
                                                                                                                        Were there reasons to doubt findings?)                                            research
                                                                                                                                                                            patients? Is more research required required before
                                                                                                                                                                                                          conclusions?)
                                                                                                                                                                            before we can draw conclusions?)
LeBlanc, A., Cobbett, S. (2000). A    Randomized, blinded trial with follow-      Suggest a reduction in probable catheter     The method of application of the products used for   Using the chlorhexidine gluconate could
0.5% chlorhexidine gluconate in       up at 72 hours after removal of I.V.        related infection when using 0.5%            skin antisepsis                                      be beneficial. Further study is needed to
70% isopropyl alcohol swab was        catheter.                                   chlorhexidine and 70% isopropyl alcohol                                                           include the method of application.
more effective than two other         300 patients in an acute care hospital      compared with alcohol followed by povidone
methods for intravenous antisepsis.   in Yarmouth, Nova Scotia, Canada.           versus povidone followed by alcohol for skin
Evidence Based Nursing 2000,          Medical, surgical, intensive care           antisepsis,
3(119)                                obstetrics, gynecology, outpatient and
                                      emergency services.

Johnston, L. (2005). A systematic     Systematic review of Six randomized         Chlorhexidine impregnated dressings reduced   Limited sample size, only one reviewer which        This is helpful in regards to pediatric
review for effective management of    controlled trials and qualified             the incidence of catheter-tip colonization.   could introduce bias. There was no information      patients, limited. Suggest furthers
central venous catheters and          controlled trials, a total of 1260          Reduced incidence of catheter colonization    available for aseptic technique or barrier          studies to include the use of aseptic
catheter sites in acute care          hospitalized pediatric patients, birth to   and catheter-related bacteremia with          precaution.                                         technique and the method such as
paediatric patients. World views on   age 18 years.                               chlorhexidine compared with povidone-                                                             friction, back and forth, circular, time
Evidence-Based Nursing 2005;                                                      iodine.                                                                                           for application and drying time.
2(1), 4-13. Retrieved from Database
of Abstracts of Reviews of Effects
(DARE),
http://www.crd.york.ac.uk/CRD
Web/ShowRecord.asp?View=Full
&ID=12005008184




                                                                                                                                                                                                                       30
Maki, D.G., et al., (1991). 2%           Single-blinded randomized controlled        Chlorhexidine is suggested as a first line skin   Threats to the validity could include: strict aseptic   Relevant information as to products
chlorhexidine versus 70% alcohol         trial. All patients over the age of 18      preparation. Site of insertion of the catheter    technique, experience of person inserting the           used for skin antisepsis using
and 10% povidone iodine for              scheduled to receive a central venous       was cleansed by vigorous scrubbing for 30         catheter, terminology of identifying infection-         chlorhexidine. Suggest more research as
cutaneous preparation and site care      or arterial catheter in a 20 bed surgical   seconds.                                          colonization versus rate of infection.                  to the method of application of
of central venous and arterial           intensive care unit. 492 patients had                                                                                                                 antisepsis product, friction, back and
catheter insertion sites a Prospective   arterial catheters and 176 had central                                                                                                                forth or circular.
Randomised Trial of Povidone-            venous catheters.
iodine, alcohol, and chlorhexidine
for prevention of infection
associated with central venous and
arterial catheters, Lancet, 1991:
338;339-343.
Citation                                 Population Studied                           Results                               (What to Validity ofwas Threats How many were in the study) of Study
                                                                                                                                          (Who Study Validity of Study
                                                                                                                                                      to                                             (Were Implications of Study
                                                                              Results of Studyof Study Population Studied Threats were the Threats studied?to Validity of StudyImplications(Were there there significant problems
(in APA format)                                                               (What were the variables? the researchers find?)
                                         (Who was studied? How many were in the       variables? What did                                    significant problems with the study? Were to resultsfindings?) results
                                                                                                                                                      with the study? study?    (How can doubt help in
                                                                                                                            (Were there significant problems with theWere there reasons there reasons to caring for help in caring for
                                         study)                               What did the researchers find?)                                doubt findings?)
                                                                                                                           Were there reasons to doubt findings?)                                             research
                                                                                                                                                                                patients? Is more research required required before
                                                                                                                                                                                                              conclusions?)
                                                                                                                                                                                before we can draw conclusions?)
Maki, G., Ringer, M., (1991). Risk       A randomized trial of two catheter          This study assessed the role of catheter          The experience of the person inserting the              The results are beneficial in selection of
factors for infusion-related phlebitis   material with consideration of 21           material in reducing pathogenesis that is         intravenous catheter influenced the risk of for         catheters for placement but further
with small peripheral venous             potential risk factors. Place is a          device related. There was a 36% to 49%            phlebitis and the site location could influence the     studies are recommended that would
catheters. Annals of Internal            university hospital. Participants were      reduction in incidence of infusion-related        results. This is a well detailed study.                 also reflect the technique used for skin
Medicine, 1991, 114(10), 845-854.        hospitalized adults without                 phlebitis with use of PEU-Vision catheter.                                                                antisepsis prior to placement.
                                         granulocytopenia who received a             Variables were infusate, duration of catheter
                                         peripheral intravenous catheter, 714        placement, site, gender, season, and unit or
                                         patients, and 1054 peripheral catheters.    person who placed the catheter
Mimoz, O., Karim, A., Mercat, A.,        403 adults in three intensive care units    2041 blood cultures were collected in 403         Improper skin preparation could increase risk of        The product of chlorhexidine is proving
Cosseron, M., Falissard, B., Parker,     in a French university hospital who         patients. 124 yielded pathogens. 1.4% with        contaminants or lack of adequate drying time after      to be superior to the use of povidone-
F. et al. (1999). Chlorhexidine          had at least one blood culture drawn        chlorhexidine compared with 3.3% aqueous          antiseptic is applied related to using ICU patients.    iodine in skin antisepsis; however, it has
compared with povidone-iodine as         through a peripheral vein.                  iodine. Skin antisepsis was done by               Increased risk of bias due to lack of blinding.         not been proven whether friction or
skin preparation before blood                                                        vigorously applying the assigned antiseptic                                                               circular motion or other method of
culture. Annals of Internal                                                          solution once and allowed to dry 15 to 30                                                                 application of the product can reduce
Medicine, 131(11), 834-837.                                                          seconds                                                                                                   the skin flora more effectively. Further
                                                                                                                                                                                               study is needed.




                                                                                                                                                                                                                                 31
Palefski, S., Stoddard, G. J., (2001).   Two hospitals 300 and 500 beds and         Demonstrated that approximately half of the Significant imbalance between the two groups.              Infusion nurses can contribute to
The infusion nurse and patient           one infusion company. Data collected       vascular access devices are preventable when Majority of the insertions were done at one of the        reducing vascular access complications.
complication rates of peripheral-        over a three consecutive months. 639       using infusion nurses                          hospital sites and a majority of those were             More research is needed which could
short catheters: a prospective           VADs were inserted by infusion                                                            performed by the infusion team nurses. High risk of include skill and technique.
evaluation. Journal of IV Nursing,       nurses and 137 by generalist nurses.                                                      bias. Skill level or technique was not assessed in
24(2), 113-123.                                                                                                                    this study.
Citation                                 Population Studied                                  Results                                (What to Validity ofwas Threats How many were in the study) of Study
                                                                                                                                                    (Who Study Validity of Study
                                                                                                                                                                 to                                             (Were Implications of Study
                                                                                    Results of Studyof Study Population Studied Threats were the Threats studied?to Validity of StudyImplications(Were there there significant problems
(in APA format)                          (Who was studied?                                   variables? What                        (Were there significant problems with theWere there reasonscandoubt findings?) results help in caring for
                                                                                    What were the variables?did the researchers find?)                          with the study? study?       Were to results help
                                                                                                                                                        significant problems with the study?(How there reasons toin caring for
                                         How many were in the study)                What did the researchers find?)                                     doubt findings?)
                                                                                                                                   Were there reasons to doubt findings?)                                                research
                                                                                                                                                                                           patients? Is more research required required before
                                                                                                                                                                                                                         conclusions?)
                                                                                                                                                                                           before we can draw conclusions?)
Pronovost, P., Needham, D.,              Collaborative cohort study using           A sustained reduction (up to 66%) in rates of Some ICUs in Michigan chose not to participate in     Infection rate was reduced and sustained
Berenholz, S., Sinopoli, D.,             multilevel Poisson regression              catheter-related bloodstream infections.      the study.                                            by using CDC recommendations. This
Chu, H., Cosgrove, S., et al.,           modeling was used to compare               Variables-geographic regions, ICU effect,     Findings were significant and beneficial.             in turn could significantly reduce
(2006). An intervention to decrease      infection rates before, during and up to   hospital bed size, teaching status, the                                                             morbidity and the costs of care
catheter-related bloodstream             18 months after start of the study         interventions which were five evidenced-                                                            associated with catheter related
infections in the ICU. The New           intervention, 108 ICUs in Michigan,        based procedures recommended by the CDC.                                                            bloodstream infections.
England Journal of Medicine,             103 reported data for a total of
355(26), 2725-2732.                      375,757 catheter-days.




                                                                                                                                                                                                                         32
Tepus, D., Fleming, E., Cox, S.,       ED department of a 973-bed                 Tincture of iodine applied to the skin in an     This was not a randomized trial comparing the           In comparing products, the
Hazelett, S., Kropp, D., (2008).       community teaching hospital. All           outward circular motion, allowed to dry two      techniques, only the products.                          ChloraprepTM was superior in
Effectiveness of ChloraprepTM in       blood cultures drawn in one year using     minutes resulted in 3.5% contamination rate.     Because the two products have distinctly different      reducing contamination rates at a
reduction of blood culture             tincture of iodine skin prep process,                                                       colors and application procedures, it is not possible   cost savings of approximately
contamination rates in emergency       7158 blood cultures, then the              ChloraprepTM applied by scrubbing it onto        to do a blinded comparison study.                       $875,000/year.
department. Journal of Nursing         following year using ChloraprepTM          the skin with a coarse sponge applicator, in a                                                           In comparing techniques in
Care Quality, 23(3), 272-276.          skin prep process, 7606 blood cultures.    back-and-forth scrubbing action to exfoliate                                                             preparation of the skin prior to
                                                                                  the top layers of skin, resulted in a 2.2%                                                               venous access, further study is
                                                                                  contamination.                                                                                           needed.
                                                                                                                                                                                           Research study recommendation:
                                                                                  Prior contamination rates: 3.5-4.3%                                                                      To compare iodine tincture and
                                                                                                                                                                                           ChloraprepTM using the same back-
                                                                                  A secondary finding was cost savings when                                                                and-forth technique of skin
                                                                                  using ChloraprepTM                                                                                       preparation.

van der Mee-Marquet, N. L.,            Multicenter randomized equivalence         Precursor signs of infection associated with     Small sample size.                                      A two-step procedure for skin
(2007). Efficacy and safety of a two   study comparing frequency of               peripheral vascular catheters were no                                                                    preparation was as safe and effective
step method of skin preparation for    precursor signs of infection at the site   different between the two procedures used                                                                as a four-step procedure which could
peripheral intravenous catheter        of insertion for two skin preparation      for insertion.                                                                                           save in time and cost.
insertion: a prospective multicentre   procedures. The study was carried                                                                                                                   Further study is needed using larger
randomized trial. BMC Anesthesiol      over an eight month period, 248                                                                                                                     sample group
7(1), retrieved March 27, 2009 from    peripheral vascular catheter sites were
http://www.pubmedcentral.nih.go        evaluated. The two-step procedure was
v/articlerender.fefi?artid=179422      used for 130 subjects and standard
6                                      four step procedure for 118 subjects.




                                                                                                                                                                                                                         33
TRACK 3            EBP Team 1: Michelle Giddens, Stevie Ford, Brenna Johnson, Rachel Wilkinson

Clinical Question: Which arterial closure method is safer, more effective, and causes less vascular complications following cardiac catheterization in adults—the use
of manual compression or the use of arterial puncture closing devices (APCDs)?
             Citation                       Population Studied                    Results of Study                 Threats to Validity of Study                 Implications of Study
         (in APA format)                (Who was studied? How many         (What were the variables? What        (Where there significant problems       (How can results help in caring for
                                            where in the study)              did the researchers find?)            with the study? Where there               patients? Is more research
                                                                                                                    reasons to doubt findings?)            required before we can draw
                                                                                                                                                                     conclusions?)
Applegate, R.J.,Sacrinty, M.,           The population studied consisted    The independent variables in this     Patients were non-randomized.            Results can help in caring for
Kutcher, M.,Gandhi, S.K., Baki, T.      of those receiving cardiac          study included Angioseal (an          Data used for this research article      patients by presenting nurses with
T., Santos, R. M., et al. (2006).       catheterization. In hospital        arterial puncture closing device--    came from one single center that         the current research on cardiac
Vascular complications with newer       outcomes of patients undergoing     APCD) and manual compression.         was not specified. Therefore, the        catheterization closure procedures
generations of angioseal vascular       diagnostic catheterization and      The dependent variable was the        generalizability of this article can     so that they may act as advocates
closure devices. Journal of             percutaneous coronary               safety, efficacy of Angioseal         be limited.                              for their patients. Nurses can
Interventional Cardiology, 19(1), 67-   intervention (PCI) at a single      among 3 generations, and the risk                                              present the current research to
74.                                     center (which was not specified)    for vascular complications such as                                             their patients‘ doctors and
                                        were evaluated. 3,898 with          hematomas, arteriovenous                                                       advocate for the use of a vascular
                                        manual compression and 3,898        fistulae, pseudoaneurysm,                                                      closure device for their patient if
                                        with Angioseal VCD; a total of      vascular bleeding, vessel                                                      the doctor deems them a
                                        7,796 were evaluated between        occlusion, and loss of pulse.                                                  candidate.
                                        July 1997 to December 2003.         Closure device success rate was
                                        Three generations of the            98.5% for generation 1, 98.6% for
                                        Angioseal device were studied:      generation 2, and 98.1% for
                                        Generation 1, 7/97-4/00;            generation 3. The odds ratio for
                                        Generation 2, 5/00-6/02; and        any vascular complications
                                        Generation 3, 7/02-12/03.           comparing Angioseal to manual
                                                                            compression was 0.92 for
                                                                            Generation 1; 0.83 for Generation
                                                                            2; and 0.75 for Generation 3. This
                                                                            article concluded that the newest
                                                                            generation of Angioseal VCD is at
                                                                            least as effective as the original
                                                                            device. Moreover, use of the
                                                                            Angioseal was associated with
                                                                            vascular complications similar to
                                                                            or lower than vascular
                                                                            complications following manual
                                                                            compression for each generation
                                                                            of Angioseal device studied.




                                                                                                                                                                                                 34
              Citation                      Population Studied                     Results of Study                 Threats to Validity of Study                   Implications of Study
          (in APA format)               (Who was studied? How many          (What were the variables? What        (Where there significant problems         (How can results help in caring for
                                            where in the study)               did the researchers find?)            with the study? Where there                 patients? Is more research
                                                                                                                     reasons to doubt findings?)              required before we can draw
                                                                                                                                                                        conclusions?)
Dumont, C. J., Keeling, A. W.,          The population studied consisted     Variables identified included:        Some limitations included using a          When taking the other research
Bourguignon, C., Sarembock, I. J., &    of 11,110 patients‘ records          gender, comorbidities, diagnostic     retrospective analysis method, a           into consideration, manual
Turner, M. (2006). Predictors of        retrieved from the Clinical          cardiac catheterization, and          secondary database, lack of                pressure is the best intervention
Vascular Complications Post             Automated Office Solutions           percutaneous intervention. Results    reliability testing for data stored in     for those with high risk factors
Diagnostic Cardiac Catheterization      database who underwent cardiac       of this study found that vascular     the database. Data on medication           such as those mentioned in the
and Percutaneous Coronary               catheterization and/or               complications occurred more           use and anticoagulation were not           results section. However, this
Interventions. Dimensions of Critical   percutaneous intervention. This      often in patients greater than 70     available through this database,           article specifically implies that
Care Nursing, 25(3), 137-142.           study was a retrospective,           years, female, having                 which may influence the degree of          high risk indicators need
                                        descriptive, correlational study.    hypertension, renal failure, and a    vascular complications.                    continued identification in order
                                                                             percutaneous intervention.                                                       to prevent vascular complications.
                                                                             Complications included: artery                                                   Since nurses perform the initial
                                                                             dissection, arteriovenous fistula,                                               assessment and spend
                                                                             pseudoaneurysm, loss of pulse,                                                   considerably more time with the
                                                                             bleeding at entry site, hematoma                                                 patient than the physician, the
                                                                             greater than 10 centimeters.                                                     nurse can be an advocate for
                                                                                                                                                              patients by identifying those
                                                                                                                                                              having multiple high risk factors.
Koreny, M., Riedmuller, E., &           The population studied consisted     The independent variables in this     The study was inconsistent with            Considering this systematic
Nikfardjam, M. (2004). Arterial         of those receiving cardiac           study included arterial puncture      the severity of complications that         review consisted of the earliest
puncture closing devices compared       catheterizations. Out of 30          closing devices (APCDs) and           claimed to be higher when using            versions of APCDs, more research
with standard manual compression        randomized control trials, 4,000     manual compression. The               APCDs (such as hematomas). For             needs to be done to determine up-
after cardiac catheterization:          patients were studied. Data from     dependent variable was the risk       example, the definition of                 to-date- safety and efficacy of
systematic review and meta-analysis.    this study was taken from a          for vascular complications such as    hematoma varied between studies:           APCDs. Nurses will then present
JAMA, 291(3), 350-357.                  database from this systematic        hematoma, local bleeding,             some authors simply mentioned              current research to their patients
                                        review such as MEDLINE,              pseudoaneurysms, and                  the presence or absence of                 and doctors. Results can help in
                                        EMBASE, CINHAL, PASCAL,              arteriovenous fistula. Based on       hematoma; others used various              caring for patients by presenting
                                        and BIOSIS                           this meta-analysis of 30              sizes for grading. Next, only two          nurses with the current research
                                                                             randomized trials, there was only     studies out of the thirty                  on cardiac catheterization closure
                                                                             marginal evidence that APCDs          randomized controlled trials used          procedures so that they may act as
                                                                             are effective and there is reason     blind outcome assessments,                 advocates for their patients.
                                                                             for concern that these devices may    intention-to-treat analysis, and
                                                                             increase the risk of hematomas        allocation concealment which are
                                                                             and pseudoaneurysms. However,         all significant to increase a study‘s
                                                                             hemostasis time was shorter in the    reliability. Also, the researchers
                                                                             group with APCDs compared             of this article identified the studies
                                                                             with manual compression.              they found on this topic as having
                                                                                                                   ―low methodological reporting
                                                                                                                   quality.‖ In addition, the studies
                                                                                                                   used in this systematic review
                                                                                                                   consisted of the earliest versions




                                                                                                                                                                                                   35
             Citation                      Population Studied                    Results of Study                 Threats to Validity of Study               Implications of Study
         (in APA format)               (Who was studied? How many         (What were the variables? What        (Where there significant problems      (How can results help in caring for
                                           where in the study)              did the researchers find?)            with the study? Where there             patients? Is more research
                                                                                                                   reasons to doubt findings?)           required before we can draw
                                                                                                                                                                 conclusions?)
                                                                                                                  of APCDs; therefore, more
                                                                                                                  effective devices may have been
                                                                                                                  created since the time this review
                                                                                                                  was conducted.


Nikolsky, E., Roxana, M., Amir, H.,    The population studied consisted    The independent variables in this     Some flaws to take into                 Results can help in caring for
Aymong, E.D., Mintz, G.S., Lasic,      of those receiving cardiac          study included arterial puncture      consideration in this article           patients by presenting nurses with
Z., Negoita, M., Fahy, M., Krieger,    catheterizations. Out of 30         closing devices (APCDs) and           include the fact that 12 of the 30      the current research on cardiac
S., Moussa, I., Moses, J.W., Stone,    studies, 37,066 patients were       manual compression. The               studies the authors used were           catheterization closure procedures
G.W., Leon, M.B., Pocock, S.J.,        studied.                            dependent variable was the risk       nonrandomized. Also, most of the        so that they may act as advocates.
Dangas, G. (2004). Vascular                                                for vascular complications such as    studies included were made up of        Nurses can present the current
complications associated with                                              hematomas, groin bleeding,            predominately male patients             research to their patients‘ doctors
arteriotomy closure devices in                                             pseudoaneurysms, arteriovenous        ranging from 56% up to 94% of           and advocate for the use of
patients undergoing percutaneous                                           fistula, retroperitoneal              the population examined. More           APCDs for their patient if their
coronary procedures: A meta-                                               hemorrhage, limb ischemia, or         studies may be needed before the        doctor deems them a candidate.
analysis. Journal of the American                                          any case requiring surgical           same results concluded in this
College of Cardiology, 44(6), 1200-                                        vascular repair. The researchers      article may be applied to women.
1209.                                                                      found the risk for vascular
                                                                           complications was similar for
                                                                           patients receiving APCDs or
                                                                           manual compression when
                                                                           undergoing diagnostic
                                                                           angiography. Patients
                                                                           undergoing percutaneous
                                                                           coronary intervention had a
                                                                           slightly higher risk of vascular
                                                                           complications when receiving a
                                                                           brand of APCD called Angioseal.
                                                                           But risks were similar for those
                                                                           receiving other types of APCDs or
                                                                           manual compression.
Nipun, A., Matheny, M.E., Sepke, C.    The population studied consisted    The independent variables in this     APCD use was not randomly               Results can help in caring for
(2006). A propensity analysis of the   of those receiving cardiac          study included arterial puncture      assigned in this population. Also,      patients by presenting nurses with
risk of vascular complications after   catheterizations at Brigham and     closing devices (APCDs) and           data used for this research article     the current research on cardiac
cardiac catheterization procedures     Women‘s Hospital. 12,937            manual compression. The               came from one single place, the         catheterization closure procedures
with the use of vascular closure       patients made up the population     dependent variable was the risk       Brigham and Women‘s Hospital            so that they may act as advocates.
devices. American Heart Journal,       studied in this article.            for vascular complications such as    Therefore, the generalizability of      Nurses can present the current
153(4), 606-611.                                                           hematomas, groin bleeding,            this article can be limited.            research to their patients‘ doctors
                                                                           pseudoaneurysms, arteriovenous                                                and advocate for the use of




                                                                                                                                                                                               36
              Citation                       Population Studied                     Results of Study                   Threats to Validity of Study               Implications of Study
          (in APA format)                (Who was studied? How many          (What were the variables? What          (Where there significant problems      (How can results help in caring for
                                             where in the study)               did the researchers find?)              with the study? Where there             patients? Is more research
                                                                                                                        reasons to doubt findings?)           required before we can draw
                                                                                                                                                                      conclusions?)
                                                                              fistula, retroperitoneal                                                        APCDs for their patient if their
                                                                              hemorrhage, limb ischemia, or                                                   doctor deems them a candidate.
                                                                              any case requiring surgical
                                                                              vascular repair. The researchers
                                                                              found that APCDs offered a
                                                                              reduced risk of vascular
                                                                              complications in appropriately
                                                                              selected patients.
Tarvis, D. R., Dey, S., Albrecht-        The population studied consisted     Variables identified included: age,     Some limitations to this study          Nurses should be advocates for
Gallauresi, B., Brindis, R. G., Shaw,    of 13,878 cardiac catheterization    gender, race (white vs. non-            include using a retrospective           their patients concerning which
R., Weintraub, W., et al. (2005). Risk   patients. Patient data was           white), type of procedure               analysis method. The study did          closure device to use when
of Local Adverse Events following        obtained from the National           (diagnostic vs. interventional          not specify number of patients          discussing treatment with the
Cardiac Catheterization by               Cardiovascular Data Registry         cardiac catheterization), type of       receiving specific closure devices      physician. The high complication
Hemostasis Device Use -- Phase II.       from 59 different institutions.      hemostasis, BMI, diabetes,              or manual compression nor did it        rate with VasoSeal brand should
Journal of Invasive Cardiology,                                               hypertension, peripheral vascular       specify anticoagulation times. The      be taken into consideration by
17(12), 644-650.                                                              disease, history of congestive          article did not specify if they had     practitioners when deciding on a
                                                                              heart failure, acute renal failure      access to the medication records.       hemostasis device. Nurses, in this
                                                                              and recent interventional cardiac       Other threats to validity include       case, should advocate that
                                                                              catheterization, emergency vs.          no follow-up after discharge.           VasoSeal not be used, but rather
                                                                              elective procedures and sheath                                                  an alternative APCD device or
                                                                              size. Independent variables                                                     manual compression.
                                                                              included vascular closing devices
                                                                              and manual compression. The
                                                                              dependent variables identified
                                                                              were risk for vascular
                                                                              complications. Of the 13,878
                                                                              patients identified, 4,179 achieved
                                                                              hemostasis by standard manual or
                                                                              mechanical compression.
                                                                              Vascular complications were
                                                                              reported in 3.37% of all patients
                                                                              using both manual and
                                                                              mechanical, with the most
                                                                              common being hematoma (2.0%),
                                                                              entry site bleeding (1.25%), and
                                                                              pseudoaneurysm (0.32%).
                                                                              Compared to manual
                                                                              compression, none of the
                                                                              hemostasis devices were
                                                                              significantly different with respect




                                                                                                                                                                                                   37
              Citation                        Population Studied                      Results of Study                   Threats to Validity of Study             Implications of Study
          (in APA format)                 (Who was studied? How many           (What were the variables? What          (Where there significant problems    (How can results help in caring for
                                              where in the study)                did the researchers find?)              with the study? Where there           patients? Is more research
                                                                                                                          reasons to doubt findings?)         required before we can draw
                                                                                                                                                                      conclusions?)
                                                                                to vascular complications except
                                                                                VasoSeal brand. Researchers
                                                                                found relatively high rates of local
                                                                                vascular complications with the
                                                                                use of VasoSeal. Perclose and
                                                                                Angio-Seal brands demonstrated a
                                                                                protective effect with respect to
                                                                                pseudoaneurysm formation.
Tarvis, D. R., Gallauresi, B. A., Rich,   The data on the population were       The independent variables in this       APCD use was not randomly             Results can help in caring for
S. E., Shaw, R. E., Weintraub, W. S.,     obtained from the American            study included vascular closing         assigned in this population. Also     patients by presenting nurses with
Brindis, R. G., et al. (2004). Risk of    College of Cardiology-National        devices (APCD) and manual               the study does not take into          the current research on cardiac
local adverse events following            Cardiovascular Data Registry.         compression. The dependent              consideration that APCD use can       catheterization closure procedures
cardiac catheterization by hemostasis     Those subjects undergoing cardiac     variable was the risk for vascular      present a higher risk to patients     so that they may act as advocates.
device use and gender. The Journal        catheterization. The sample size      complications such as hematomas,        when inserted by a less               Nurses can present the current
of Invasive Cardiology , 16 (9), 459-     of the univariate analysis 166,680    groin bleeding, pseudoaneurysms,        experienced physician. But these      research to their patients‘ doctors
464.                                      and the sample of the                 arteriovenous fistula,                  reasons were not significant          and advocate for the use of
                                          multivariante 156,853.                retroperitoneal hemorrhage, limb        enough to doubt the findings.         APCDs for their patient if their
                                                                                ischemia, or any case requiring                                               doctor deems them a candidate,
                                                                                surgical vascular repair. Results                                             and to especially emphasize that
                                                                                showed that the risks for vascular                                            female patients were twice as
                                                                                complications were greater for                                                likely to develop a complication
                                                                                females than for males                                                        versus males.
                                                                                undergoing cardiac catheterization
                                                                                whether or not they used manual
                                                                                pressure or an APCD. There also
                                                                                was a positive association
                                                                                between comorbidity and vascular
                                                                                complications. The results of this
                                                                                study indicate that patients with
                                                                                various serious coexisting
                                                                                cardiovascular problems were at
                                                                                relatively high risk for
                                                                                complications. Also, patients
                                                                                were more likely to receive
                                                                                hemostasis devices if they did not
                                                                                have these co-existing problems.




                                                                                                                                                                                                    38
TRACK 3             EBP Team 3: Meagan Inouye, Ashley Hill, Amalia Floyd &, Kristen Monroe

Clinical Question: For adults 18 and older receiving subcutaneous heparin therapy, does rotating sites, duration of injection, pre and post application of ice reduce the
side effects of bruising, pain, and hematomas at the injection site compared with the standard technique?
              Citation                        Population Studied                          Results of Study                   Threats to Validity of Study                   Implications of Study
          (in APA format)                 (Who was studied? How many               (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                              where in the study)                    did the researchers find?)              with the study? Where there                  patients? Is more research
                                                                                                                              reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                 conclusions?)
Akpinar, R. B., & Celebioglu, A.        The population was formed by the          Independent variables were 4500IU        Randomization was not applied in         The results from the study provide
(2008). Effect of injection duration    patients who were hospitalized at         LMWH dose, 27 gauge prefilled            the selection of region and treatment    new information for nursing practice
on bruising associated with             Chest Disease and Surgery Hospital        syringes, insertion angle 90, site      order. The current study is limited to   about bruising associated with
subcutaneous heparin: a quasi-          and ordered to receive subcutaneous       location right, left or lower abdomen    a small sample affected by chronic       subcutaneous heparin. Waiting 10s
experimental within-subject design.     LMWH. There were 36 patients in           at least 5cm from the umbilicus, area    obstructive pulmonary disease. There     before withdrawing the needle after
International Journal of Nursing        the study.                                cleaned with alcohol before injection    was a larger number of male patients     10s injection duration may be more
Studies , 45, 812-817.                                                            and allowed to dry and after             in the study than female.                preferable in clinical practice because
                                                                                  injection, applying light pressure at                                             less time is needed for administration
                                                                                  the injection site after the injection                                            of heparin.
                                                                                  and not massaging the site.
                                                                                  Dependent variables were injection
                                                                                  technique A: 10s injection duration,
                                                                                  technique B: 30s injection duration,
                                                                                  technique C: waiting 10s before
                                                                                  withdrawing the needle after 10s
                                                                                  injection duration. Findings
                                                                                  demonstrated that 30s duration
                                                                                  injection and waiting 10s before
                                                                                  withdrawing the needle after 10s
                                                                                  injection duration significantly
                                                                                  results in fewer and smaller bruises.
Beyea, S. C., & Nicoll, L. H. (1996).   This was a systematic review in           Brenner, Wood, and George – found        There is no evidence suggesting any      From the evidence reviewed they
Subcutaneous administration of          which covered 6 different studies. In     standard injection technique resulted    threats to the validity of the study.    came up with new practice
heparin: an integrative review of       all of the studies they were all adults   in more large hematomas when                                                      implications when giving a
research. The Onling Journal of         over the age of 18 years.                 compared to modified injection                                                    subcutaneous heparin injection.
Knowledge Synthesis for Nursing , 3                                               technique. McGowan and Wood                                                       Including using a 25-guage needle,
(1), 1-5.                                                                         found no statistical difference                                                   3mL syringe, insert at a 90-degree
                                                                                  demonstrated related to bruising                                                  angle (adjust to 45-degrees
                                                                                  between the four techniques used.                                                 depending on amount of
                                                                                  Ross and Soltes found ice had no                                                  subcutaneous fat), use abdomen,
                                                                                  effect on size or occurrences of                                                  thigh or arm, bunch skin, inject
                                                                                  hematoma, but patient‘s perception                                                medication slowly, do not aspirate,
                                                                                  of pain was less. Stewart-Fahs and                                                slowly withdraw needle, do not
                                                                                  Kinney found no statistical                                                       massage afterward, apply gauze to




                                                                                                                                                                                                              39
              Citation                        Population Studied                        Results of Study                   Threats to Validity of Study                    Implications of Study
          (in APA format)                 (Who was studied? How many             (What were the variables? What          (Where there significant problems         (How can results help in caring for
                                              where in the study)                  did the researchers find?)              with the study? Where there                   patients? Is more research
                                                                                                                            reasons to doubt findings?)                required before we can draw
                                                                                                                                                                                conclusions?)
                                                                                differences found among groups for                                                 site gently, and re-asses for side
                                                                                bruising at 60 and 72 hours post-                                                  effects. More research needs to be
                                                                                injection and APTT (activated partial                                              conduct to minimize negative
                                                                                thromboplastin time). Vanbree,                                                     outcomes such as needle size, angle
                                                                                Hollerbach, and Brooks found none                                                  of insertion, and health and age
                                                                                of the three techniques were                                                       status.
                                                                                statistically significant in terms of
                                                                                smaller or fewer bruises.
                                                                                Wooldridge and Jackson found a
                                                                                technique using a 3mL syringe with a
                                                                                25-guage, 5/8 inch needle, a change
                                                                                of the needle, use of an air bubble,
                                                                                and use of a dry sponge resulted in a
                                                                                few areas of induration and smaller
                                                                                areas of bruising and induration.
Chan, H. (2000). Effects of injection   34 subjects were recruited from an      Independent variable in the study        The characteristics and size of the       Again the study has concluded that
duration on site-pain intensity and     acute stroke-care unit. The subjects    was the injection duration and the       sample pose a threat to the               the 30 second duration injection
bruising associated with                were 40years of age or older, able to   dependent variables, site-pain and       applicability of the study. The sample    significantly reduces site-pain during
subcutaneous heparin. Issues and        provide written consent, and already    bruise size.                             size is small, the subjects were all      injection and results in fewer and
Innovations in Nursing Practice ,       receiving subcutaneous injections of    The injection duration was measured      stroke victims, and they were all         smaller bruises. A major implication
882-892.                                5000 units of Dalteparin twice a day.   in a 10second duration injection and     Caucasian with an unequal number          for the nursing practice is that
                                        All of the subjects were Caucasian.     a 30 second duration injection.          of males and females 40 years of age      reduced sit-pain and bruising
                                                                                Immediately after each injection the     or older. These factors affect the        preserves more potential abdominal
                                                                                subjects were given a Visual             ―generalisability‖ of the study. Also,    skin sites for subsequent injections as
                                                                                Analogue Scale to rate their pain.       the sequence of administering the         well as reducing the psychological
                                                                                Injection site-bruising were measured    injection techniques should have          discomfort of the patient. More
                                                                                at 48 and 60 hours after each            been randomized to avoid                  research is required on a sample that
                                                                                injection. The researchers concluded     introducing bias into the patient data.   more represents the population to
                                                                                from this study that the 30 second                                                 form more ―generalisable‖ results.
                                                                                duration injection significantly
                                                                                reduces site-pain during injection and
                                                                                results in fewer and smaller bruises.
Kuzu, N., & Ucar, H. (2001). The        The population for the research was     The independent variable                 The sample was also tested to             Cold application only helps with pain
effect of cold on the occurance of      formed by the patients who were         (local dry cold application) and the     determine whether age or sex, body        does not help with bruising and the
bruising haematoma and pain at the      hospitalized at Hacettepe University    dependent variables (age, sex, body      mass index, patients‘ current             standard injection technique can be
injection site in subcutaneous low      Hospital Orthopedics and Internal       mass index, patient‘s current            medications, latest platelet and APTT     effective both in preventing and
molecular weight heparin.               Medicine Services and who were          medications, last platelet and last      values had an effect on the incidence     reducing the occurrence of bruising
International Journal of Nursing        ordered to receive subcutaneous         APTT values).                            of bruise formation, pain intensity       and haematoma and in decreasing the
Studies , 38, 51-59.                    LMWH. The sample for the research       As a result, when the findings of the    and duration. No significant              perception and duration of injection
                                        was formed by 63 patients. The          study are examined, it can be said       differences were observed. No other       pain.




                                                                                                                                                                                                             40
             Citation                   Population Studied                         Results of Study                    Threats to Validity of Study                    Implications of Study
         (in APA format)            (Who was studied? How many              (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                        where in the study)                   did the researchers find?)               with the study? Where there                  patients? Is more research
                                                                                                                        reasons to doubt findings?)               required before we can draw
                                                                                                                                                                           conclusions?)
                                  patients, who were hospitalized on       that the standard injection technique     threats to validity were noted.           However, it is necessary for this
                                  these services between the dates of      can be effective both in preventing                                                 study to be repeated by using a
                                  14 July 1997 and 27 January 1998,        and reducing the occurrence of                                                      representative sample in order to
                                  met the study criteria and received 2x   bruising and haematoma and in                                                       confirm or contradict the results.
                                  20 mg (0.2 ml) enoxaparine daily.        decreasing the perception and
                                  They did not have any coagulapathy,      duration of the injection pain; the
                                  and were not treated with any            pre-injection, pre-and post-injection
                                  anticoagulant drug within the last 7     or post-injection cold at the injection
                                  days. Their platelet values were         site is not effective in reducing or
                                  within the normal limits before the      preventing the occurrence of bruising
                                  research. They were not given any        and haematoma, but especially the
                                  injection during the days of research    pre-injection and post- injection cold
                                  part from the study.                     application is effective in decreasing
                                                                           the pain duration and perception.
Ross, S., & Soltes, D. (1995).    70 healthy, Caucasian subjects (54       My independent variables were two         All of the results were in favor of       The use of ice significantly
Heparin and haematoma: does ice   females, 16 males), who were             subcutaneous injections of 5000 IU        non-use of ice for the decrease           minimized patient discomfort
make a difference? Journal of     predominantly employees of a large       at a ninety degree angle, 25 gauge        formation of haematomas but this          associated with injections and the
Advanced Nursing , 21, 434-439.   urban, teaching hospital, were           needle, an alcohol swab used to           contradicts the suggestion made by        intervention is worth consideration
                                  included on a volunteer basis. Were      cleanse the site gently prior to          Genton (1974), Lundin (1978), and         but it did not support the use of this
                                  18 years or older and able to provide    administration, ice (wrapped in           Caprim et al (1977), who actually         technique to reduce the incidence or
                                  informed consent, did not have any       plastic) was applied lightly to one of    advocate the use of ice as a means to     size of haematoma formation.
                                  known clotting disorder and had not      the injection sites for 2 minutes pre-    minimize the formation of                 However, minimizing patient
                                  taken any anticoagulant medication       and post- injection, a visual analogue    haematomas at the injection site.         discomfort is one of our top priorities
                                  in the previous 7 days.                  scale was used to rate the intensity of   There were many reasons to doubt          as a caregiver and the relationship of
                                                                           the sensation the patient perceived at    the study because of the biases in this   ice application and patient perception
                                                                           the time of the injection.                study. It was limited to Caucasian        of discomfort during injection
                                                                           The findings were that this study did     subjects and all were healthy. Also it    requires further study.
                                                                           not support the hypothesis that the       is possible that unintentional bias
                                                                           application of ice to the site prior to   was introduced due to the fact that
                                                                           and following subcutaneous                none of the subjects were blinded of
                                                                           injections of heparin results in fewer    the treatment.
                                                                           and smaller haematomas. However,
                                                                           the application of ice pre- and post-
                                                                           injection did significantly minimize
                                                                           the patient‘s discomfort of injection.




                                                                                                                                                                                                         41
              Citation                         Population Studied                         Results of Study                    Threats to Validity of Study                   Implications of Study
          (in APA format)                  (Who was studied? How many              (What were the variables? What           (Where there significant problems        (How can results help in caring for
                                               where in the study)                   did the researchers find?)               with the study? Where there                 patients? Is more research
                                                                                                                               reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                  conclusions?)
Zaybak, A., & Khorshid, L. (2007).       The sample for this study consisted      The independent variable (injection       The main limitation was the small        As a result, the current research
A study on the effect of duration of     of 50 patients. The population for the   duration) and the dependent variables     number of subjects. Also, the            demonstrated that administering a
subcutaneous heparin injection on        research was formed from patients        (site-pain, site pain duration and        subjects were conscious and affected     subcutaneous heparin injection over a
bruising and pain. Journal of Clinical   who were hospitalized at the             bruise size).                             by cardiovascular disease, fracture      longer duration (30 seconds)
Nursing , 378-385.                       Neurology, Orthopedics and               The percentage of bruising                and strokes. For these reasons,          significantly reduced the occurrence
                                         Cardiology units of a university         occurrence was 64% with the               ―generalizability‖ of the research       of bruising, bruising size, site-pain
                                         hospital and for whom subcutaneous       injection of 10 seconds duration and      findings is limited to similar groups.   intensity and site-pain duration.
                                         LMWH had been prescribed. Patients       42% in the 30- second injection. It                                                Although the relationship between
                                         in these units between 1 March 2003-     was determined that the size of the                                                the application of subcutaneous
                                         1 May 2004 and receiving                 bruising was smaller in the 30 second                                              heparin 10 or 30 seconds to bruising
                                         subcutaneous injections of LMWH          injection. Pain intensity and pain                                                 occurrence and size was shown to be
                                         twice a day. Subjects were 20 years      period were statistically lower for the                                            significant in this study, further
                                         of age or older, conscious enough to     30 second injection than for the 10-                                               research using different durations and
                                         answer questions about their pain and    second injection. The findings in this                                             a larger sample is suggested.
                                         receiving subcutaneous injections of     research study supported the use of a
                                         LMWH twice a day. Their platelet         30- second duration for administering
                                         values were within the normal limits     heparin injections to reduce the
                                         before the research.                     incidence or size of bruising.
Zeraatkari, K., Karimi, M., Shahrzad,    This semi experimental complete          Independent variable: arm, abdomen        Subject size was small, only 58          According to the results of this study,
M., & Changiz, T. (2005).                crossover study designed and was         and thigh                                 participants. The researchers do not     abdomen area may be considered as
Comparison of heparin subcutaneous       performed on 58 patients who             Dependent variable: bruise size and       specify the characteristics of the       the preferred site for subcutaneous
injection in thigh, arm, and abdomen.    received subcutaneous heparin            pain.                                     bruising nor did they provide            heparin injection because of less pain
Canadian Journal of Anesthesia , 52      injection (5000 Iu subcutaneous) in      The pain intensity was estimated          demographic information regarding        intensity. This may be attributed to
(A60), 1.                                randomly ordered sites (abdomen,         immediately after injection using         the participants.                        the scarce distribution of pain
                                         arm, and thigh) with a 12 hours          visual analog scale (VAS). Bruise                                                  receptors in the abdomen in
                                         interval.                                size was observed and measured 24,                                                 compared to thigh and arm or may be
                                                                                  48 and 72 hours after injection. Pain                                              due to psychological factors.
                                                                                  intensity was significantly decreased
                                                                                  from arm to thigh and then to
                                                                                  abdomen.




                                                                                                                                                                                                               42
TRACK 3            EBP Team 20: Temequah Breckenridge, Nancy Hancin, Shannon Rials, Dana Stipes

Clinical Question: In bedridden patients in hospital settings, is subcutaneous Lovenox/Heparin or pneumatic compression stockings most effective in preventing
venous thromboembolism?
             Citation                         Population Studied                        Results of Study                   Threats to Validity of Study                   Implications of Study
         (in APA format)                  (Who was studied? How many             (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                              where in the study)                  did the researchers find?)              with the study? Where there                 patients? Is more research
                                                                                                                            reasons to doubt findings?)               required before we can draw
                                                                                                                                                                              conclusions?)
Camporese G., Bernardi E., Prandoni     1761 consecutive adult patients who     Intervention was using compression       Stockings were used instead of a         Findings of the study challenge
P., et al (2008). Low-molecular-        were 18 years and older that were       stockings or LMWH in prevention of       placebo. Low risk participant study      current practice of not using
weight-heparin (LMWH) versus            undergoing outpatient knee              deep vein thrombosis (DVT)               sample. Not double blind or double       thromboprophylaxis after knee
compression stockings for               arthroscopy between March 2002 and      following arthroscopic knee surgery.     dummy.                                   arthroscopy surgery. This is the
thromboprophylaxis after knee           January 2006.                           Outcome - LMWH 7 day                                                              largest randomized study of venous
arthroscopy: A randomized trial.                                                prophylactic regime is superior to                                                thromboprophylaxis after knee
Annals of Internal Medicine, 149: 73-                                           other methods in preventing DVT.                                                  arthroscopy.
82.
Goldhaber, S.Z., Tapson, V.F., Uri,     A total of 4,990 patients immobilized   Enoxaparin 30 mg/40 mg doses             Some high-risk patients were             The hospital benefits, cost-
E. Gideon B., & Comp, P.C. et al.       with severe chest (cardio-pulmonary)    versus Heparin 5,000 U three times a     excluded, i.e. stroke or MI. A very      effectiveness, and decrease mortality
(2003). Prophylaxis of venous           disease, infection without septic       day were used in the study along         minimum amount of the results were       in patients show that the results not
thromboembolism (VTE) in the            shock, rheumatic disorders, arthritis   with a placebo group. In patients that   considered unrelated to the study by     only benefit the patient but make it a
hospitalized medical patient.           of the legs, and/or having              are not at a high-risk for bleeding      the investigators.                       win-win situation for the healthcare
Hospital Medicine Consensus             inflammatory bowel disease.             then the use of low-molecular-                                                    industry.
Reports, (5), 1-20.                                                             weight-heparinoid is preferred over
                                                                                the use of mechanical compression
                                                                                devices. Enoxaparin is associated
                                                                                with fewer deaths, less bleeding and
                                                                                significantly fewer adverse events
                                                                                than Heparin.
Goldhaber, S.Z., Dunn, K., Gerhard-     150 patients who were 18 years and      The variables were enoxaparin 40mg       No threats to validity except that the   The study implied that multimodality
Herman M., Park, J., Black, P.          older that were undergoing              daily and heparin 5000 U twice a         ultrasound was performed to detect       approach was beneficial in
(2002). Low rate of venous              craniotomy for brain tumor.             day. All patients had graduated          an early asymptomatic DVT. This          preventing symptomatic DVT.
thromboembolism after craniotomy                                                compression stockings. The results       was a double-blinded test. No            These results show that with
for brain tumor using multimodality                                             were that none showed symptomatic        significant problems were noted or       consistent use of either enoxaparin or
prophylaxis. Chest, 122(6):1933-7.                                              deep vein thrombosis (DVT) or            reasons to doubt findings.               heparin in combination with the
                                                                                pulmonary embolism (PE). There                                                    graduated compression stockings
                                                                                were no significant differences in the                                            consistently prevented VTE. Yes,
                                                                                two prophylaxis groups. The overall                                               additional research could be done to
                                                                                rate of asymptomatic venous                                                       find out if discontinuing the use of
                                                                                thromboembolism (VTE) was 9.3%.                                                   graduated compression stockings
                                                                                Ten out of the fourteen patients who                                              would increase the risk of DVT.
                                                                                were identified as having VTE was
                                                                                limited to the deep veins of the calf.




                                                                                                                                                                                                           43
              Citation                      Population Studied                        Results of Study                   Threats to Validity of Study                    Implications of Study
          (in APA format)               (Who was studied? How many             (What were the variables? What          (Where there significant problems         (How can results help in caring for
                                            where in the study)                  did the researchers find?)              with the study? Where there                   patients? Is more research
                                                                                                                          reasons to doubt findings?)                required before we can draw
                                                                                                                                                                              conclusions?)
Kakkos, S.K., Caprini, J.A.,          A total of 7431 surgery patients were   Compared with compression alone,         There were no significant problems        More research is needed on the use
Geroulakos, G., Nicolaides, A.N.,     studied. Ages ranged from 18 years      the use of combined modalities           with the study but there were             of pharmacological prophylaxis
Standsby, G.P., Reddy, D.J., et al.   old and older. The mean age was         reduced significantly the incidence of   concerns about needing more studies       alone to help prevent PE‘s. The
(2008). Combined intermittent         65.5 years old.                         both symptomatic deep vein               on their role in PE prevention,           results of this study would in caring
pneumatic leg compression and                                                 thrombosis (DVT) and pulmonary           compared with pharmacological             for patients by knowing that the use
pharmacological prophylaxis for                                               embolism (PE).                           prophylaxis alone, are well needed.       of compression stockings works great
prevention of venous                                                                                                                                             alone to prevent blood clots but in
thromboembolism in high-risk                                                                                                                                     high-risk patients the combination of
patients. International Angiology,                                                                                                                               the compression stockings and
25(2): 101-61.                                                                                                                                                   pharmacological prophylaxis works
                                                                                                                                                                 best.




TRACK 4             EBP Team 4: Erika Bartee, Julie Chenoweth, Deborah Graves, Honie Hager

Clinical Question: What is the effect of a computer-assisted emergency department triage system compared to traditional memory-led triage systems on patient
outcomes, staff satisfaction, and hospital cost among adult patients?
              Citation                      Population Studied                        Results of Study                   Threats to Validity of Study                    Implications of Study
          (in APA format)               (Who was studied? How many             (What were the variables? What          (Where there significant problems         (How can results help in caring for
                                            where in the study)                  did the researchers find?)              with the study? Where there                  patients? Is more research
                                                                                                                          reasons to doubt findings?)                required before we can draw
                                                                                                                                                                              conclusions?)
Dong, S., Bullard, M., Meurer, D.,    Purpose:                                Independent Variable:                       Short study period (5weeks)           More research is needed in a variety
   Colman, I., Blitz, S., Holroyd,    To determine agreement between a        e-TRIAGE System and                         Only one facility was studied         of settings and patient populations to
   B., et al. (2005). Emergency       computer decision tool and memory       memory-led paper 5-level triage             Sample size was only 100 patients     support the reliability of computer
   triage: Comparing a novel          based triage in the emergency           system                                      Triage drift occurred with the duty   triage.
   computer triage program with       department.                                                                          nurses‘ acuity scores. This triage
   standard triage. Society of        Design:                                 Dependent Variable:                          drift most prominently affected       The research into computer triage
   Academic Emergency Medicine.       Prospective observational and           Nurses‘ score using the e-TRIAGE             the level 2 agreement of              will allow United States Emergency
   12(6): 502-507.                    retrospective review.                   vs. the memory led paper 5-level             admission rates (73.7% for            Departments to implement one
                                      Sample;                                 triage system.                               memory based triage versus            uniform reliable form of triage that
                                      Adult patients 17 years and older                                                    37.25%). This difference in           insures patient safety and satisfaction




                                                                                                                                                                                                           44
    Citation            Population Studied                        Results of Study                   Threats to Validity of Study              Implications of Study
(in APA format)     (Who was studied? How many             (What were the variables? What          (Where there significant problems   (How can results help in caring for
                        where in the study)                  did the researchers find?)              with the study? Where there            patients? Is more research
                                                                                                      reasons to doubt findings?)          required before we can draw
                                                                                                                                                    conclusions?)
                  presenting to the emergency             Results:                                   admission rate was due to the     and improves resource utilization and
                  department during a study nurse‘s       There was an overall fair agreement        difference in level 2 triage      staff satisfaction.
                  shift were eligible for inclusion. 37   (0.2< k< 0.4) between the volunteer        assignment.
                  ―duty‖ nurses, who were volunteer,      duty triage nurses and the review
                  experienced emergency triage nurses,    panel Agreement between study
                  were included to utilize the memory-    nurses using e-TRIAGE and the
                  led paper system. Two study nurses      expert review panel improved to
                  were recruited and trained to use the   moderate agreement (0.4< k< 0.6).
                  e-TRIAGE system.
                                                          During overcrowding, the duty
                  722 patients were triaged during the    nurses using memory-led triage
                  study.                                  down triaged patients which is
                                                          known as ―triage drift‖. Only 3%
                  100 patients were randomly selected     were assigned to level 2 (compared
                  to be studied through retrospective     to 24.7% assigned by the expert
                  review by a panel of experts.           panel) while other stable but high
                                                          risk patients were down triaged to
                  Two patients were excluded due to       level 3, potentially causing a delay
                  missing documentation.                  in much needed physician
                                                          assessment. The study nurses on the
                                                          other hand, assigned 20.6% of the
                                                          patients to level two.

                                                          A discrepancy was found among
                                                          nurses using memory driven paper
                                                          based triage. The study Nurses
                                                          assigned a higher acuity in 25
                                                          patients and a lower acuity score in
                                                          26 patients when compared with the
                                                          memory nurses.

                                                          The study Nurses triage scores were
                                                          found to be reliable (with an
                                                          interrater agreement of K=0.76) with
                                                          triage nurses that have at least three
                                                          years experiences.




                                                                                                                                                                               45
             Citation                      Population Studied                        Results of Study                     Threats to Validity of Study                   Implications of Study
         (in APA format)               (Who was studied? How many             (What were the variables? What            (Where there significant problems        (How can results help in caring for
                                           where in the study)                  did the researchers find?)                with the study? Where there                 patients? Is more research
                                                                                                                           reasons to doubt findings?)               required before we can draw
                                                                                                                                                                              conclusions?)
Dong, S., Bullard, M., Meurer, D.,   Purpose:                                Independent Variable:                       The author states that there is a      According to the author, more
     Blitx, S., Ohinmaa, A.,         To compare agreement between two        eTriage web-based triage tool and            variation and grey zones exist in      research is required to look at the
     Holroyd, B., et.al.             blinded, independent users of the       ED overcrowding                              triage because each nurse will see a   long term reliability and efficacy of
     (2006). Reliability of          web-based triage tool (eTRIAGE) to                                                   patient‘s situation differently.       computerized triage.
     computerized                    examine the effects of ED crowding      Dependent Variable:                         The study was conducted at a single
     emergency triage.               on triage reliability.                  Interrater reliability of nurses‘ scores     large urban emergency department       Reliability of the eTriage is
     Society of Academic             Design:                                 using e-TRIAGE.                              and may only be comparable to          important for patient outcomes of
     Emergency Medicine,             Prospective observational in a real                                                  other large urban emergency            safety and satisfaction.
     13(3): 269-275.                 time environment.                       Results:                                     departments.
                                                                                                                         While the study nurse made her          Staff satisfaction could be improved
                                     Sample:                                 For e-TRIAGE, the triage score               own decisions on the complaint         due to proper assignment of acuity
                                     All patients over the age of 17 who     reliability was compared between             section she did not do her own         scores, ease of use for the computer
                                     came to the ED during the study         two study nurses to study the                assessment, she was required to just   system, and the nursing staff would
                                     hours were eligible for inclusion.      interrater reliability of the computer       listen and observe the first nurses    be utilized correctly for the patients
                                     575 Patients triaged by two study       software during ED                           assessment.                            who need them.
                                     nurses over a 9 week period had their                                               There is no uniform definition of
                                     charts reviewed.                        Agreement was good to moderate               overcrowding.                          Facility cost would be affected by
                                                                             between the two nurses, with good                                                   resource utilization. Unnecessary
                                     Complete data was available for 569     defined as K > 0.8 and moderate                                                     tests and procedures would not be
                                     of the patients.                        defined as K > 0.6 < 0.8 , CI 95%.                                                  preformed for patients who are up
                                                                                                                                                                 triaged during times of lower patient
                                     Overcrowding data was also              Data were also collected every two                                                  volume. Facilities would benefit
                                     complied for 353 patients.              hours to compare the effect of ED                                                   from proper triage in the areas of
                                                                             overcrowding on the study nurses                                                    liability.
                                     8 nurses were recruited based on        triage score reliability while using
                                     their triage experience with a range    ―eTriage.‖
                                     of 3 to 12 years. Two study nurses
                                     were included to perform the second     No statistical or clinically important
                                     independent eTRIAGE assessment of       agreement differences were
                                     comparison.                             identified between the nurses at
                                                                             different levels of overcrowding. The
                                     Critically ill patient were excluded    kappa weighted linear (KWL) was
                                     from the study due to their need for    used to define agreement (kwl=0.56
                                     immediate intervention.                 [95% CI =0.49 to 0.64].

                                                                             The agreement did not change due to
                                                                             periods of ambulance diversion,
                                                                             number of admitted patients in the
                                                                             ED, the number of patients in the
                                                                             waiting room, or the number of




                                                                                                                                                                                                          46
              Citation                      Population Studied                        Results of Study                   Threats to Validity of Study               Implications of Study
          (in APA format)               (Who was studied? How many             (What were the variables? What          (Where there significant problems      (How can results help in caring for
                                            where in the study)                  did the researchers find?)              with the study? Where there             patients? Is more research
                                                                                                                          reasons to doubt findings?)           required before we can draw
                                                                                                                                                                        conclusions?)
                                                                              patients registered over a two hour
                                                                              period.




Dong, S., Bullard, M., Meurer, D.,    Purpose:                                Independent Variable:                     The large sample size may reduce     Hospital administrators can more
      Blitz, S., Akhmetshin, E.,      To examine the validity of e-           eTRIAGE                                    the study‘s efficiency.              accurately define resource needs,
      Ohinmaa, A., et. al. (2007a).   TRIAGE on the basis of resource                                                                                         compare sites and regions, and
      Predictive validity of a        utilization (specialist consultation,   Dependent Variable:                       The eTRIAGE system was               perform benchmarking comparisons
      computerized emergency          use of CT scans, and ED length of       Predictive validity of resource            introduced 6 months before study     with a valid computerized triage
      triage tool. Society of         stay [LOS]) and cost as measures of     utilization and cost as measures of        and they had no way to know if       system. This will potentially improve
      Academic Emergency              acuity. This was to evaluate the        acuity was the dependent variable.         some of the nurses were still        budgeting and cost efficiency.
      Medicine. 14(1): 16-21.         validity of e-TRIAGE to predict                                                    learning at the time of the study.   According to the author, more
                                      severity, resource utilization and      Results:                                                                        research is required and should focus
                                      incurred ED and inpatient costs.        Resource Utilization:                     Also, this study may not be          on specific presenting complaints in
                                                                              There was a significant correlation        generalizable to other facilities    order to assess more accurately the
                                      Design:                                 between triage score and the odds for      that have different volumes and      validity of eTriage.
                                      This study examined data from the       a specialist consultation and CT scan.     experience levels.
                                      Ambulatory Care Classification          LOS and triage score were also
                                      System database in Alberta Canada       significantly correlated (p<0.001).
                                      over a 6 month period.
                                                                              Cost
                                      Sample:                                 A correlation between cost and the
                                      29,524 adults aged 17 years and over    triage score was statistically
                                      who were presented to the ED over a     significant (p=0.05).
                                      6 month period were included in this
                                      study. This was conducted at a large,
                                      urban, tertiary care center which had
                                      implemented e-TRIAGE 6 months
                                      prior to the study and has an annual
                                      volume of approximately 67,000 ED
                                      visits.




                                                                                                                                                                                                      47
             Citation                        Population Studied                         Results of Study                     Threats to Validity of Study                  Implications of Study
         (in APA format)                 (Who was studied? How many              (What were the variables? What            (Where there significant problems       (How can results help in caring for
                                             where in the study)                   did the researchers find?)                with the study? Where there                patients? Is more research
                                                                                                                              reasons to doubt findings?)              required before we can draw
                                                                                                                                                                               conclusions?)
Dong, S., Bullard, M., Meurer, D.,     Purpose:                                 Independent variables:                      The results may only be               The implication of the study is
      Blitz, S., Holroyd, B. & Rowe,   To describe the interrater agreement     The independent variable is the              generalizable for a large Ed          quality assurance and safety for the
      B. (2007b). The effect of        and Nurse manual overrides of            additional specialized training on           serving an urban population.          patient being admitted to an ED
      training on nurse agreement      nurses using e-Triage for 2 different    effective use of the E- triage
      using an electronic triage       intensities of staff training.           computerized 5 level triage program.        The study nurses‘ reliability         Implications for nursing practice
      system. Canadian Journal of      Design:                                                                               scores may be affected by the fact    involve recommending better
      Emergency Medicine. 9(4):        The study is a prospective               Dependant variables:                         that they are highly motivated        educational preparation before
      260-266.                         observational design.                    The dependant variable is the                professionals.                        implementation of software driven
                                       Sample:                                  reliability of the assigned triage score    The scores for the extra training     triage system.
                                       The Population was approximately         Results:                                     may be effected by the fact that
                                       67,000 patients who visited a large      The Study nurses triage reliability in       the nurses having already been        More evaluation is needed on the
                                       urban Canadian teaching hospital in      Phase two and agreement with an              exposed to the program in the first   long-term effects of improved
                                       one year.                                experienced triage nurse improved            phase.                                education on the results of triage
                                                                                with additional training when                                                      acuity scores.
                                       The study employed 77 triage nurse,      compared with the standard three-           The patients may not have given
                                       known as the standard trained Nurse      hour in- service given to the duty           the same answers to questions
                                       (STN).                                   Nurses.                                      asked by each triage nurse

                                       In phase one, 24 triage nurses where     Weighted Kappa scores were the              The sequence of triage, duty nurse
                                       given the 3 hour in-service and then     primary outcome for this study               followed by triage nurse in the
                                       asked to share what they learned with                                                 study may have been a source of
                                       their colleagues.                        Excellent was defined as K > 0.8,            bias.
                                                                                good is defined as K > 0.6 to < 0.8,
                                       The 24 nurses given a 3-hour in-         moderate is defined as K > 0.4 to <         If a patient was critically ill the
                                       service are known as the study           0.6.                                         duty nurse would immediately
                                       nurses.                                                                               place them in a resuscitation bed
                                                                                K= 0.55in phase 1 the agreement              this could cause a bias on the part
                                       In phase two a target group of 8         between the Standard triage nurse            of the study nurse who would
                                       triage nurse underwent further           and the study nurse was moderate.            place them automatically at a
                                       training with e-triage. The 8 triage                                                  higher triage score/.
                                       nurses are known as the trained triage   K=0.65 in phase 2 the agreement
                                       Nurse (TTN).                             between the TTN‘s and the study
                                                                                                                            Also if a patient was placed in a
                                                                                nurses was good.                             fast track waiting room this could
                                       Phase one, 569 patients were selected
                                                                                                                             influence the study nurses to
                                       for triage by both the experienced       Phase two showed an improvement
                                                                                                                             assign a lower triage score and
                                       nurse and the study nurse with just a    although the CI of 95% overlaps in           cause a bias.
                                       3-hour in-service.                       both phase1 and phase 2.

                                       Phase two, an experienced ED nurse       The duty triage nurses overrides did
                                       and the study nurse receiving            not significantly differ from phase




                                                                                                                                                                                                          48
             Citation                      Population Studied                           Results of Study                    Threats to Validity of Study                 Implications of Study
         (in APA format)               (Who was studied? How many                (What were the variables? What           (Where there significant problems        (How can results help in caring for
                                           where in the study)                     did the researchers find?)               with the study? Where there               patients? Is more research
                                                                                                                             reasons to doubt findings?)             required before we can draw
                                                                                                                                                                             conclusions?)
                                     additional training selected 577           one to phase two.
                                     patients for triage.
                                                                                Nor was there a difference in study
                                     56 patients ( Phase I), and 22 patients    nurse overrides in phase one versus
                                     (Phase 2), had missing or incomplete       phase two. (p < 0.01 in both phase
                                     data sets and were excluded .              one and phase two)

                                     All adults over 17 where available         The study nurses in each phase where
                                     for inclusion                              more likely to use the override
                                                                                function to lower the acuity score
                                     Patients assessed at a level one and in    than to raise it (the p value is < 0.01
                                     need of immediate where not sent to        in both phase one and phase two)
                                     be triaged by the study nurses after
                                     their initial triage for safety reasons.
Gilboy, N. & Tanabe, P. (2008).      Purpose: The purpose of the study          Independent variables:                    Problems with the study include the      Yes, more research is needed and
      Who is leaving the emergency   was to understand the characteristics      The number of patients who left the       use of a single site, limited funding,   more funding needed to study
      department without being       of patients that leave the emergency       ED without being seen.                    and loss of follow up on around 200      multiple sites. The study helps to
      seen? Advanced Emergency       department before being seen                                                         patients.                                raise awareness as to the scope of the
      Nursing. 30(1): 3-10.                                                     The reasons for leaving the ED                                                     problem and just how many patients
                                     Design: This is a prospective study        without being seen: overcrowded           The study may have had different         leave emergency departments.
                                     designed to answer questions.              conditions, being fed up with the         results if it had been in different
                                                                                wait and feeling better.                  hospital settings with different
                                     Sample: All adults and pediatrics                                                    populations served.
                                     that left without being seen were          Dependent Variable:
                                     eligible for inclusion in the study.       There were no dependent variables in
                                     15,660 patients where initially            this study since the patients were
                                     triaged during the selected 11 day         interviewed and since there were no
                                     period.                                    variables that were manipulated.
                                     A total of 711 patients that left
                                     during the 11 day period were              Results: 4.5% of the patients left
                                     selected for review.                       without being seen during the eleven
                                     498 ( approximately 70% of them            day period.
                                     were successfully contacted)               This study found that the majority of
                                                                                patients, 252 of the 498 patients,
                                                                                cited their number one reason for
                                                                                leaving as being fed up with the wait
                                                                                times.
                                                                                 Acuity level did not play a role in
                                                                                who left, although the majority who
                                                                                left were triaged at a level 3 or 4.




                                                                                                                                                                                                            49
             Citation                        Population Studied                         Results of Study                   Threats to Validity of Study                Implications of Study
         (in APA format)                 (Who was studied? How many              (What were the variables? What          (Where there significant problems       (How can results help in caring for
                                             where in the study)                   did the researchers find?)              with the study? Where there              patients? Is more research
                                                                                                                            reasons to doubt findings?)            required before we can draw
                                                                                                                                                                           conclusions?)
                                                                                Follow up care was sought by 59%
                                                                                of the patients who left without being
                                                                                seen, 40% of those sought care at
                                                                                another Emergency Department.


Maningas, P., Hime, D., Parker, D. &   Purpose: The purpose of this study       Independent Variable: Soterion            Patients who were non-                Though this study had limitations, it
     McMurray, T. (2006).              was to evaluate the system‘s inter-      Rapid Triage System (SRTS).                ambulatory ambulance patients         did show high inter-rater reliability
     Computers in emergency            rater reliability and validity for                                                  and those who needed immediate        and validity. The accuracy of the
     medicine: The soterion rapid      stratifying patient acuity.              Dependent Variable: The nurses             attention were not triaged and thus   SRTS is important for building trust
     triage system: Evaluation of                                               triage score using the SRTS vs.            not included in the study. These      in the system. Decreasing ED length-
     inter-rater reliability and       Design: Quantitative retrospective       nurse‘s score using traditional            patients represented 12% of the       of-stay essentially improves patient
     validity. Journal of              evaluation of validity.                  memory-led system.                         total ED visits. Had these patients   flow, patient wait times, and thus
     Emergency Medicine. 30(4):                                                                                            been included, it would have          patient satisfaction. This could also
     461-469.                                                                                                              affected the outcomes more            reduce liability from delays in patient
                                       Sample:                                  Results:                                   significantly.                        treatment. For all ED patients and
                                       Inter-rater reliability                  Inter-rater reliability                                                          staff, these factors combine to make
                                       423 patients were triaged by 16          There was an exact agreement              Not using survival as an outcome      the ED more efficient, and a less
                                       different nurses. This occurred          between the SRTS triage assignment         measure was another limitation.       stressful environment.
                                       during eight 8 hr shifts between the     and the standard nurse-led triage in
                                       historical peak times of 1500 to 2300    89% of the patients. A prospective        This studied only one institution
                                       during a 10 day period.                  evaluation found a weighted kappa of       and may not be generalizable to
                                       Validity                                 0.87 (95% confidence interval [CI]         different types of institutions and
                                       All patients triaged by the SRTS         0.84, 0.91, n=423).                        levels of experience.
                                       system over an 8 month period in
                                       2003 were included. This came to a       Validity
                                       total of 33,850 patients. Those          In-hospital admission rates:
                                       excluded from the use of the SRTS        Admission rates for Level 1 through
                                       system were non-ambulatory patients      Level 5 were 43%, 30%, 13%, 3%
                                       who arrived by ambulance and those       and 1% respectively (p<0.0001).
                                       who the triage nurse felt needed to be   Length of Stay: The average ED
                                       seen immediately.                        length-of- stay after implementation
                                                                                of the SRTS was 126 min compared
                                                                                to 163 min in 2002 before
                                                                                implementation.
                                                                                Hospital Charges: There were
                                                                                significant differences in the means
                                                                                for all hospital charges (p<0.0001).
                                                                                These decreased as patient acuity
                                                                                decreased.




                                                                                                                                                                                                           50
             Citation                         Population Studied                        Results of Study                   Threats to Validity of Study                   Implications of Study
         (in APA format)                  (Who was studied? How many             (What were the variables? What          (Where there significant problems          (How can results help in caring for
                                              where in the study)                  did the researchers find?)              with the study? Where there                 patients? Is more research
                                                                                                                            reasons to doubt findings?)               required before we can draw
                                                                                                                                                                              conclusions?)
                                                                                CPT Codes: These were analyzed
                                                                                with a chi-square test for
                                                                                independence and were found to be
                                                                                significant (p<.0001).




TRACK 4        EBP Team 8: Kala Gaydos, Melody Jacobson, Meg Dick, and Hannah Hudgins
Clinical Question: In hospitalized patients aged 1 day to 18 years, does family-centered care when compared to conventional care, improve patient satisfaction scores
and decrease the length of hospital stay?
             Citation                         Population Studied                        Results of Study                   Threats to Validity of Study                     Implications of Study
         (in APA format)                  (Who was studied? How many             (What were the variables? What          (Where there significant problems           (How can results help in caring for
                                              where in the study)                  did the researchers find?)              with the study? Where there               patients? Is more research required
                                                                                                                            reasons to doubt findings?)               before we can draw conclusions?)

Byers, J. F., Lowman, L. B., Francis,   114 premature infants from 24 weeks     Independent Variable:                    -100% interrater reliability for all the   More research is required before we can
J., Kaigle, L., Lutz, N. H., Waddell,   to 32 weeks. The parents participated   Family-centered care versus              physiological and behavioral               draw any conclusions. As of right now,
T., et al. (2006). A Quasi-             in the study through voluntary          conventional care                        variables                                  we would not change current traditional
Experimental Trial on Individualized,   completion of a parental perception     Dependant variables:                     - For parental satisfaction and            NICU standard of care to
Developmentally Supportive Family-      of the NICU and satisfaction survey.    Infant physiological variables,          perceptions of the NICU experience,        developmentally supportive family-
Centered Care. JOGNN Clinical                                                   growth, behavioral stress cues, return   a panel of experts established content     centered care.
Research , 35 (1), 105-115.                                                     to sleep state, medical and              validity
                                                                                developmental progress,                  -Survey reliability was not assessed
                                                                                complications, resource utilization,     -Outcomes may have been due to the
                                                                                parental perception of the NICU          wide age range of the participants
                                                                                experience, and overall satisfaction     Larger sample size is needed
                                                                                of the NICU.                             -Data collectors were not blinded
                                                                                                                         -Other nurses were floated in without
                                                                                Findings:                                education and training on family-
                                                                                -No statistically significant            centered care
                                                                                differences between the two groups




                                                                                                                                                                                                              51
              Citation                        Population Studied                         Results of Study                   Threats to Validity of Study                   Implications of Study
          (in APA format)                 (Who was studied? How many              (What were the variables? What          (Where there significant problems         (How can results help in caring for
                                              where in the study)                   did the researchers find?)              with the study? Where there             patients? Is more research required
                                                                                                                             reasons to doubt findings?)             before we can draw conclusions?)
                                                                                 (conventional care infants vs. family-
                                                                                 centered care infants) on any of the
                                                                                 outcome variables
                                                                                 -Infants in the family-centered care
                                                                                 group received 8% less
                                                                                 sedatives/narcotics and 15% less
                                                                                 vasopressors
                                                                                 -Infant stress cues were lower at
                                                                                 every point in the data collection for
                                                                                 the family-centered care group of
                                                                                 infants



Cooper, L. G., Gooding, J. S.,          This study compares sites who have       Dependant Variables:                     This study only used a post-project      More research is needed to determine
Gallagher, J., Sternesky, L., Ledsky,   had all elements of a NICU family        - family-centered care and parental      evaluation strategy rather than a pre-   what is comforting to families, how and
R., & Berns, S. D. (2007). Impact of    support program in place for at least    involvement such as communication        and post-project evaluation to           why family-centered change occurs,
a family-centered care initiative on    one year (fully implemented sites) to    between professionals and parents,       determine the overall change             including observational studies and
NICU care, staff and families.          sites who have had the project in        involvement of parents in decision-      following NFS project                    research that looks at short- and long-
Journal of Perinatology, 27, S32-       place for not more than 6 months and     making, and a partnership between        implementation. NICU staff rated         term health outcomes of newborns,
S37.                                    only some of the elements of the         professionals and parents                perception of change retrospectively.    length of stay, readmission rates, and
                                        project in place (partially              -information and comfort, such as        Also, there was a variation in the       family stability and cohesion. However,
                                        implemented) and to sites who have       knowing what to expect regarding         number of staff and family survey        this study does show that the family-
                                        none of the elements of the project in   baby‘s medical condition and growth      responses obtained.                      centered care initiative had a positive
                                        place (not yet implemented). 8 of 23     and development.                                                                  impact on stress level, comfort level, and
                                        NFS sites matching non-randomly-                                                                                           parenting confidence.
                                        selected case sites (fully               Findings:
                                        implemented) to comparison sites         Families in fully implemented sites
                                        (partially or not-yet implemented)       indicated that NFS reduced stress and
                                        were chosen.                             made them feel confident.
                                                                                 -Families also felt more comfortable
                                                                                 knowing what to expect
                                                                                 -Staff indicated that their attitudes
                                                                                 changed towards family-centered
                                                                                 care
                                                                                 -Families expressed that their
                                                                                 opinions were respected and that they
                                                                                 were involved in the care and
                                                                                 decision making of their baby.




                                                                                                                                                                                                                52
              Citation                         Population Studied                          Results of Study                   Threats to Validity of Study                  Implications of Study
          (in APA format)                  (Who was studied? How many               (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                               where in the study)                    did the researchers find?)              with the study? Where there            patients? Is more research required
                                                                                                                               reasons to doubt findings?)            before we can draw conclusions?)

Crais, E. R., Roy, V. P., & Free, K.     -Agencies providing services to           Dependant Variable:                      -Respondents did not complete all       The results of this study can help us
(2006). Parents' and Professionals'      children with disabilities from birth     -Agreement between families and          the items on the survey                 narrow the gap between ideal health care
Perceptions of the Implementation of     to age 5                                  health care professionals that family-   -Selection process was biased           practices and actual health care practices
Family-Centered Practices in Child       -50 agencies participated                 centered care interventions were         because administrators and              performed. Both professionals and
Assessments. American Journal of         -Both the family and two of the           implemented and the care was ideal       assessment coordinators of an agency    families agreed family-centered care
Speech- Language Pathology , 15,         professionals from the team were          Findings:                                chose whether or not they wanted to     practices were ideal.
365-377.                                 surveyed                                  Both professionals and families          participate and what families and
                                         -134 professionals and 58 families        agreed that family-centered care         professionals would participate
                                         participated                              practices occurred and were ideal
                                                                                   -Professionals and families agreed
                                                                                   that 69% of the time family-centered
                                                                                   care practices had occurred
                                                                                   81.9% agreed that care was ideal

Hughs, M. (2007). Parents‘ and           Attitudes of parents and nurses to the    Variables included:                      Many of the statements could have       With increased understanding of parent
nurses‘ attitudes to family-centered     model of care on an in-patient            -whether parents were given              benefitted from more in-depth           perspectives, nurses can increase efforts
care: an Irish perspective. Journal of   children‘s unit                           sufficient information regarding their   analysis of the opinions of both        to use family-centered care model of care
Clinical Nursing, 16, 2341-48.           -Participants were selected using a       child                                    groups. Also, there was a lack of       in order to decrease stress and anxiety in
                                         simple random-sampling plan               -whether parents should be permitted     inclusion of non-English-speaking       sick children and empower parents to
                                         - Inclusion criteria included: parents    to carry out the majority of care for    parents. The findings cannot be         become advocates for the children. More
                                         who read and write English, had           their child                              generalized, as the study takes place   research is definitely needed. This study
                                         stayed overnight with their sick child,   -whether the facilities for parents      in one unit only.                       gains a large amount of information but
                                         and had not been bereaved                 were comfortable                                                                 is superficial.
                                         -All nurses working on the unit were      -visiting policy
                                         included                                  -whether parents knew what was
                                         -The response rate was 43% for            expected of them
                                         parents and all were mothers
                                         -The response rate from the nurses        Results:
                                         was 65%                                   Over half of the parent group
                                                                                   admitted that they did not know what
                                                                                   was expected of them. The nurse
                                                                                   group said that they underestimate
                                                                                   what parents can learn to do for their
                                                                                   child and some parents felt that they
                                                                                   had to stay with their child because
                                                                                   the nurse looked too busy.
                                                                                   The nurses recognize that it is
                                                                                   advantageous for the child and parent
                                                                                   if they can be resident with their
                                                                                   child.




                                                                                                                                                                                                                 53
             Citation                         Population Studied                        Results of Study                    Threats to Validity of Study                    Implications of Study
         (in APA format)                  (Who was studied? How many             (What were the variables? What           (Where there significant problems          (How can results help in caring for
                                              where in the study)                  did the researchers find?)               with the study? Where there              patients? Is more research required
                                                                                                                             reasons to doubt findings?)              before we can draw conclusions?)

Kelly, M. (2007). Achieving family-     -Parents and nurses on participating    Findings:                                 There were not any reasons                -Implementation takes time and
centered care: working on or working    unit implementing family-centered       -Model directly affected interactions     mentioned to doubt or question the        commitment on behalf of the team to
with stakeholders? Neonatal,            model of care                           between nurses and parents                validity of the study. However, the       explore and change their culture in order
Pediatric, and Children Health          -13 of 26 nursing staff satisfaction    -Differing interpretations as to its      major downfall of the study is the        to improve clinical practice and achieve
Nursing, 10(3).                         surveys were completed and returned     usefulness                                number of participants.                   effective family-centered care
                                        27 of 112 parent satisfaction surveys    -Families understood what was
                                        were completed and returned             meant by ―negotiated care‖ and they
                                                                                were aware that staff was conducting
                                                                                a trial in order to find different ways
                                                                                of working with families
                                                                                -Majority of families reported they
                                                                                felt themselves to be a part of the
                                                                                team caring for their child
                                                                                -Documentation of the child‘s
                                                                                assessment at commencement of a
                                                                                shift was rarely completed.

Melnyk, B. M., Feinstein, N. F.,        -COPE is another term for family-       Variables include: maternal/paternal      Strengths include:                        The COPE program stresses the
Alpert-Gillis, L., Fairbanks, E.,       centered care                           emotional outcomes such as anxiety        the use of an RCT with a comparison       importance of parent participation and
Crean, H.F., Sinkin, R. A., et al.      -Conducted in 2 NICUs with home         and depression, maternal/paternal         intervention, the use of self-report as   knowledge in order to improve both
(2006). Reducing premature infants‘     interventions and follow-up visits      functional outcomes such as               well as observational measures, the       parent and infant outcomes. More
length of stay and improving parents‘   completed by research nurses            interaction with infant and               inclusion of fathers, and the inclusion   research is needed to determine the
mental health outcomes with the         - Inclusion criteria: mothers and       involvement in care, and infant           of LOS outcomes to provide                longer-term outcomes (after 2 months
creating opportunities for parent       fathers >18 who could read and          length of stay in NICU and overall.       administrators with cost information      corrected age) as well as the effects of
empowerment (COPE) neonatal             speak English and who had not had                                                 Limitations include:                      COPE for younger, smaller, sicker
intensive care unit program: A          another infant admitted to the NICU     Findings:                                 it was conducted in only 2 NICUs,         infants, and parents of multiple births.
randomized controlled trial.            whose infant met the following          -No differences between COPE and          and differences in practice may           Also, further understanding of how
Pediatrics, 118 (5), e1414-e1427.       criteria:                               comparison at baseline -Mothers in        influence generalizability, and           COPE is effective is needed (although it
                                        -gestational age 26-34 weeks            the COPE program reported                 sample includes relatively healthy        is hypothesized that it is through parental
                                        -birth weight <2500 g and               significantly less overall parental       preterm infants                           beliefs).
                                        appropriate for gestational age         stress
                                        -anticipated survival                   -No difference between fathers -
                                        -singleton birth                        Mothers and fathers in the COPE
                                        -no severe handicapping conditions      program reported significantly higher
                                        -born at study sites                    parental beliefs about their role and
                                                                                what to expect
                                        -247 participated of the 562            - Blind observers rated parents in the
                                        premature births that met the           COPE program as having more
                                        eligibility criteria                    positive parent-infant interactions
                                        -147 assigned to the COPE               -The total NICU length of stay was




                                                                                                                                                                                                                  54
              Citation                        Population Studied                        Results of Study                  Threats to Validity of Study                    Implications of Study
          (in APA format)                 (Who was studied? How many             (What were the variables? What         (Where there significant problems          (How can results help in caring for
                                              where in the study)                  did the researchers find?)             with the study? Where there              patients? Is more research required
                                                                                                                           reasons to doubt findings?)              before we can draw conclusions?)
                                        intervention and 113 assigned to the    3.8 days shorter for those in the
                                        comparison group                        COPE group and the total hospital
                                                                                length of stay was 3.9 days shorter


Neal, A., Frost, M., Kuhn, J., Green,    38 parents and 75 staff completed      Variables:                              This was a small cross-sectional          Though families were satisfied with care,
A. Gance-Cleveland, B., Kersten, R.,    satisfaction surveys in an infant-      environment, nursing care/clinical      study using a convenience sample of       their responses clearly demonstrated a
(2007). Family-centered care within     toddler unit caring for infants and     application, education, respect and     parents and staff. Demographic data       need for ongoing staff education
an infant-toddler unit. Pediatric       toddlers with acute and chronic         equality, and communication.            were not collected, to help protect the   regarding the importance of including
Nursing, 33(6), 481-487.                medical needs                                                                   privacy of subjects; however, the         families in pain assessment and seeking
                                                                                Findings:                               lack of demographic data is a             their input into pain management
                                                                                -Staff and family responses were        limitation.                               practices. Pain policies and procedures
                                                                                significantly different across the                                                should incorporate parent involvement in
                                                                                major areas                                                                       pain assessment and management. Future
                                                                                -Family responses were more                                                       research is needed with larger samples
                                                                                positive than staff responses                                                     across multiple sites. In addition,
                                                                                -Staff were more likely to choose a                                               longitudinal studies are needed to
                                                                                neutral response than families                                                    evaluate the impact of Family-Centered
                                                                                -Areas of concern differed across the                                             Care interventions.
                                                                                two groups: the families were most
                                                                                concerned about educational issues
                                                                                and the staff were most concerned
                                                                                about the unit environment -
                                                                                Significant differences in staff and
                                                                                family perception of pain assessment,
                                                                                with staff reporting pain assessment
                                                                                more often than families

Nijhuis, B., Reinders-Messelink,        38 families of children with cerebral   Findings:                               -Results of the various professional      Based on the findings on importance
H.A., Blecourt, A., Groothoff, J.,      palsy, aged 4-8, and 204                -For enabling and partnership and       team members were presented as            ratings, we believe that in our attempts to
Hitters, W., Nakken, H., & Postema,     professionals providing their           specific information about the child,   team scores; it is possible that the      advance family-centered care, we should
K. (2006). Family-centered care in      children‘s rehabilitation and           parents considered the behaviors to     teams‘ compositions differed              focus more on the way services are
family-specific teams. Clinical         educational services completed          be significantly more important than    considerably because the physical,        geared to each parent‘s preferences and
Rehabilitation, 21, 660-671.            surveys                                 rehabilitation professionals            psychological, social, and                how we can optimize the
                                                                                -In all domains, a considerable         educational needs of the children         individualization of service designs,
                                                                                number of parents did not receive the   were diverse                              rather than using a group as a reflection
                                                                                care they deemed important               -Professionals‘ team means were          of the family-centeredness of
                                                                                -Differences in attitudes towards       computed from the scores from             organizations and family-centered
                                                                                importance of specific care behaviors   varying professions, which could          services in clinical practices. Additional
                                                                                of team members, which                  have affected the outcomes                research with a broader scope in a larger
                                                                                subsequently may have caused the         -Small sample size and the specific      sample is required to be able to correctly




                                                                                                                                                                                                                55
             Citation                        Population Studied                         Results of Study                       Threats to Validity of Study                   Implications of Study
         (in APA format)                 (Who was studied? How many              (What were the variables? What            (Where there significant problems           (How can results help in caring for
                                             where in the study)                   did the researchers find?)                 with the study? Where there             patients? Is more research required
                                                                                                                               reasons to doubt findings?)              before we can draw conclusions?)
                                                                                relatively high incidence of parents      setting, namely children with              generalize to other settings.
                                                                                not receiving the care they deemed        cerebral palsy and Dutch pediatric
                                                                                important                                 rehabilitation makes data difficult to
                                                                                                                          generalize
                                                                                                                          -Parents reported having difficulties
                                                                                                                          with judging the behaviors of health
                                                                                                                          care providers
                                                                                                                          -Parents found it difficult to
                                                                                                                          distinguish between the care
                                                                                                                          delivered by the rehabilitation facility
                                                                                                                          and the care provided by other
                                                                                                                          services

Titone, J., Cross, R., Sileo, M., &    -30 families that had received prior     Findings:                                 -Selection of families to participate      I believe more research is needed on the
Martin, G. (2004). Taking Family-      care on the unit and some other          -Families that participated felt they     on the advisory board created a bias       effects of implementing family-centered
Centered Care to a Higher Level on     families that had received care in       were more informed about the plan         -90% of the residents did not feel         care such as decreasing the length of
the Heart and Kidney Unit. Pediatric   other health care organizations          of care and were easily able to           comfortable presenting and learning        stay, cost of care, patient outcomes.
Nursing , 30 (6), 495-497.             served as a family advisory board to     participate in the plan of care and the   in front of parents before
                                       promote better communication and         child‘s overall care                      implementation and after
                                       enhance collaboration                    -Families felt strongly that the          implementation 70% still felt this
                                       -Families, staff, and residents on a     medical team communicated well            way
                                       heart and kidney unit completed          with them and did a good job on
                                       questionnaires to evaluate the success   sharing information
                                       of a family-centered model of care.      -Families stated that the interventions
                                                                                implemented helped them understand
                                                                                the roles of the health care
                                                                                professionals better
                                                                                -Residents‘ surveys showed 10%
                                                                                thought it was beneficial to have
                                                                                parents participate during rounds
                                                                                prior to the implementation
                                                                                -After implementation, the %
                                                                                increased to 30%.
                                                                                -Nurses‘ questionnaires showed that
                                                                                they felt families were better
                                                                                informed, more capable of caring for
                                                                                their children, and better able to
                                                                                identify the team members and what
                                                                                their roles were
                                                                                -Nurses‘ surveys showed the families
                                                                                were more active in the decision




                                                                                                                                                                                                                56
              Citation                         Population Studied                         Results of Study                   Threats to Validity of Study                  Implications of Study
          (in APA format)                  (Who was studied? How many              (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                               where in the study)                   did the researchers find?)              with the study? Where there            patients? Is more research required
                                                                                                                              reasons to doubt findings?)            before we can draw conclusions?)
                                                                                  making of the plan of care
                                                                                  - Nurses reported a higher level of
                                                                                  confidence that families felt more
                                                                                  comfortable participating in daily
                                                                                  rounds


Shields, L., Pratt, J., Hunter, J.       Systematically qualitative studies on    Variables for inclusion:                 This is a systematic review and no      Further research is needed to generate
(2006). Family-centered care: a          the use of family-centered care in       -Any healthcare intervention that        threats to the validity of the review   evidence about family-centered care in
review of qualitative studies. Journal   children‘s hospitals                     aims to promote the family centered      were noted.                             situations arising from modern models of
of Clinical Nursing, 15, 1317-1323.                                               model of care during a child‘s                                                   care in which family-centered care is
                                                                                  hospitalization                                                                  thought to be an inherent part, but which
                                                                                  -Studies that provide clear evidence                                             leave families with the care of sick
                                                                                  that the family and/or child were                                                children with little or no support.
                                                                                  actively involved in the planning
                                                                                  and/or delivery of healthcare during
                                                                                  the child‘s hospitalization
                                                                                  -Studies that compare family
                                                                                  centered models or standard models
                                                                                  of care

                                                                                  Findings:
                                                                                  -Negotiation between staff and
                                                                                  families and perceptions held by both
                                                                                  parents and staff roles influenced the
                                                                                  delivery of family-centered care
                                                                                  - A sub-theme of cost of family-
                                                                                  centered care to families and staff
                                                                                  was discovered including both
                                                                                  financial and emotional costs


TRACK 4             EBP Team 10: Roland Harrison, Brant Mahan, David McAllister, Jeff Struttmann

Clinical Question: Can having family present during cardiopulmonary resuscitation have positive benefits to both family members and nurses?
                                  Citation                                         Population Studied              Results of Study                Threats to Validity of       Implications of Study
                              (in APA format)                                    (Who was studied? How         (What were the variables?                  Study                (How can results help in
                                                                                   many where in the            What did the researchers         (Where there significant       caring for patients? Is
                                                                                         study)                         find?)                   problems with the study?      more research required




                                                                                                                                                                                                               57
                                                                                                                                                  Where there reasons to           before we can draw
                                                                                                                                                      doubt findings?)                 conclusions?)
American Association of Critical Care Nurses, (2004). Family presence         This is a position             Paper lists steps one can         This paper is not a scientific   This paper shows a
during CPR and invasive procedures. Retrieved on April 10 th, 2009 from       statement by the American      take if their facility does not   study, but simply a              professional organization‘s
www.aacn.org/WD/Practice/Docs/Family_Presence_During_CPR_11-                  Association of Critical        have a FWR policy .It also        systematic review of the         view of FWR and its
2004.pdf.                                                                     Care Nurses (AACN). It         provides evidence for the         literature. All sources are      importance to all those
                                                                              is based on a systematic       implementation of policy.         provided so anyone can           involved in health care.
                                                                              review of literature.          Paper also lists components       review the publications to
                                                                                                             that should be included in        see if they agree with
                                                                                                             policies, procedures, and         AACN‘s recommendations
                                                                                                             educational development           or not.
                                                                                                             when implementing FWR.
Bassler, P. C. (1999). The impact of education on nurses‘ beliefs regarding   Convenience sample of 46       In the pre-test survey 56%        The sample was a                 This study helps because it
family presence in a resuscitation room. Journal for Nurses in Staff          nurses, 14 critical care, 22   of participants believed          nonrandomized convenience        shows with education many
Development, 15(3), 126-131.                                                  emergency, and 10 of           families should be given the      sample. The data was             nurses become more open
                                                                              undefined specialty.           option to be present during       collected during the month of    to the importance of family
                                                                              Participation required six     resuscitation. While, in the      February when the critical       witnessed resuscitation. By
                                                                              months work experience         post-test survey 89% of           care and emergency               presenting the evidence,
                                                                              in the ER or ICU. Sample       participants believe that         departments had a very high      family beliefs, current
                                                                              was obtained from              families should be given the      census which prevented           practices, and some ideas
                                                                              advertisements on bulletin     option to be present during       many nurses‘ from being          for implementation the staff
                                                                              boards in the emergency        resuscitation. When asked         able to attend the classes. It   changed their mind about
                                                                              and ICU departments.           in the pretest, only 11% of       could not be determined          FWR and its benefits to
                                                                              Participants completed a       nurses responded that they        which factors, if any,           families.
                                                                              questionnaire before and       gave families the option to       influenced the change in
                                                                              after class.                   be present during                 nurses‘ opinions because
                                                                                                             resuscitation. When asked         many different things were
                                                                                                             in the posttest if they           covered in the class.
                                                                                                             planned to give families a
                                                                                                             choice 79% of nurses said
                                                                                                             yes.
Boudreaux, E. D., Francis, J. L., & Loyacano, T. (2002). Family presence      This review of the             Variables among study             The researchers state that       This article shows and
during invasive procedures and resuscitations in the emergency department:    literature consisted of the    methods including survey          problems with                    supports a re-emergence of
A critical review and suggestions for future research. Annals of Emergency    evaluation of 20 articles      methodology and quasi-            representativeness affect the    the emphasis of family
Medicine, 40(2), 193-205.                                                     that were based on             experimental with                 generalizability of study        centered care. It shows that
                                                                              empirical study and if it      randomization and control         results and stem from several    we need to focus on ways
                                                                              were published in a peer       groups. Most research in          sources in the review of         to better train and promote
                                                                              reviewed journal. The          adult setting. Conclusion:        literature. Many of the          a positive attitude from
                                                                              databases CINAHL,              family members want to be         surveys failed to present        health care workers on the
                                                                              MEDLINE, and                   presented with the option to      sample demographics. The         topic of family presence.
                                                                              PSYCHINFO were used            be present. Given option          use of small sample sizes        Families continue to
                                                                              to retrieve the articles.      family members remain             continues to provide studies     demand their ―right‖ to be
                                                                              They divided the articles      present at the bedside and        problems with sample             present and are consistent
                                                                              based on whether they          give favorable reports of the     generalizations. There was       throughout the past 2
                                                                              pertained to resuscitation     experience, benefits to them      no mention of how statistical    decades to want to be




                                                                                                                                                                                                               58
                                                                                 or invasive procedures.         and patient. Providers give     analyses were conducted.           present and want the option
                                                                                                                 mixed opinions; nurses                                             to be presented to them.
                                                                                                                 show a more favorable view                                         This better defines the need
                                                                                                                 of FWR than physicians.                                            to come up with policies
                                                                                                                 Experience with FWR is                                             and training programs to
                                                                                                                 one of the variables that                                          better facilitate families
                                                                                                                 tend to increase the                                               needs to be present.
                                                                                                                 favorability of having the
                                                                                                                 family member at the
                                                                                                                 bedside. Those with little
                                                                                                                 experience in a resuscitation
                                                                                                                 tend to be more negative
                                                                                                                 toward the idea.
Dingeman, S., Mitchell, E., Meyer, E., & Curley, A. Q. (2007). Parent            This article reviewed a         Out of the 15 total articles,   There have been no studies         Some of the information in
presence during complex invasive procedures and cardiopulmonary                  total of 15 different studies   10 (67%) were conducted in      reporting the pediatric            this article helps to
resuscitation: A systematic review of the literature. Pediatrics, 120(4), 842-   that met the researcher‘s       the ED, 2 in PICU, and 1        patients‘ perspective on           advocate for the family
854.                                                                             qualifications. The studies     study enrolled members of       parent presence. A                 presence by showing a few
                                                                                 were arranged                   the AAP and ACEP, and           shortcoming of the existing        organizations that have
                                                                                 chronologically according       represented both the ED and     literature is that only 5 of the   adopted a policy towards
                                                                                 to level of evidence. The       PICU. The remaining             15 articles examined parent        the matter. The American
                                                                                 population of the included      studies were conducted          presence outside of the            Academy of Peds, Society
                                                                                 studies was pediatric           during the Annual               Emergency department and           of Critical Care Medicine,
                                                                                 patients which were             conference of American          that there is limited data from    American Heart
                                                                                 defined as being below or       College of Chest Physicians     PICU settings. Many of the         Association, American
                                                                                 equal to the age of 18.         and AAP Annual                  articles failed to differentiate   College of Emergency
                                                                                 Parents were                    Uniformed Services of           between acutely and                Physicians, and the ENA
                                                                                 acknowledged as                 Pediatric Seminar.              chronically ill children. No       have all endorsed protocols
                                                                                 biological or legal             Conclusion: rising trend        study as reviewed the impact       and policy about family
                                                                                 guardians. Level III            that more parents who were      of education, debriefing, and      presence. This goes to
                                                                                 survey research described       given the option to stay did    professional guidelines and        show that Family Centered
                                                                                 perspectives of staff on        so. Bauchner study in 1991      their effect on healthcare         care includes allowing
                                                                                 family presence.                showed less than half of        workers opinions.                  family presence at the
                                                                                                                 parents wanted to be                                               bedside of pediatric
                                                                                                                 present, but study done by                                         patients. Parents clearly
                                                                                                                 Boie a decade later revealed                                       want the option, and many
                                                                                                                 that 87% wanted to be                                              parents are taking the
                                                                                                                 present and did not regret                                         option. These articles show
                                                                                                                 their decision. Researchers                                        the need to research topics
                                                                                                                 also found during their                                            such as what policies
                                                                                                                 review that there were                                             should be implemented,
                                                                                                                 almost no instances of                                             how the effects of
                                                                                                                 family member interference                                         education over the subject
                                                                                                                 with FWR, which should                                             may help to improve the
                                                                                                                 ease some of the criticism                                         positive view held by
                                                                                                                 held by healthcare workers                                         healthcare workers.




                                                                                                                                                                                                                   59
                                                                                                         that family would get in the
                                                                                                         way. The reviewers spoke
                                                                                                         of the how resuscitations
                                                                                                         survivors didn‘t feel that
                                                                                                         confidentiality had been
                                                                                                         breached and that family
                                                                                                         presence made them feel
                                                                                                         less alone. Parent
                                                                                                         perspectives of presence:
                                                                                                         Provided peace of mind
                                                                                                         Chance to tell child they
                                                                                                         loved them,
                                                                                                         Let them know that
                                                                                                         everything had been done to
                                                                                                         treat them.
                                                                                                         Clinician perspectives of
                                                                                                         presence:
                                                                                                         Parental presence might be
                                                                                                         beneficial
                                                                                                         Services need to be
                                                                                                         implemented to help
                                                                                                         encourage family presence.
                                                                                                         Suggest educational efforts,
                                                                                                         departmental protocol, and
                                                                                                         dedicated family support
                                                                                                         staff.

Ellison, S. (2003). Nurses‘ attitudes toward family presence during          208 Purposefully selected   Family presence were            The sample was taken from       This study implies that
resuscitative efforts and invasive procedures. Journal of Emergency          hospital nurses and New     strongly correlated to          one hospital and one            nurses are more likely to be
Nursing, 29(6), 515-521.                                                     Jersey ENA members          education, specialty            professional organization.      favorable to and see benefit
                                                                             completed a 13-item         certification, professional                                     from family presence the
                                                                             survey. The survey was      designation and specialty                                       higher the education level,
                                                                             designed to identify        area. 58% felt family did                                       certification or working in
                                                                             attitudes toward family     interfere with job                                              an ER type setting. Since
                                                                             presence during CPR         performance. 56%                                                the greatest predictor of a
                                                                             and/or invasive             indicated they would want                                       positive view is education,
                                                                             procedures.                 to be present during CPR if                                     in addition to instating a
                                                                                                         the patient was their family                                    policy of family presence
                                                                                                         member. 87% would want                                          an aggressive training
                                                                                                         family present if they                                          program. More study is
                                                                                                         themselves were the patient.                                    necessary to draw a hard
                                                                                                                                                                         fast conclusion or to make
                                                                                                                                                                         generalization.
Emergency Nurses Association, (2005). Family presence at the bedside         This paper is a position    It is the position of the ENA   This was not a scientific       This position statement
during invasive procedures and cardiopulmonary resuscitation. Retrieved on   statement written by the    that:                           study so there are no threats   gives organizations a great




                                                                                                                                                                                                        60
April 4th, 2009 from http://www.ena.org/about/position/position/default.asp   Emergency Nurses              Collaboration between all      to the validity.                 starting point when
                                                                              Association (ENA). It is     disciplines is needed to                                         thinking about
                                                                              not a study, but is based    develop guidelines                                               implementation of a FWR
                                                                              upon a systematic review     regarding FWR. Health                                            policy.
                                                                              of relevant literature.      care organizations should be
                                                                                                           responsible for developing
                                                                                                           and distributing formal
                                                                                                           written policies and
                                                                                                           educational materials on this
                                                                                                           topic. All health care
                                                                                                           providers should be
                                                                                                           responsible for continuous
                                                                                                           education on FWR.
Fallis, W. M., McClement, S., & Pereira, A. (2008). Family presence during    Convenience sample of        92% of participants             The study utilized               This study illustrates the
resuscitation: A survey of Canadian critical care nurses‘ practices and       450 nurses. An online        supported the option of         nonrandomized convenience        vast majority (92%) of the
perceptions. Canadian Association of Critical Care Nurses, 19(3), 22-28.      survey was sent to all       family presence during          sampling to collect data.        members of CACCN
                                                                              members of the Canadian      resuscitation (FPDR) either                                      support FPDR regardless of
                                                                              Association of Critical      with or without a written                                        the presence, or absence, of
                                                                              Care Nurses (CACCN).         policy. 32.5% of                                                 a written policy regarding
                                                                              Participation in the study   participants indicated that                                      FPDR at their hospital.
                                                                              required active              they had taken a patient‘s
                                                                              membership in CACCN,         family to the bedside during
                                                                              and an email address on      CPR in the past year, or
                                                                              file for which to receive    would do so if the
                                                                              the survey                   opportunity arose. 18.5%
                                                                                                           indicated that they had been
                                                                                                           asked by family members to
                                                                                                           be present at the bedside
                                                                                                           during CPR. 8% of
                                                                                                           participants reported that a
                                                                                                           written policy/guideline for
                                                                                                           FPDR was available at their
                                                                                                           hospital.
MacLean, S. L., Guzzetta, C. E., White, C., Fontaine, D., Eichhorn, D. J.,    The study of this article    Variables that were             This study had several           This study shows that
Meyers, T. A., et al. (2003). Family presence during cardiopulmonary          was conducted on nurses      measured on the survey          limitations. This survey         nurses are open to family
resuscitation and invasive procedures: Practices of critical care and         who were members of          were the demographic            underwent testing by a panel     presence at the bedside,
emergency nurses. Journal of Emergency Nursing, 29(3), 208-221.               either the American          characteristics of the          of experts and pilot testing,    whether there is
                                                                              Association of Critical-     respondents, questions about    but there was a failure to put   implementation of written
                                                                              Care Nurses or               the respondent‘s practices,     the survey through reliability   policies or not. This survey
                                                                              Emergency Nurses             preferences, and hospital       testing, which fails to          serves to benefit the
                                                                              Association. A 30 item       policies related to family      establish construct validity.    argument family members
                                                                              survey was sent out to       presence. The nurses were       Only 1/3 of the sample           are making to be allowed at
                                                                              1500 nurses belonging to     allotted a space to add any     returned the survey (33%         the bedside. The survey
                                                                              each of the previously       comments that they felt         respondent rate) the             showed that 31% of the
                                                                              listed associations. There   necessary to share.             generalizability of the          nurse had been asked by




                                                                                                                                                                                                           61
                                                                                  were a total of 948          5% of all respondents           findings are limited to this      family to be present and
                                                                                  respondents between the      worked on a unit with           group. Only members of the        45% were allowing it. This
                                                                                  groups.                      policies written allowing       American Association of           shows promise in the
                                                                                                               family presence.                Critical Care Nurse and           advocacy of allowing
                                                                                                               45% of the nurses allowed       Emergency Nurses                  family presence. Still, more
                                                                                                               family presence without any     Association were surveyed,        research is needed outside
                                                                                                               written policy in place.        meaning that their responses      of jus the two organizations
                                                                                                               37% preferred written           may not represent the             that were surveyed to
                                                                                                               policies, 39% indicated they    preferences of all emergency      continue to help us
                                                                                                               preferred unwritten policies.   and critical care nurses in the   understand more about the
                                                                                                               36% of the individuals had      US.                               feelings of the family and of
                                                                                                               taken family to the bedside,                                      nurses the subject of family
                                                                                                               21% said they would do it in                                      presence.
                                                                                                               the future. 31% claimed
                                                                                                               family asked to be present.
Mangurten, J., Scott, S. H., Guzzetta, C. E., Clark, A. P., Vinson, L., Sperry,   Purposefully selected        In 100% of the cases, patient   Threats to the study include      Study results imply that
J., et al. (2006). Effects of family presence during resuscitation and invasive   sample of parents of         care was uninterrupted.         small sample size. Apart          FWR has an overall
procedures in a pediatric emergency department. Journal of Emergency              children undergoing          Patients were positive about    from this, there seems to be      positive outcome for both
Nursing, 32(3), 225-233.                                                          resuscitation intervention   the events, believed it         no other threat to the validity   parents and providers.
                                                                                  (RI). The study included     helped their child and          of the study. Selection           Family presence potentially
                                                                                  both parents and             reported that it eased their    process, survey models,           creates a calming effect to
                                                                                  providers. A total of 22     fears. 3 months later, no       validity and reliability          both parent and child,
                                                                                  parents and 92 providers     parents reported being          measures were excellent and       provides for the increase in
                                                                                  were surveyed and/or         negatively affected. Of the     well documented.                  parental knowledge
                                                                                  interviewed.                 64 events in the study, 28                                        regarding healthcare and
                                                                                                               (44%) were resuscitation                                          health status of child,
                                                                                                               events. 70% of parents                                            increases the parent‘s
                                                                                                               supported family presence                                         confidence with healthcare
                                                                                                               (FP) during RIs, as did 92%                                       provider. For the provider,
                                                                                                               of nurses and 78% of                                              family presence potentially
                                                                                                               physicians. Only 35% of                                           improves relationships to
                                                                                                               residents supported RI. 5                                         parents, increases the
                                                                                                               qualitative themes were                                           provider‘s care potential to
                                                                                                               identified of parents as well                                     the patient. The positive
                                                                                                               as 5 for providers.                                               results of this study indicate
                                                                                                                                                                                 a need for change in the
                                                                                                                                                                                 basic doctrine of family
                                                                                                                                                                                 presence during critical life
                                                                                                                                                                                 events. More study is
                                                                                                                                                                                 needed before results are
                                                                                                                                                                                 transferable to general
                                                                                                                                                                                 populace.




                                                                                                                                                                                                                  62
McClenathan, B. M., Torrington, K. G., & Uyehara, C. F. T. (2002). Family   Individuals attending an     Variables identified: health     Questionnaire presented was    Results reflect need to
member presence during cardiopulmonary resuscitation: A survey of US and    international meeting held   care members surveyed:           optional, only given out to    examine means of
international critical care professionals. Chest, 122, 2204-2211.           by the American College      doctors, nurses, allied health   those in attendance of the     promoting a positive
                                                                            of Chest Physicians.         care workers. 39% surveyed       international meeting. The     attitude re: FWR . Many
                                                                            Included were543             with previous experience         majority of the clinicians     clinicians opposed FWR.
                                                                            doctors, 28 nurses, 21       would allow it again, 78%        were associated with adult     More studies on how
                                                                            allied health members.       opposed it. Demographic          care, Less than 2/3 of the     protocols, education, and
                                                                            Survey asked questions re:   regions in the US varied. NE     individuals surveyed claimed   having support staff are
                                                                            previous experience          had 5% approval. Midwest         to have had any experience     necessary to help clinicians
                                                                            opinions on FWR.             had 21%.                         with FWR resuscitation.        change .




                                                                                                                                                                                                        63
TRACK 5             EBP Team 7: Stephanie Bilby, Briley Fogleman, Jennifer Geiger, & Brook Oney

Clinical Question: Would early education, by nurses on MRSA prevention and transmission reduce the number of patients’ under18 years of age from contracting
Community Acquired MRSA?
              Citation                         Population Studied                       Results of Study                    Threats to Validity of Study                   Implications of Study
          (in APA format)                  (Who was studied? How many            (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                               where in the study)                 did the researchers find?)               with the study? Where there                  patients? Is more research
                                                                                                                             reasons to doubt findings?)                required before we can draw
                                                                                                                                                                               conclusions?)
Alfaro, C., Mascher-Denen, M.,           The point prevalence study was         Of the 350 children studied, 125          Limitations to the study consisted of     The study presents the increased
Fergie, J., Purcell, K. (2006).          conducted on pediatric patients        were colonized with Staphylococcus        no genetic testing of the isolates to     prevalence of MRSA nasal carriers.
Prevalence of methicillin-resistant      (n=350) admitted to a tertiary care    aureus and 76 of those were               determine whether they were               This knowledge is useful for the
Staphylococcus aureus nasal carriage     teaching hospital in Corpus Christi,   colonized with MRSA. The MRSA             CAMRSA or nosocomial strains and          diagnosis and early treatment of
in patients admitted to Driscoll         TX from February 15 through March      colonization rate was higher in           the study was performed on sick           MRSA infections. However, the
Children‘s Hospital. The Pediatric       15, 2005. There were 202 boys and      children older than 5 years of age and    children who were hospitalized            study was only performed on sick
Infectious Disease Journal, 25(5),       148 girls between the ages of 1        most had one or more risk factors for     during the respiratory syncytial virus    children and genetic testing was not
459-461.                                 month to 18 years of age.              MRSA identified. The prevalence of        and influenza season. In addition, the    performed.
                                                                                MRSA colonization is increasing.          study issued a questionnaire and did
                                                                                The study identified the most             not state whether all admitted            Further testing needs to be done to
                                                                                common risk factors as recent             children were participates.               determine the prevalence outside of
                                                                                antibiotic use, recent emergency                                                    the south Texas area.
                                                                                department visit, chronic disease,
                                                                                recent hospitalization, recent surgery,
                                                                                daycare center attendance, and a
                                                                                household contact that had a history
                                                                                of MRSA infections or colonization.
Arnold, S. R., Elias, D.,                Retrospective study conducted          There were 158 cases of acute             Diagnostic tests and treatments were      An increase in the incidence and
Buckingham, S. C., Thomas, E. D.,        between 01-01-00 and 12-31-04 at       osteoarticular infection. The             not used equally across all patients.     severity of acute osteoarticular
Novais, E., Arkader, A., & Howard,       Le Bonheur Children‘s Medical          incidence increased from 2.6 to 6.0       Treatments were not used equally          infections in children was perceived
C. (2006). Changing patterns of acute    Center in Memphis, TN (n=158); the     per 1000 admissions between 2000          across all patients. There were many      after the emergence of CA-MRSA in
hematogenous osteomyelitis and           average age was 9 years old.           and 2004. The Proportion of               cases with unidentified pathogens         the community and this is important
septic arthritis. Journal of Pediatric                                          infections caused by methicillin-         (44%). This study did not specifically    to nursing and the health care field
Orthopaedics, 26(6), 703-708.                                                   susceptible S. aureus remained            extract data regarding the presence of    because patients with CA-MRSA
                                                                                constant (10-13%) but those               risk factors for health-care associated   infections are at higher risk for
                                                                                infections caused by MRSA rose            MRSA infection. Calculated                contracting subperiosteal abscesses
                                                                                from 4% to 40%.                           incidence rates were based on             requiring surgical intervention.
                                                                                                                          hospital admissions and were not
                                                                                                                          population based.                         More research is needed, but the
                                                                                                                                                                    study is still extremely reliable.




                                                                                                                                                                                                           64
              Citation                          Population Studied                        Results of Study                    Threats to Validity of Study                    Implications of Study
          (in APA format)                   (Who was studied? How many             (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                                where in the study)                  did the researchers find?)               with the study? Where there                  patients? Is more research
                                                                                                                               reasons to doubt findings?)                required before we can draw
                                                                                                                                                                                   conclusions?)
Brooks, L., Shaw, A., Sharp, D., &        Qualitative analysis study (n=150)      The study found there is uncertainty      Limitations to the study included         Many primary care patients are
Hay, A. D. (2008). Towards a better       that focused on a purposeful sample     among patients concerning the nature      younger men from lower socio-             unaware of what antibiotic resistance
understanding of patients‘                of primary care patients selected in    and implications of antibiotic            economic groups were under-               is and how it arises. As healthcare
perspectives of antibiotic resistance     two stages. Two general practices       resistance. In seeking to explain the     represented in the sample, and the        providers we are responsible for
and MRSA: A qualitative study.            with contrasting levels of antibiotic   causes of antibiotic resistance, blame    views of these and other participants     educating our patients about
Family Practice, 25, 341–348.             use and practice populations; both      was primarily directed to other           not responding to the study invitation    antibiotics, use and misuse, and how
                                          men and women, aged (16–49 and          patients who used antibiotics             may have different views than those       to prevent further resistance.
                                          >50 years).                             irresponsibly, GP‘s who                   who did.
                                                                                  overprescribed antibiotics in the past,
                                                                                  and in the case of MRSA, poor             However, The results of the study are
                                                                                  hospital hygiene.                         consistent with studies performed in
                                                                                                                            other countries, indicating the results
                                                                                                                            are relevant internationally.
Buckingham, S. C., McDougal, L.           Chart review study (n=289)              The study found that community-           With a lack of a consistent definition    The optimal strategies for
K., Cathey, L. D., Comeaux, K.,           evaluated from January 2000 to June     associated MRSA isolates were             of community-associated MRSA,             management of community
Craig, A. S., Fridkin, S. K., &           2002 at The Children‘s Hospital in      recovered from patients with invasive     patients with apparent community-         associated
Tenover, F.C. (2004). Emergence of        Memphis, TN. The median age of          infections as frequently as were          associated infections might have had      MRSA infections have not been
community-associated methicillin-         patients was 2.4 years.                 health care-associated isolates. It       risk factors that were not documented     established. It is likely that
resistant                                                                         demonstrated that community-              in medical records; and patients with     approaches to these infections will
Staphylococcus aureus at a Memphis,                                               associated MRSA infections can be         apparent health care-associated           need to vary based on local
Tennessee,                                                                        life-threatening and emphasized the       MRSA infections might have                epidemiologic and susceptibility
Children‘s Hospital. The Pediatric                                                need for improved treatment and           actually acquired colonization in the     data.
Infectious Disease Journal, 23(7),                                                prevention strategies. Testing            community.
619-624.                                                                          implied that community-associated
                                                                                  and health care-associated MRSA are
                                                                                  distinct from one another. And that
                                                                                  clindamycin is active in vitro
                                                                                  against most community-associated
                                                                                  MRSA isolates.



Creech, C. B., Beekman, S. E., Chen,      Surveyed 197 pediatric infectious       Our study suggests pediatric IDCs         The survey specifically targeted          The extreme variability in both
Y., & Polgreen, P. M. (2008).             diseases consultants in 2007 to whom    are seeing many more cases of             pediatric Infectious Disease              treatment and decolonization
Variability among pediatric               the surveys were distributed via        MRSA SSTIs than in previous years         Consultant members of the EIN and         practices in pediatric infectious
infectious diseases specialists in the    email and/or mail,                      and are reporting higher frequencies      not general pediatricians, who more       diseases specialists highlights the
treatment and prevention of               114 (58%) responded from 39             of more severe cases of MRSA; no          frequently encounter these infections.    need for randomized, placebo-
methicillin-resistant Staphylococcus      different states.                       statistically significant difference                                                controlled, clinical trials of pediatric
aureus skin and soft tissue infections.                                           based on geographic or practice           Not only is there a lack of consensus     MRSA colonization and disease that
The Pediatric Infectious Disease                                                  location (e.g., urban versus rural), or   for first-line outpatient therapy, but    will provide more clear guidance for




                                                                                                                                                                                                                 65
              Citation                          Population Studied                         Results of Study                     Threats to Validity of Study                   Implications of Study
          (in APA format)                   (Who was studied? How many              (What were the variables? What            (Where there significant problems        (How can results help in caring for
                                                where in the study)                   did the researchers find?)                with the study? Where there                 patients? Is more research
                                                                                                                                 reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                    conclusions?)
Journal, 27(3), 270-272.                                                           practice setting (e.g., academic           there also seems to be a strong lack     the management of these difficult
                                                                                   versus private practice); no current       of agreement about whether to use a      clinical situations.
                                                                                   consensus regarding treatment              second agent.
                                                                                   approaches.


Creech II, C. B., Kernodle, D. S.,        Nasal swabs were collected from 249      Overall, 182 children (36.4%) were         The only limitation within this study    Prior studies concluded nasal
Alsentzer, A., Wilson, C., &              children presenting to the Vanderbilt    colonized for S. aureus and 46 of          this that it was conducted at a single   colonization with MRSA occurs
Edwards, K. M. (2005). Increasing         University Medical Center Pediatric      those isolates (9.2%) were positive        site and may not reflect colonization    infrequently in the healthy pediatric
rates of nasal carriage of methicillin-   Primary Care Clinic, TN, and 251         for MRSA.                                  rates throughout the country.            population. However, infections
resistant Staphylococcus aureus in        children from Old Harding Pediatric                                                                                          caused by CA-MRSA have increased
healthy children. The Pediatric           Associates from April to September                                                                                           remarkably in recent years. This
Infectious Disease Journal, 24(7),        2004. Average age of subjects was 1-                                                                                         study demonstrates the prevalence of
617-621.                                  4 years.                                                                                                                     CA-MRSA in children.

                                                                                                                                                                       With few limitations and a large
                                                                                                                                                                       sample, this study is very reliable.
                                                                                                                                                                       Further studies in other locations and
                                                                                                                                                                       population groups are needed to
                                                                                                                                                                       determine the host and pathogen
                                                                                                                                                                       determinants of colonization.
Fisher, R. G., Chain, R. L., Hair, P.     The study tested in vitro hypochlorite   Hypochlorite (10 minutes,                  This study looked at a small             The present study provides evidence
S., & Cunnion, K. M. (2008).              (bleach) killing of community-           37°C) demonstrated dose-dependent          population group which would             that weak hypochlorite solutions are
Hypochlorite killing of community-        associated methicillin-resistant         killing of S. aureus (control strain)      indicate that the results may not hold   effective in killing staphylococcal
associated methicillin-resistant          Staphylococcus aureus isolates to        compared with municipal tap water          true if a larger sample size was used.   isolates in vitro, including invasive
Staphylococcus aureus. The Pediatric      determine optimal concentration and      without hypochlorite.                                                               and colonizing clinical isolates of
Infectious Disease Journal, 27(10),       duration.                                                                                                                    MRSA.
934-935.                                                                           Our clinical experience suggested
                                          Participants were from The               that the concentration of 2.5-_L/mL                                                 Further research needs to be done to
                                          Children‘s Hospital of the The           dilution of bleach for 5-minutes                                                    determine if a 2.5-_L/mL dilution of
                                          King‘s Daughters, Norfolk, VA,           showed the best results and was not                                                 bleach is approximately equivalent to
                                          during March 2008. The sample size       excessively noxious for children.                                                   one-half cup (120 mL) of bleach in
                                          (n=10) consisted of five isolates were                                                                                       one-quarter filled tub of water (13
                                          from children with invasive MRSA         The range of killing for the different                                              gallons of water in a 50-gallon
                                          infections and five isolates were from   CA-MRSA isolates was 99.94–100%                                                     standard tub) would translate into
                                          children with MRSA colonization.         and not statistically different (n = 3).                                            decreased frequency of
                                                                                   No difference was found for                                                         staphylococcal skin infections in
                                                                                   susceptibility to hypochlorite                                                      patients with recurrent furunculosis.
                                                                                   comparing 5 colonizing isolates with
                                                                                   5 invasive isolates.




                                                                                                                                                                                                                66
              Citation                        Population Studied                         Results of Study                  Threats to Validity of Study                   Implications of Study
          (in APA format)                 (Who was studied? How many              (What were the variables? What         (Where there significant problems        (How can results help in caring for
                                              where in the study)                   did the researchers find?)             with the study? Where there                  patients? Is more research
                                                                                                                            reasons to doubt findings?)               required before we can draw
                                                                                                                                                                               conclusions?)
Hulte´n, K. G., Kaplan, S. L.,          Review of records (n=899) aged 0-10      CO HCA-S. aureus infections             The clindamycin susceptibility           Findings emphasize the importance
Gonzalez, B. E., Hammerman, W.          years, at the Texas Children‘s           remained steady over the 3-year         patterns of community                    of separating community acquired
A., Lamberth,L. B., Versalovic, J., &   Hospital in Houston, TX, between         study. Clindamycin resistance           S. aureus isolates do not accurately     from community onset health care-
Mason Jr., E. O. (2006). Three-year     August 1, 2001 through July 31,          increased >4-fold for CO HCA-S.         reflect those of the CO HCA-S.           associated S. aureus infections so
surveillance of community onset         2004.                                    aureus isolates over the 3 years and    aureus strains in our setting. The       that the most appropriate empirical
health                                                                           is no longer appropriate for empiric    recommendations that have been           antibiotic regimen can be
care-associated Staphylococcus                                                   treatment of invasive infections        developed for the medical staff at       determined; the importance of
aureus infections in children. The                                               suspected to be caused by CO HCA-       Texas Children‘s Hospital and are        clindamycin susceptibility testing
Pediatric Infectious Disease Journal,                                            MRSA at our hospital. In our setting,   not intended to be applicable to other   among S. aureus isolates; awareness
25(4), 349-353.                                                                  CO HCA-MRSA infections are              institutions.                            of both similarities and differences in
                                                                                 steady in number despite substantial                                             epidemiologic subgroups of patients,
                                                                                 increases in community-acquired                                                  especially with regard to antibiotic
                                                                                 MRSA infections and both being                                                   resistance patterns.
                                                                                 related to the same clone.

Loeb, M. B., Main, C., Eady, A., &      Original review in 2003, reviewed        No difference in MRSA eradication       Only two reviewers were used to          There is insufficient evidence to
Walkers-Dilks, C. (2003).               again 2009 at McMaster University        was detected in four of the studies.    independently assess validity of         support the use of topical or systemic
Antimicrobial drugs for treating        in Hamilton, Canada; 31 studies were                                             included studies; not all studies used   antimicrobial therapy for eradicating
methicillin-resistant Staphylococcus    identified, only 6 trials, some state-   Adverse events with systemic agents     in review were state-side; and only      MRSA. There is no demonstrated
aureus colonization. Cochrane           side and some abroad, (384               occurred in up to 20% of                two studies out of the six looked at     superiority of topical, systemic, or
Database of Systematic Reviews          participants with colonized with         participants. All trials reported       participants under 18, with 16 being     the combinations of both agents.
2003, Issue 4. Art. No.: CDC003340.     MRSA either nasally or at extra-         development of resistance to            youngest.                                Potentially serious adverse events
DOI: 10.1002/14651858.CD003340.         nasal sites including perineum,          antimicrobial agents used.                                                       can arise from use of systemic
                                        wounds, axilla, groin, catheter exit                                                                                      agents.
                                        sites) met criteria for review.
                                                                                                                                                                  Larger RCTs are needed to
                                                                                                                                                                  demonstrate efficacy of systemic or
                                                                                                                                                                  topical antimicrobial therapy in
                                                                                                                                                                  eradicating MRSA. Careful
                                                                                                                                                                  documentation of adverse effects and
                                                                                                                                                                  the development of resistance to
                                                                                                                                                                  antimicrobial agents are necessary.




                                                                                                                                                                                                            67
              Citation                          Population Studied                          Results of Study                   Threats to Validity of Study                    Implications of Study
          (in APA format)                   (Who was studied? How many               (What were the variables? What          (Where there significant problems         (How can results help in caring for
                                                where in the study)                    did the researchers find?)              with the study? Where there                  patients? Is more research
                                                                                                                                reasons to doubt findings?)                required before we can draw
                                                                                                                                                                                    conclusions?)
Ochoa, T. J., Mohr, J., Wanger, A.,       This is a retrospective review of         The study concluded that CA-MRSA         The present study lacks molecular         The study confirms the increasing
Murphy, J. R., & Heresi, G. P.            records. The population (N=239)           is occurring more frequently with        genetic analysis of the various strains   prevalence of CA-MRSA. By
(2005). Community-associated              studied was all pediatric patients (≤     more severe infections and               of CA-MRSA to determine the               knowing the potential complications
methicillin-resistant Staphylococcus      18 years of age) who were admitted        complications in comparison to CA-       magnitude of its complications.           of CA-MRSA as well as
aureus in pediatric patients.             to Memorial Hermann Children‘s            MSSA.                                                                              susceptibility patterns of the various
Emerging Infectious Diseases, 11(6),      Hospital in Houston, TX, during a                                                                                            strains, primary care providers can
966-968.                                  36-month interval (July 2000 to June                                                                                         better diagnose and treat the
                                          2001 and January 2002 to December                                                                                            infection.
                                          2003) with a laboratory confirmation
                                          of Staphylococcus aureus.                                                                                                    More research is needed on the
                                                                                                                                                                       various strains of CA-MRSA in order
                                                                                                                                                                       to better understand treatment for
                                                                                                                                                                       those strains.

              Citation                          Population Studied                          Results of Study                   Threats to Validity of Study                    Implications of Study
          (in APA format)                   (Who was studied? How many               (What were the variables? What          (Where there significant problems         (How can results help in caring for
                                                where in the study)                    did the researchers find?)              with the study? Where there                  patients? Is more research
                                                                                                                                reasons to doubt findings?)                required before we can draw
                                                                                                                                                                                    conclusions?)
Purcell, K., & Fergie, J., (2005).        This is a retrospective study. All        94% of the confirmed cases had no        The study may have overestimated          By understanding the prevalence and
Epidemic of community-acquired            confirmed Staphylococcus aureus           identified risk factors and 72% had      the number of children without risk       potential invasive infections of
methicillin-resistant Staphylococcus      cases at Driscoll Children‘s Hospital     one or more risk factors. Cases with     factors and the increased number of       CAMRSA, a more rapid diagnosis
aureus infections: A 14-year study at     from October 21, 1990, to December        risk factors were more likely to have    confirmed cases may be due to more        and appropriate empirical treatment
Driscoll Children‘s Hospital.             31, 2001, and January 1, 2002, to         invasive infections and the number of    aggressive attempts at making a           can be initiated. More research is
Archives of Pediatrics & Adolescent       December 31, 2003. The total              cases rose from 2.9% in 1990 to          microbiological diagnosis. There was      necessary to study the specific
Medicine, 159, 980-985.                   number of cases was 1002 of which         62.4% in 2003. Identified risk factors   also not adequate data to compare         virulence genes of CAMRSA to
                                          928 were community-acquired.              included: chronic disease, recent        clinical outcomes and the study had a     determine if severe clinical outcomes
                                                                                    hospitalization or surgery, residence    small sample size.                        and invasive infections are a result of
                                                                                    in a long-term care facility, an                                                   specific genes.
                                                                                    indwelling catheter, child daycare
                                                                                    center attendance, intravenous drug
                                                                                    use, household contact, antibiotic
                                                                                    use, or history of MRSA infections
                                                                                    or colonization.
Purcell, K., Fergie, J., & Peterson, M.   This study is a chart review.             Inpatient, outpatient, total expenses,   The exact number of children              Recent studies have confirmed the
D., (2006). Economic impact of the        Financial and enrollment data from        and the number of covered lives and      involved in the study was not stated.     increasing prevalence of CAMRSA.
community-acquired methicillin-           January 1, 200, through December          per member per month expenses            The etiology of all cellulitis and        The magnitude of the economic
resistant Staphylococcus aureus           31, 2004, were analyzed for the           were reviewed.                           abscess diagnoses was not analyzed        strain in puts on patients and the
epidemic on the Driscoll Children‘s       Driscoll Children‘s Health Plan for       Cellulitis and abscess diagnoses         to confirm CAMRSA and there was           health care systems can prompt more
Health Plan. The Pediatric Infectious     all inpatient and outpatient cellulitis   increased from 2001 to 2004. They        much variability in the results to        prevention strategies and education




                                                                                                                                                                                                                 68
              Citation                        Population Studied                       Results of Study                   Threats to Validity of Study                     Implications of Study
          (in APA format)                 (Who was studied? How many            (What were the variables? What          (Where there significant problems          (How can results help in caring for
                                              where in the study)                 did the researchers find?)              with the study? Where there                   patients? Is more research
                                                                                                                           reasons to doubt findings?)                 required before we can draw
                                                                                                                                                                                conclusions?)
Disease Journal, 25(2), 178-180.        and abscess diagnoses.                 accounted for 3.3% of the total health   confirm the objective of the study.        on prevention techniques.
                                        The exact number of participants was   plan expenses and the per member                                                    More research is necessary. Future
                                        not stated.                            per month expenses increased from                                                   focus should include assessing which
                                                                               $.74 in 2001 to $1.19 in 2004                                                       outpatient interventions, either
                                                                                                                                                                   prevention or treatment, are most
                                                                                                                                                                   effective in reducing the need for
                                                                                                                                                                   hospitalization.
Zaoutis, T. E., Toltzis, P., Chu, J.,   A retrospective cohort study           Most common site of infection being      Ascertainment bias may have                This study confirms the increasing
Abrams, T., Dul, M., Kim, J.,           conducted over a 3-year period at      skin or soft tissue. Out of those 446    contributed to the apparent rise in        prevalence of CA-MRSA in children.
McGowan, K. L., et al. (2006).          The Children‘s Hospital of             children, 134 had infections caused      CA-MRSA infections in the                  These results can help healthcare
Clinical and molecular epidemiology     Philadelphia, all patients who had a   by MRSA. This study confirms from        community; an expanding awareness          providers become more aware of the
of community-acquired methicillin-      positive culture obtained from the     2001-2003, the proportion of S.          of CA-MRSA may have increased              infectious disease in the community
resistant Staphylococcus aureus         ED or an inpatient unit for CA-        aureus infections caused by MRSA         the frequency of physicians obtaining      and in children and by increasing
infections among children with risk     MRSA (n=446) from 01-01-01             rose from 15% in 2001 to 40% in          cultures with suspected S. aureus          heath care professionals awareness,
factors for health care-associated      through 12-31-2003, with a median      2003.                                    infections; there is suspected data        hopefully better diagnosis, treatment
infection. The Pediatric Infectious     age of 5 years.                                                                 about RF-HAI which might have              and prevention strategies will be
Disease Journal, 25(4), 343-348.                                                                                        been incompletely captured. There          developed.
                                                                                                                        was not a systematic omission of
                                                                                                                        specimens retained by the laboratory
                                                                                                                        (e.g., by body site or year), this might
                                                                                                                        have introduced error into the
                                                                                                                        findings. Antibiotic pressures may
                                                                                                                        have contributed to differences in
                                                                                                                        antibiotic susceptibilities. Also
                                                                                                                        referral bias might have increased the
                                                                                                                        frequency with which children with
                                                                                                                        CA-MRSA infections were referred
                                                                                                                        for evaluation and care.




                                                                                                                                                                                                           69
TRACK 5            EBP Team 11: Brandi Fuselier, Courtney Garner, Rachael Robison, & Katy Stewart

Clinical Question: In adults age 18 years and older is the use of non-pharmacological agents (such as guided imagery, quitlines, and exercise) as compared to
pharmacological agents more effective in smoking cessation?
         Citation                             Population Studied                       Results of Study                 Threats to Validity of Study                    Implications of Study
     (in APA format)                      (Who was studied? How many            (What were the variables? What        (Where there significant problems         (How can results help in caring for
                                              where in the study)                 did the researchers find?)            with the study? Where there                   patients? Is more research
                                                                                                                         reasons to doubt findings?)                required before we can draw
                                                                                                                                                                             conclusions?)
Bauld, L., Chesterman, J., Ferguson,     Total of 1785 service users who set   In the pharmacy-based service 18.6%    This study relies on short term (4        Specialist-led group-based services
J., & Judge, K., (2009). A Comparison    a quit date between March and May     of users were co-validated as a        week) cessation outcomes. Relapse         appear to have higher quit rates than
of the Effectiveness of Group-Based      2007.                                 quitter at 4 weeks compared with       beyond 4 weeks is common. An              one-to-one services provided by
and Pharmacy-Led Smoking Cessation                                             35.5% in the group-based service. In   additional limitation involves the        pharmacies but the pharmacy led
Treatment in Glasgow. Addiction, 104,                                          a multivariate model, restricted to    study design. As this was an              services treat many more smokers.
308-316.                                                                       participants with data allowing        observational study it is important to    More research is needed to determine
                                                                               adjustment for socio-demographic       note that it is not possible to compare   what can be done to bring the success
                                                                               and behavioral characteristics and     directly the two models of service        rates of pharmacy services up to
                                                                               including action terms, users who      under one review. Clients chose           those of specialist-led groups and
                                                                               accessed the group-based services      which service they attended rather        hope to expand access to group-
                                                                               were almost twice as likely as those   than being randomized to receive one      based services. The findings clearly
                                                                               who used pharmacy-based support to     of the two models of treatment, and       indicate that health-care managers
                                                                               have quit smoking at a 4 week follow   as with all observational research,       and others should not abandon more
                                                                               up.                                    selection bias is an important            intensive (group-based) models of
                                                                                                                      limitation. As a result, and despite      treatment in favor of less intensive
                                                                                                                      best efforts to collect a large amount    support. Rather, they should look for
                                                                                                                      of data from each client to identify      ways in which pharmacy-based
                                                                                                                      any possible factors that might have      services can improve success rates to
                                                                                                                      influenced results, it is possible that   bring them up to the level of
                                                                                                                      the outcomes observed were                specialist-led group-based services
                                                                                                                      attributable, in par, to factors not      and how such services can be made
                                                                                                                      examined in this research.                more attractive to a wider range of
                                                                                                                                                                smokers.
Grohs, U., Kemmler, G., Kriechbaum,      Female and male smokers (cigarette    This study was conducted in order to   There were no significant problems        The findings in this study can
N., Saria, A., Wallner, R., & Zernig,    consumption of at least 15            assess the effectiveness of            noted in this study nor were there        positively influence the care
G. (2008). A randomized trial of short   cigarettes per day in the last 3      psychotherapy (guided imagery--IV)     reasons to doubt the findings. The        delivered for those seeking smoking
psychotherapy versus sustained-          months) at least 18 years of age      in comparison to a medication          researchers utilized several methods      cessation because it offers them
release bupropion for smoking            with the intention to quit.           (bupropion) in regard to smoking       to assess efficacy of the differing       alternative methods. Often times,
cessation [Electronic version].                                                cessation (abstinence rates--DV).      treatments including CO-                  individuals are prescribed
Addiction, 103, 2024-2031.               -779 participants were randomized.                                           breathalyzers, self-reports, and          medications when they inform their
                                                                               12-mon follow-up: The researchers      interviews with the family members        healthcare provider they are
                                                                               found that psychotherapy was twice     of the participants.                      interested in quitting. The findings in
                                                                               as effective as pharmacological                                                  this study offer these individuals
                                                                               treatment in smoking cessation                                                   other options that can result in better




                                                                                                                                                                                                          70
         Citation                               Population Studied                         Results of Study                   Threats to Validity of Study                  Implications of Study
     (in APA format)                        (Who was studied? How many              (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                                where in the study)                   did the researchers find?)              with the study? Where there                patients? Is more research
                                                                                                                               reasons to doubt findings?)              required before we can draw
                                                                                                                                                                                conclusions?)
                                                                                   efforts. The smoking abstinence rate                                              outcomes and reduce the risk of
                                                                                   was 39.1% for the guided imagery                                                  complications/side effects that
                                                                                   and 12.3% for the bupropion.                                                      pharmacological agents often
                                                                                                                                                                     contain.

                                                                                                                                                                     Further studies are necessary to help
                                                                                                                                                                     support these findings. However, this
                                                                                                                                                                     study presents valid
                                                                                                                                                                     results/conclusions about the use of
                                                                                                                                                                     psychotherapy (guided imagery) for
                                                                                                                                                                     smoking cessation.
Institute for Clinical Systems            This is a guideline that was             (MAJOR RECOMMENDATIONS)                  There were no significant problems       A comprehensive tobacco control
Improvement (2004). Tobacco use           formulated from a wide variety of        ASSISTING THE PATIENT IN                 with the study or reasons to doubt the   program may reduce disease,
prevention and cessation for adults and   research not specifically mentioned      SMOKING CESSATION:                       findings. There were methods that        disability, and death related to
mature adolescents. National              in the report. It was then piloted and   a. Ask a tobacco user who is ready to    were used to ensure guideline            tobacco use for anyone. This would
Guideline Clearinghouse, 1-25.            reviewed for best recommendations.           quit his/her own quit date.          validation. The three methods            allow anyone in the healthcare field
                                          The target population was adults         b. Three treatment elements are          included: Clinical validation-pilot      working with patients know which
                                          and mature adolescents.                      effective for smoking cessation      testing, comparison with guidelines      types of smoking cessation
                                                                                       intervention: pharmacotherapy,       from other groups, and an internal       techniques to provide to their
                                                                                       social support for cessation, and    peer review.                             patients. Also, it would help them in
                                                                                       skills training/problem solving.                                              knowing how to question their
                                                                                   c. On average, nicotine replacement                                               patients about their smoking habits
                                                                                       therapy (NRT) and Zyban (                                                     and how to provide support for them
                                                                                       bupropion SR) double the                                                      once they have quit smoking.
                                                                                       probability of success.
                                                                                   d. Combining nicotine patches with
                                                                                       other self-administered forms of
                                                                                       NRT (gum, spray) is more
                                                                                       effective than a single form of
                                                                                       NRT.
                                                                                   e. Minnesotans have high-quality
                                                                                       free telephone line counseling for
                                                                                       smoking cessation.
                                                                                   f. Other resources include local
                                                                                       tobacco cessation classes,
                                                                                       community support systems, and
                                                                                       self-help brochures and materials
                                                                                       from drug companies.
                                                                                   e. Counsel to support cessation and
                                                                                       build abstinence skills.




                                                                                                                                                                                                             71
         Citation                             Population Studied                       Results of Study                    Threats to Validity of Study                  Implications of Study
     (in APA format)                      (Who was studied? How many            (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                              where in the study)                 did the researchers find?)               with the study? Where there                patients? Is more research
                                                                                                                            reasons to doubt findings?)              required before we can draw
                                                                                                                                                                             conclusions?)

                                                                               ENSURING THE PATIENT
                                                                               REMAINS SMOKE FREE
                                                                               Congratulate on quitting/encourage
                                                                               in-office or referral counseling for
                                                                               the first 12 months, especially during
                                                                               the first month.
Lichtenstein, E., Glasgow, R. E.,        13 randomized trials, all which had   Researchers found that reactive           Cost of proactive phone calls to the      This overall is a cost effective
Ossip-Klein, D. J., & Boles, S. M.       over 1,000 participants. Both adult   smoking cessation help-lines appear       clients, and the fact that it typically   method for smoking cessation. Most
(1996). Telephone Counseling for         men and women were studied.           to be a useful public health smoking      takes several times to reach a            smokers cannot or will not attend
Smoking Cessation: Rationales and                                              control strategy for large populations,   participant.                              cessation classes, and would rather
Meta-Analytic review of Evidence.                                              and that telephone calls may also be                                                make time in a phone conversation,
Health Education Research Theory &                                             used to augment nicotine                                                            and many smokers live in rural areas
Practice, 11(2), 243-257.                                                      replacement therapy by providing                                                    where telephone counseling may be
                                                                               support and behavioral counseling.                                                  one of few feasible sources of
                                                                                                                                                                   personal support. More research on
                                                                                                                                                                   the usefulness of telephone
                                                                                                                                                                   counseling for more specific
                                                                                                                                                                   populations.
Pan, W. (2006). Proactive telephone      There were 22 studies reviewed        Proactive telephone counseling as an      There were no significant problems        This study will have a positive
counseling as an adjunct to minimal      involving both men and women          adjunct to                                that threatened the validity of the       impact on increasing the rate of
intervention for smoking cessation: a    smokers.                              minimal interventions (i.e. a single or   study. It used strict criteria when       people who are able to successfully
meta-analysis. Health Education                                                combination of a few less intensive       choosing the articles to be reviewed.     quit smoking. It shows the
Research. 21, 416-427.                                                         or self-help interventions, such as       They had to have sufficient               importance of combining therapies
                                                                               self-help materials, nicotine             quantitative information. They also       with proactive telephone counseling.
                                                                               replacement therapy (NRT), reactive       had to have ‗proactive‘ telephone         Instead of using any one type of
                                                                               telephone hotlines or help-lines,         counseling and be a randomized            therapy by itself. Health care
                                                                               computer programs or Internet,            design. Lastly they had to provide a      providers will be able to use this
                                                                               physician advice was more effective       telephone counseling treatment group      information when developing
                                                                               than telephone counseling or minimal      and a comparable comparison group.        treatment programs for their patients.
                                                                               intervention alone.
Silagy, C., Lancaster, T., Mant, D., &   103 controlled trials of the          There is weak evidence that               None found                                All of the commercially available
Fowler, G. Nicotine Replacement          effectiveness of NRT. Over 35,600     combinations of forms of NRT are                                                    forms of NRT (gum, transdermal
Therapy for Smoking Cessation            participants,                         more effective. Higher doses may                                                    patch, nasal spray, inhaler, sublingual
(Review). Cochrane Database of                                                 produce small increases in quit rates,                                              tablet, lozenges) are effective as part
Systematic Reviews, 3, 1-8.                                                    quit rates were higher with bupropion                                               of a strategy to promote smoking
                                                                               were higher than with nicotine patch                                                cessation. They increase the odds of
                                                                               or placebo.                                                                         quitting approximately 1.5 to 2 fold
                                                                                                                                                                   regardless of setting. The
                                                                                                                                                                   effectiveness of NRT appears to be




                                                                                                                                                                                                             72
         Citation                              Population Studied                           Results of Study                   Threats to Validity of Study                   Implications of Study
     (in APA format)                       (Who was studied? How many                (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                               where in the study)                     did the researchers find?)              with the study? Where there                 patients? Is more research
                                                                                                                                reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                  conclusions?)
                                                                                                                                                                      largely independent of the intensity
                                                                                                                                                                      of additional support provided to the
                                                                                                                                                                      smoker.



Stead, L. F., Perera, R., & Lancaster,   The review includes 14 trials that         Telephone counseling is an effective     This study failed to detect an effect    Based on the findings a reasonable
T., (2007). A Systematic Review of       recruited callers to quit-lines. 10        intervention for assisting smokers to    of the type of counseling or the type    hypothesis would be that counseling
Interventions for Smokers Who            trials evaluated call-back                 quit. Self-help materials also offer a   of self help materials supplied as       helps maintain cessation in the early
Contact Quitlines. Tobacco Control,      counseling, 2 trials evaluated the         small benefit. This review singles out   adjuncts to quit-line counseling. It     stages of a quit attempt. Quit-lines
16(1), 3-8.                              counseling method at the initial call,     the evidence supporting the benefit      does not directly address how much       also have a potential impact on
                                         and 3 trials compared adjunctive           of call-back counseling to help          quit-line services increase quitting     public health beyond that of the
                                         self help materials at the initial call.   smokers who are seeking support via      compared to an ―unassisted‖ attempt.     services they provide to individuals.
                                                                                    quit-lines, showing that such                                                     Their promotion reinforces the
                                                                                    counseling improves quit rates. This                                              importance of quitting and the
                                                                                    review also considers the effect of                                               availability of help should smokers
                                                                                    different types of counseling methods                                             choose to use them. Call back
                                                                                    and adjunctive self help materials.                                               counseling increases efficacy, but
                                                                                                                                                                      based on a limited number of trails
                                                                                                                                                                      failed to show that any particular
                                                                                                                                                                      method of counseling or adjunctive
                                                                                                                                                                      self help materials leads to higher
                                                                                                                                                                      success rates.
Ussher, M., Taylor, A., & Faulker, G.    This is a review of 13 studies             Interventions included programs of       As this is a Cochrane Systematic         Exercise should be offered as a
(2008). Exercise interventions for       performed on smokers wishing to            supervised or unsupervised exercise      Review, the results are a great review   method to reduce tobacco withdrawal
smoking cessation (Review).              quit or recent quitters.                   alone or as an adjunct to a smoking      of the research that has been done.      and cravings. Further research is
Cochrane Database of Systematic                                                     cessation intervention, compared to a    The trials that did not show a           needed to understand how best to
Reviews, 4, 1-37.                                                                   smoking cessation program alone.         significant effect of exercise on        integrate this advice into current
                                                                                    Only one of the thirteen trials          smoking abstinence were either too       smoking cessation programs. Further
                                                                                    reviewed offered evidence for            small to exclude reliably and effect     trials are needed with larger sample
                                                                                    exercise aiding smoking cessation in     of intervention, had numerous            sizes, sufficiently intense exercises,
                                                                                    the long term. There is insufficient     methodological limitations or            and equal contact control conditions,
                                                                                    evidence to recommend exercise as a      included an intervention which was       and measures of exercise adherence
                                                                                    specific aid to smoking cessation.       not intense enough to produce the        across the sample. More work is also
                                                                                    However, there is strong evidence to     required changes in exercise levels.     needed to unravel the relationship
                                                                                    recommend exercise as an aid for                                                  between different intensities and
                                                                                    reducing tobacco withdrawal and                                                   timings of exercise intervention and
                                                                                    cravings.                                                                         the effect on smoking abstinence and
                                                                                                                                                                      on underlying processes such as
                                                                                                                                                                      tobacco withdrawal and cravings.




                                                                                                                                                                                                               73
        Citation                             Population Studied                        Results of Study                Threats to Validity of Study                     Implications of Study
    (in APA format)                      (Who was studied? How many             (What were the variables? What       (Where there significant problems          (How can results help in caring for
                                             where in the study)                  did the researchers find?)           with the study? Where there                   patients? Is more research
                                                                                                                        reasons to doubt findings?)                 required before we can draw
                                                                                                                                                                            conclusions?)
Wu, P., Wilson, K., Dimoulas, P., &     This is a systematic review and        The findings confirm the              Possible limitations include the           The mechanisms of action of these
Mills, E. (2006). Effectiveness of      meta analysis of pharmacological       effectiveness for smoking cessation   potential for publication bias, as this    three drugs are all distinctly different
smoking cessation therapies: A          interventions for smoking cessation    of the established pharmacological    review only included published trials.     and suggest the possibility of
systematic review and meta-anaylsis.    including: NRT, bupropion, and         interventions, NRT and bupropion.     Since varenicine is a new agent and        combination therapy or therapy
Biomed Central Public Health, 6, 300-   varenicline. There were 70 studies     However, the evidence suggests that   studies synthesized were the first         targeted on the particular symptoms
316.                                    examining NRT versus control           varenicline is more effective than    clinical trials evaluating its             experienced during cessation. Further
                                        interventions; 12 studies involving    placebo, bupropion, and in indirect   effectiveness, it is unlikely that other   studies could examine the option of
                                        bupropion; and 4 studies evaluating    comparisons with NRT.                 negative studies existed at the time       combination therapy with these
                                        varenicline.                                                                 this meta analysis was completed.          medications. Future studies should
                                                                                                                     Indirect comparisons were made             further examine the safety and
                                                                                                                     comparing NRT versus varenicline           effectiveness in reducing morbidity
                                                                                                                     which some evidence suggests may           and mortality of all three of these
                                                                                                                     provide misleading measures of             pharmacological therapies in patients
                                                                                                                     superiority. The meta-analysis did         with active smoking related disease.
                                                                                                                     not evaluate in detail other aspects of
                                                                                                                     therapy, such as compliance and
                                                                                                                                                                As varenicline is a fairly new drug,
                                                                                                                     tolerance that may influence real life
                                                                                                                                                                there were only 4 studies reviewed
                                                                                                                     clinical effectiveness.
                                                                                                                                                                about this modality of treatment.
                                                                                                                                                                Further studies comparing
                                                                                                                                                                varenicline versus either NRT or
                                                                                                                                                                bupropion are needed
Wynd, C. (2005). Guided health          Female and male smokers (cigarette     This study was conducted to examine   The fact that the participants in this     This study does demonstrate the
imagery for smoking cessation and       consumption 5 cigarettes per day       the effectiveness of guided imagery   study were not necessarily planning        effectiveness of guided imagery in
long-term abstinence [Electronic        for a minimum of 1 year) at least 18   (IV) as a nursing intervention for    on quitting smoking at the time they       smoking cessation efforts. There
version]. Journal of Nursing            years of age.                          immediate smoking cessation and       started the study had an effect on the     needs to be more studies with larger
Scholarship, 37, 245-250.                                                      long-term abstinence (DV). There      outcomes. Had they only recruited          sample sizes (there were 71
                                        -71 participants were randomized.      was also a placebo-control group      individuals with the                       participants in this study) before
                                                                               utilized in this study.               intent/willingness to quit, the results    conclusions can be drawn.
                                                                                                                     of smoking cessation efforts probably
                                                                               24-mon follow-up: The researchers     would have yielded better results.         As previously noted (Article #5), the
                                                                               found that guided imagery was more                                               findings in this study can positively
                                                                               effective than counseling alone in                                               influence the care delivered for those
                                                                               smoking cessation efforts. The                                                   seeking smoking cessation because it
                                                                               smoking abstinence rate was 26% for                                              offers them alternative methods.
                                                                               the intervention group and 12% for                                               These options can result in better
                                                                               the control.                                                                     outcomes and reduce the risk of
                                                                                                                                                                complications/side effects that
                                                                                                                                                                pharmacological agents often
                                                                                                                                                                contain. This was also one of the few
                                                                                                                                                                ―nursing intervention‖ studies




                                                                                                                                                                                                           74
         Citation                                 Population Studied                     Results of Study                   Threats to Validity of Study                   Implications of Study
     (in APA format)                          (Who was studied? How many          (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                                  where in the study)               did the researchers find?)              with the study? Where there                 patients? Is more research
                                                                                                                             reasons to doubt findings?)              required before we can draw
                                                                                                                                                                               conclusions?)
                                                                                                                                                                   conducted evaluating smoking
                                                                                                                                                                   cessation aids.




TRACK 5            EBP Team 16: Brina Boyles, Julie Hanselman, Julie Nevins, Melinda Rose, and Teresa Wooten

Clinical Question: For children with obesity, are diet and exercise alone as effective for weight loss as diet and exercise with medication as an adjunct treatment?
                Citation                            Population Studied                   Results of Study                   Threats to Validity of Study                   Implications of Study
            (in APA format)                     (Who was studied? How many        (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                                    where in the study)             did the researchers find?)              with the study? Where there                 patients? Is more research
                                                                                                                             reasons to doubt findings?)               required before we can draw
                                                                                                                                                                               conclusions?)
Berkowitz, Robert I.; Fujioka, Ken;            The population studied was 498     Participants who took the               The study lasted only one year. It did   Further research should be conducted
Daniels, Stephen R.; Hoppin, Alison G.;        obese adolescent males & females   medication on average lost weight       not measure changes in weight after      before prescribing Sibutramine to
Owen, Stanford; Perry, Arlette C.;             age‘s 12-16 years old. The         rapidly during the first 8 months       stopping Sibutramine treatment.          obese adolescents. Researchers do
Sothern, Melinda S.; Renz, Cheryl L.;          individuals had to have a body     and maintained weight until one         About one quarter of the participants    not know the longer-term effects of
Pirner, Mark A.; Walch, Julia K.; Jasinsky,    mass index (BMI) that was at       year. Adolescents who took              did not complete the study. There is     the medication. The study does
Olga; Hewkin, Ann C.; Blakesley, Vicky         least 2 units more than the U.S.   Sibutramine lost approximately 14       the risk of bias because Abbott, the     indication that the medication can
A.. Effects of Sibutramine Treatment in        weighted mean of the 95th          pounds while those who took the         manufacturer of the drug, sponsored      have positive results in combination
Obese Adolescents. Annals of Internal          percentile based on age and sex,   placebo usually gained weight.          the study.                               with behavior modification such as
Medicine, 7/18/2006, Vol. 145 Issue 2,         to the upper limit of 44 kg/m2.    Treatment with Sibutramine was                                                   diet and exercise.
p81-W20, 11p.                                                                     associated with greater
                                                                                  improvements in body weight,
                                                                                  waist circumference, triglyceride
                                                                                  levels, HDL cholesterol levels,
                                                                                  insulin levels, & insulin sensitivity
                                                                                  compared to the placebo. Variables
                                                                                  included the amount of physical




                                                                                                                                                                                                          75
                 Citation                         Population Studied                    Results of Study                  Threats to Validity of Study                 Implications of Study
             (in APA format)                  (Who was studied? How many         (What were the variables? What         (Where there significant problems        (How can results help in caring for
                                                  where in the study)              did the researchers find?)             with the study? Where there               patients? Is more research
                                                                                                                           reasons to doubt findings?)             required before we can draw
                                                                                                                                                                           conclusions?)
                                                                                 activity performed by the
                                                                                 participant, amount of stress
                                                                                 undergone by the individual, &
                                                                                 amount of food consumed.


 Budd, G., Hayman, L., Crump, E.,            There were a total of 82            The variables of the study were        Each participant had a history &         Pediatric obesity is a growing
 Pollydore, C., Hawley, K., Cronquist, J.,   participants. 34 African            weight loss with diet & exercise or    physical to determine they were fit      problem. If adding medication to the
& Berkowitz, R. (2007) Weight loss in        American adolescents‘ age 13-17     weight loss with diet, exercise &      for the study. It may have been more     weight loss program proves effective
obese African American and Caucasian         & 45 Caucasian adolescents also     Sibutramine. Lifestyle changes         reliable if the same practitioner did    in increasing the rate of weight loss,
adolescents. Journal of Cardiovascular       age 13-17.                          such as diet & exercise along with     every history & physical so that the     this could take a large amount of
Nursing, 22 (4) 288-296.                                                         Sibutramine proves effective in        exam was the same for every              initial weight off the child &
                                                                                 this study of increasing the rate at   participant. This could potentially      decrease their risk for having other
                                                                                 which weight is lost. The percent      create bias. There was also a small      illnesses. However, it is
                                                                                 of change between each group was       sample size.                             recommended that close supervision
                                                                                 not a significant change but the                                                be used when administering these
                                                                                 Caucasian adolescents had a                                                     medications to children.
                                                                                 greater percent of change in BMI
                                                                                 than the African American group.
 Chanione, J.P., M.D., PhD, Hampl, S.,       The population studied was          Variables: Participants who took       Limitations to the study included diet   The results of this study show
M.D., FAAP, Jenson, C., M.D., Boldrin,       adolescents with a BMI of 28.5      Orlistat 120 mg three times a day      & exercises were not standardized,       statistical significance that Orlistat in
M., M.S., & Hauptman, J., M.D. (2005)        for boys and 29.5 for girls at 12   or participants who took the           participants were mostly white           combination with diet and exercise
Effect of orlistat on weight and body        years of age to 31.8 & 31.9         placebo three times a day. Results:    females, & the average participant       will reduce BMI of this population.
composition in obese adolescents. Journal    respectively, at 16 years of age.   In conjunction with a reduced          was at the 98th percentile for BMI. It   By reducing BMI, you also reduce
of American Medical Association, 293(23),    There were 539 randomized           calorie diet, exercise, & behavioral   is not certain if less obese             the risk of other health problems,
2873-2883.                                   participants in this study.         modification, treatment with 120       adolescents would achieve similar        such as diabetes & future chronic
                                                                                 mg of Orlistat three times daily for   results. There is no reason to doubt     disease. Successful use the results of
                                                                                 52 weeks statistically significantly   the study results. This study was a      this study can occur without further
                                                                                 decreased BMI, waist                   large, multicenter, randomized,          research. In the ever- changing
                                                                                 circumference, & body fat              double blind study that was done         world of healthcare additional
                                                                                 compared with the placebo.             over a one-year period. Data             research is warranted.
                                                                                                                        collection and analysis appears
                                                                                                                        reliable. Results reported statistical
                                                                                                                        significance for this population.




                                                                                                                                                                                                             76
                 Citation                        Population Studied                      Results of Study                    Threats to Validity of Study                  Implications of Study
             (in APA format)                 (Who was studied? How many           (What were the variables? What           (Where there significant problems        (How can results help in caring for
                                                 where in the study)                did the researchers find?)               with the study? Where there                 patients? Is more research
                                                                                                                              reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                conclusions?)
Godoy-Matos, A., Carraro, L., Vieira, A.,   The population studied was 60         Variables: participants who took         The statistics support the use of        The results clearly indicate weight
Oliveira, J., Guedes, E., Mattos, L.,       adolescents aged 14-17 year for 6     Sibutramine versus participants          Sibutramine & lifestyle changes to       reduction using Sibutramine, lifestyle
Rangel, C., Moreira, R., Coutinho, W., &    months. Participants were both        who took the placebo. A single           produce weight loss. However, there      changes & exercise. Sibutramine can
Appoliario, J. (2005) Treatment of obese    boys and girls, with a BMI of 30-     blind, 4-wk, placebo run-in period       are limitations in this study such as    be incorporated into practice for the
adolescents with sibutramine: a             45.                                   was followed by a 6-month,               dietary restrictions & exercises that    treatment of childhood obesity with
randomized, double-blind, controlled                                              randomized, double blind, placebo-       were not standardized.                   the thought that continual research be
study. Journal of Clinical Endocrinology                                          controlled period.                                                                conducted.
& Metabolism, 90 (3), 1460-1465.                                                  Results: Researchers demonstrated
                                                                                  a weight reduction of 7.8kg with
                                                                                  the paired use of Sibutramine and
                                                                                  lifestyle changes compared to the
                                                                                  placebo group‘s weight loss of
                                                                                  3.2kg.
McGovern, L., Johnson, J.N., Paulo, R.,     A systematic review of seventy-       Variables included prescribed            A high probability of reporting bias     The study showed a short-term
Hettinger, A., Singhal, V., Kamath, C.,     six trials was completed. Of the      exercise and diet plans (combined        exists, with possible publication bias   efficacy in combination lifestyles
Erwin, P.J., & Montori, V.M. (2008,         seventy-six trials sixty-one trials   lifestyles); diet only; exercise only;   (overestimation of treatment effect).    with medication. Long-term efficacy
December). Treatment of Pediatric           were eligible for meta-analysis.      & medication administration.             The trials have limited                  and safety remains unclear. Past
Obesity: A systematic review and meta-      The total number of participants is   Medications tested Sibutramine,          methodological features & were           studies correlate with these findings.
analysis of randomized trials. Journal of   unknown.                              Orlistat & Metformin.                    limited in duration (lengths             More research with longer studies
Clinical Endocrinology Metabolism,                                                                                         unknown).                                would be beneficial.
93(12), 4600-4605.

Van Mil, E.G., Westerterp, K.R., Kester,    Obese Adolescents age 12-17           The trials prescribed exercise &         Short-term study; only 12 weeks for      The results of this study indicate a
A.D., Delemarree-van De Waal, H.A.,         years. Twenty-four participants.      diet with Sibutramine as test &          intervention period and 12 weeks for     very limited study period, which
Gerver, W.J., and Saris, W.H. (2009,                                              with placebo control for a 12-week       follow-up period. Small sample size.     makes the healthcare providers
April). The Effect of Sibutramine on                                              test period, then a 12-week follow-      Selection techniques of participants     involvement unclear. More research
Energy Expenditure and Body                                                       up period with no medication             and number of participants that          with longer studies would be
Composition in Obese Adolescents. The                                             administration. During the               refused are unknown.                     beneficial.
Journal of Endocrinology and Metabolism,                                          intervention period no significant
92(4): 1409-1414.                                                                 difference in body composition in
                                                                                  either group. Basal Metabolic
                                                                                  Rate (BMR) decreased in the
                                                                                  placebo group compared to
                                                                                  Sibutramine under the same
                                                                                  physical activity levels (PAL) &
                                                                                  total energy expenditures (TEE).
                                                                                  In the follow-up period, Body
                                                                                  Mass Index (BMI) decreased in the
                                                                                  placebo group & increased in the
                                                                                  Sibutramine group while Basal




                                                                                                                                                                                                             77
                Citation                        Population Studied                   Results of Study                  Threats to Validity of Study              Implications of Study
            (in APA format)                 (Who was studied? How many        (What were the variables? What         (Where there significant problems     (How can results help in caring for
                                                where in the study)             did the researchers find?)             with the study? Where there            patients? Is more research
                                                                                                                        reasons to doubt findings?)          required before we can draw
                                                                                                                                                                     conclusions?)
                                                                              Metabolic Rate (BMR) increased
                                                                              in placebo group & increased in
                                                                              the Sibutramine group.




TRACK 6           EBP Team 17: Garrett, Stacy; Hampton, Cathi; Martin, Elizabeth; Pina, Lily; Vogele, Tana

Clinical Question: Is Demerol or Fentanyl the safest medication for adequate pain control for postoperative clients older than 65?

                                                                                  Population Studied                Results of Study         Threats to Validity of Study         Implications of Study
                                   Citation                                     (Who was studied? How           (What were the variables?     (Where there significant           (How can results help in
                               (in APA format)                                    many where in the              What did the researchers     problems with the study?            caring for patients? Is
                                                                                        study)                           find?)              Where there reasons to doubt        more research required
                                                                                                                                                      findings?)                   before we can draw
                                                                                                                                                                                      conclusions?)
American Geriatrics Society Panel on Persistent Pain in Older Persons. The     The clinical guidelines      The panel found that             Poor pain management does          The guidelines will assist
Management of Persistent Pain in Older Persons. (2002). Retrieved March 12,    targets elderly patients     persistent pain is common in     not occur in the all elderly       healthcare providers in
2009 from www.americangeriatrics.org                                           experiencing persistent      the elderly and the poor         patients and should be properly    performing a thorough
                                                                               pain.                        management of such pain can      assessed to achieve an effective   assessment of the pain
                                                                                                            lead to adverse outcomes         and individualized treatment       experienced by the elderly
                                                                                                            such as depression and           plan.                              population, making pain
                                                                                                            decreased quality of life.                                          management more
                                                                                                                                                                                successful in the
                                                                                                                                                                                population.




                                                                                                                                                                                                             78
                                                                                     Population Studied               Results of Study             Threats to Validity of Study         Implications of Study
                                    Citation                                       (Who was studied? How          (What were the variables?         (Where there significant           (How can results help in
                                (in APA format)                                      many where in the             What did the researchers         problems with the study?            caring for patients? Is
                                                                                           study)                          find?)                  Where there reasons to doubt        more research required
                                                                                                                                                            findings?)                   before we can draw
                                                                                                                                                                                            conclusions?)
American Society of Anesthesiologists Task Force on Acute Pain                     The clinical guidelines       The task force concluded that     Although the findings seem         The results can lead to
Management. Practice Guidelines for Acute Pain Management in the                   addressing proper pain        pain management in the            appropriate, follow through of     improved pain
Perioperative Setting: An Updated Report by the American Society of                management in the             postop elderly was                the guidelines might be            management in the post
Anesthesiologists Task Force on Acute Pain Management. [Guideline, Journal         postoperative patient         undertreated and developed        inappropriate to smaller           operative setting while
Article. Practice Guideline. Research Support, Non-U.S. Gov‘t] Anesthesiology.                                   specific guidelines to improve    hospital due to decreased          reducing risks and
100(6): 1573-81, 2004 Jun UI 15166580.                                                                           pain management in this           financial resources.               maintaining patient safety.
                                                                                                                 population.


Apfelbaum, Jeffrey L, Chen, Connie, Mehta, Shilpa S., Gan, & Tong J., (2003).      A total of 250 postsurgical   59% of the patients were          The study was done using the       The study helps readers
Postoperative pain experience: results from a national survey suggest              patients were studied with    more concerned with post          survey method from a market        gain insight into the
postoperative pain continues to be under managed. International Anesthesia         an average age of 46 years.   operative pain than whether       research organization. Study       participant‘s perceptions
Research Society. Retrieved February 10, 2009 from www.anesthesia-                                               the surgery would improve         included adults who had            and experiences during the
analgesia.org                                                                                                    their health. The most            surgery within the last 5 years.   pre and post surgical
                                                                                                                 common pain meds used were                                           phase. However, because
                                                                                                                 morphine, meperidine, and                                            the study is a survey,
                                                                                                                 Tylenol with codeine. 23%                                            further research is required
                                                                                                                 experienced adverse reactions                                        before considering the
                                                                                                                 to meds.                                                             results.
Aydin, O., Ugur, B., Kir, E., & Ozkan, S., (2004). Effect of Single- Dose          70 patients aged >60 years    There were two randomized         This study‘s principal goal was    More research is required
Fentanyl on the Cardiorespiratory System in Elderly Patients Undergoing Cataract   who underwent cataract        groups of 35; one group           providing patient comfort          to determine or obtain
Surgery. Journal of Clinical Anesthesia, 16, 98-103. Retrieved February 6, 2009,   surgery with topical          receiving fentanyl and the        while under sedation. The          more precise results in the
from CINAHL database.                                                              anesthesia.                   control group received a          depth of sedation can result in    cardiorespiratory effects
                                                                                                                 placebo. The results showed       respiratory complications as       with clear outlines to the
                                                                                                                 that fentanyl can be used         well as disorientation and lack    amount and method of O2
                                                                                                                 safely in elderly patients to     of cooperation. Recommended        administration. The study
                                                                                                                 improve comfort without           routine use of supplemental O2     does take into effect the
                                                                                                                 cardiorespiratory side effects.   and SPO2 monitoring is             elderly patients sensitivity
                                                                                                                                                   required. However studies          to opiods and adjusts the
                                                                                                                                                   have shown that different          dosage to a safe dose that
                                                                                                                                                   results are obtained with          could be implemented for
                                                                                                                                                   difference in O2 is                patient care in the elderly.
                                                                                                                                                   administered and whether or
                                                                                                                                                   not SPO2 monitoring is
                                                                                                                                                   accurate.




                                                                                                                                                                                                                     79
                                                                                     Population Studied              Results of Study            Threats to Validity of Study          Implications of Study
                                    Citation                                       (Who was studied? How         (What were the variables?        (Where there significant            (How can results help in
                                (in APA format)                                      many where in the            What did the researchers        problems with the study?             caring for patients? Is
                                                                                           study)                         find?)                 Where there reasons to doubt         more research required
                                                                                                                                                          findings?)                    before we can draw
                                                                                                                                                                                            conclusions?)
Chelly, J.E., Grass, J., Houseman, T.W., Minkowitz, H., & Pue, A. (2004). The      205 patients who had         This was a randomized,           It is important to achieve          Future studies need to be
Safety and Efficacy of a Fentanyl Patient-Controlled Transdermal System for        undergone major              double-blinded, placebo-         analgesic comfort before            done testing the efficacy of
Acute Postoperative Analgesia: A Multicenter, Placebo-Controlled Trial.            abdominal, orthopedic, or    controlled trial comparing the   relying on a PCA for pain           PCA with a defined pain
Anesthesia Analg, 98, 427-33. Retrieved February 6, 2009, from CINAHL              thoracic surgery.            safety of on-demand fentanyl     management. This study did          score.
database.                                                                                                       against a placebo in the 24      not reflect a defined pain score.
                                                                                                                hour period after major          Early withdrawal of patients
                                                                                                                surgery. The study proved        with higher pain scores at the
                                                                                                                that fentanyl was better than    study entry occurred with those
                                                                                                                the placebo for the control of   who did not achieve adequate
                                                                                                                moderate to severe pain after    pain control.
                                                                                                                major surgery with no patient
                                                                                                                experiencing relevant
                                                                                                                respiratory depression.
DynaMed. Oct 17, 2008. Meperidine. Retrieved Feb 12, 2009 from                     All ages are included in     Meperidine is an opiate          No reason to doubt findings.        This information helps us
http://dynaweb.ebscohost.com/Detail.aspx?id=233074&sid=d2055d95-296c-              this dosage and              agonist used to relieve                                              to safely administer this
4303-96ff-16                                                                       administration guide.        moderate to severe pain such                                         drug if all other opiates
                                                                                                                as that associated with acute                                        have been determined not
                                                                                                                and some chronic medical                                             to be the best to use. This
                                                                                                                disorders including renal or                                         information states that
                                                                                                                biliary colic, acute trauma,                                         reduced dosage is
                                                                                                                postoperative pain, and                                              indicated in poor-risk
                                                                                                                cancer. It is used to provide                                        patients, in geriatric and
                                                                                                                analgesia and preoperative                                           very young patients, renal
                                                                                                                sedation. Use as first line                                          or hepatic impairment, and
                                                                                                                opiate therapy is discouraged                                        in patients receiving other
                                                                                                                because of central excitatory                                        CNS depressants. It lists
                                                                                                                toxicity of metabolite                                               warnings and precautions
                                                                                                                (normeperidine). Not                                                 that need to be taken when
                                                                                                                recommended for chronic                                              administering this drug.
                                                                                                                pain because of short duration
                                                                                                                of effect and risk of
                                                                                                                accumulation of
                                                                                                                normeperidine.
Fong, H.K., Sands, L.P., & Leung, J.M. 2006. The Role of Postoperative             Clinical trials and          Variables included effects of    The validity of the articles was    According to the results,
Analgesia in Delirium and Cognitive Decline in Elderly Patients: A Systematic      observational studies were   different opioid analgesics      assessed by randomization,          Meperidine increases the
Review. [Review] [76 ref] [Journal Article.Research Support, N.I.H., Extramural.   included. A total of 10      and IV vs. epidural modes of     blinding, withdrawals and           alterations in mental status
Review] Anesthesia and Analgesia. 102 (4): 1255-66, 2006 Apr. UI 16551934          studies were included that   analgesia on delirium or         dropouts. There was no threat       changes in the
                                                                                   focused on opioids (also     postoperative cognitive          to validity. There were no          postoperative elderly client
                                                                                   some non opioid) for the     decline. The results of the      significant problems with the       and should be avoided. As




                                                                                                                                                                                                                    80
                                                                                    Population Studied               Results of Study           Threats to Validity of Study            Implications of Study
                                    Citation                                      (Who was studied? How          (What were the variables?       (Where there significant             (How can results help in
                                (in APA format)                                     many where in the             What did the researchers       problems with the study?              caring for patients? Is
                                                                                          study)                          find?)                Where there reasons to doubt          more research required
                                                                                                                                                         findings?)                      before we can draw
                                                                                                                                                                                            conclusions?)
                                                                                  use of postoperative          study were that Meperidine      study and no reason to doubt         stated above, nurses should
                                                                                  analgesia.                    was consistently associated     the findings.                        advocate for the patients
                                                                                                                with an increased risk of                                            and question the doctors if
                                                                                                                delirium in elderly surgical                                         they write the orders for
                                                                                                                patients, but the current                                            this medication in the
                                                                                                                evidence has not shown a                                             elderly postoperative
                                                                                                                significant difference in                                            client. Further study could
                                                                                                                postoperative delirium or                                            be completed. Pain relief
                                                                                                                cognitive decline among other                                        is not discussed and needs
                                                                                                                more frequently used                                                 to be examined to
                                                                                                                postoperative opioids. The                                           determine the best choice
                                                                                                                studies suggest that IV or                                           of opioid for postoperative
                                                                                                                epidural techniques do not                                           pain control.
                                                                                                                influence cognitive function
                                                                                                                differently.
Koczmara, C., Hyland, S., Perri, D., Rousseaux., L., (2005) Spring. Meperidine    Adults receiving              The use of meperidine in pain   One study at a university            ISMP Canada recommends
(Demerol) safety issues. Dynamics (Pembroke, Ont), 16 (1), 8-12. Retrieved Feb    meperidine for pain control   management should be            hospital reviewed 185 charts of      health care facilities
12, 2009 from MEDLINE database.                                                                                 restricted.                     patients who received                evaluate their use of
                                                                                                                                                meperidine by PCA. Another           meperidine to improve its
                                                                                                                                                study included 412 patients          safety. (JCAHO ) The
                                                                                                                                                who were administered                joint commission on
                                                                                                                                                meperidine PCA due to history        Accreditation of Health
                                                                                                                                                of allergy or new onset adverse      Care Organizations
                                                                                                                                                reaction was conducted. They         published pain
                                                                                                                                                concluded that adverse events        management guidelines,
                                                                                                                                                were related to dasage and           standards, and quality care
                                                                                                                                                length of time meperidine was        indicators that discourage
                                                                                                                                                administered. No reason to           use of meperidine.
                                                                                                                                                doubt findings.
Kudoh, A., Hajime, T., & Tomoko, T. (2004). A Comparison of                       150 patients aged >70         Randomly divided into two       While the Mini-Mental State          The results of this study
Anesthetic Quality in Propofol-Spinal Anesthesia and Propofol-Fentanyl            years undergoing total        groups; one group to receive    test provides global measure of      reflect a need for change to
Anesthesia for Total Knee Arthroplasty in Elderly Patients. Journal of Clinical   knee arthroplasty.            spontaneous ventilation         cognitive function, the data         decrease cost for the
Anesthesia, 16, 405-410. Retrieved February 6, 2009 from CINAHL database.                                       during propofol-spinal          does not reflect impairment of       patient. With a stable
                                                                                                                anesthesia, and one group to    a specific cognitive function.       hemodynamic state and an
                                                                                                                receive mechanical              This test may also be affected       improved recovery during
                                                                                                                ventilation with endotracheal   by intelligence and social class.    propofol-spinal anesthesia,
                                                                                                                tube during propofol-fentanyl   This test does take little time to   vs. propofol-fentanyl
                                                                                                                anesthesia.                     complete and is useful as a          anesthesia, further studies
                                                                                                                Research found that the         screening test to evaluate the       need to be done comparing




                                                                                                                                                                                                                    81
                                                                                       Population Studied                Results of Study              Threats to Validity of Study         Implications of Study
                                     Citation                                        (Who was studied? How           (What were the variables?          (Where there significant           (How can results help in
                                 (in APA format)                                       many where in the              What did the researchers          problems with the study?            caring for patients? Is
                                                                                             study)                           find?)                   Where there reasons to doubt        more research required
                                                                                                                                                                findings?)                   before we can draw
                                                                                                                                                                                                 conclusions?)
                                                                                                                    propofol-spinal anesthesia         cognitive function of the          the long-tem affects as
                                                                                                                    provided better and faster         elderly.                           these were short term
                                                                                                                    recovery than did the                                                 results.
                                                                                                                    propofol-fentanyl group for
                                                                                                                    elderly patients.
Silbert, B., Scott, D., Evered, L., Lewis, M. Kalpokas, M., Maruff, P., Myles, P.,   350 patients scheduled to      The patients were randomized       This study was found to be         This study found that
& Jamrozik, K. (2006). A Comparison of the Effect of High- and Low-Dose              undergo elective coronary      into two groups to receive         valid as this trial had a large    patients with early POCD
Fentanyl on the Incidence of Postoperative Cognitive Dysfunction after Coronary      artery bypass graft surgery.   either low-dose fentanyl or        patient sample compared with       spent an average of 1.2
Artery Bypass Surgery in the Elderly. Anesthesiology, 104 No. 6, 1137-1145.                                         high-dose fentanyl as the          similar studies. Loss to follow-   days longer in the hospital
Retrieved February 6, 2009, from CINAHL database.                                                                   basis of anesthesia.               up is a major concern because      compared with those with
                                                                                                                    168 in the low-dose group          cognitive function cannot be       normal cognitive function.
                                                                                                                    and 158 patients in the high-      ruled out as a factor. This        The high-dose fentanyl
                                                                                                                    dose group were included.          study had a very high retention    was found to have no
                                                                                                                    The high-dose fentanyl is not      rate lending credibility to the    increased incidence of
                                                                                                                    associated with any difference     results.                           POCD and the low-dose
                                                                                                                    in postoperative cognitive                                            fentanyl has shown
                                                                                                                    dysfunction.                                                          increased incidence of
                                                                                                                                                                                          early POCD. By changing
                                                                                                                                                                                          to high-dose fentanyl the
                                                                                                                                                                                          patient will have decreased
                                                                                                                                                                                          length of stay with no
                                                                                                                                                                                          increase in POCD after
                                                                                                                                                                                          CABG surgery.
Spine Universe For Professionals. Feb 19, 2007. Postoperative Pain Control:          Adults postoperative           Meperidine is commonly             There is no reason to doubt        Meperidine should be
Opioid Administration. Retrieved on March 12, 2009 from                              receiving opioids for pain     underdosed and administered        these findings. No one             reserved for a very brief
http://www.spineuniverse.com/displayarticle.php/article2754.html                     control                        too infrequently even by           mentioned was excluded.            course in otherwise healthy
                                                                                                                    physicians aware of its                                               patients who have
                                                                                                                    pharmocokinetics. It is                                               demonstrated an unusual
                                                                                                                    contraindicated in patients                                           reaction or allergic
                                                                                                                    with impaired renal function                                          response during treatment
                                                                                                                    and those receiving MAOI‘s.                                           with other opioids.
                                                                                                                    Meperidine contains a toxic
                                                                                                                    metabolite called
                                                                                                                    normeperidine which is a
                                                                                                                    cerebral irritant that can cause
                                                                                                                    effects ranging from
                                                                                                                    dysphoria and irritable mood
                                                                                                                    to convulsions. These effects
                                                                                                                    have also been ovserved in




                                                                                                                                                                                                                      82
                                                                                    Population Studied                Results of Study              Threats to Validity of Study        Implications of Study
                                    Citation                                      (Who was studied? How           (What were the variables?          (Where there significant          (How can results help in
                                (in APA format)                                     many where in the              What did the researchers          problems with the study?           caring for patients? Is
                                                                                          study)                           find?)                   Where there reasons to doubt       more research required
                                                                                                                                                             findings?)                  before we can draw
                                                                                                                                                                                            conclusions?)
                                                                                                                 young, otherwise healthy
                                                                                                                 patients given sufficiently
                                                                                                                 high doses of normeperidine
                                                                                                                 postoperatively.
Strassels, S. Aug 13, 2008. Meperidine (penthidine) for treatment of              Adults > 18 years              Results pending. The               Studies will be included if they   Pending
postoperative pain in adults (Protocol). Cochrane Database of Systematic          undergoing operative           objective is to assess the         are published, randomized,
Reviews, Retrieved February 12, 2009 from Cochrane Database of Systematic         procedures                     analgesic efficacy and             double blind trials of single or
Reviews Database.                                                                                                adverse event profile of           multiple doses of meperidine
                                                                                                                 meperidine for moderate to         administered for moderate to
                                                                                                                 severe postoperative pain in       severe postoperative pain.
                                                                                                                 adults and to directly or          Also included will be studies
                                                                                                                 indirectly compare its             containing data on at least one
                                                                                                                 effectiveness with other           of the outcome variables.
                                                                                                                 analgesics used in this setting.   Postpartum trials will be
                                                                                                                                                    included provided the pain
                                                                                                                                                    investigated was due to
                                                                                                                                                    episiotomy or Caesarean
                                                                                                                                                    section. Studies where
                                                                                                                                                    meperidine is administered for
                                                                                                                                                    indications other than
                                                                                                                                                    postoperative pain (such as
                                                                                                                                                    labor pain, biliary colic,
                                                                                                                                                    headaches and postoperative
                                                                                                                                                    shivering) will be excluded.
Titler, MG., Herr K., Schilling ML., Marsh JL., Xie XJ., Ardery G., Clarke WR.,   This study included            Variables include types and        Content validity was achieved      Results show that
Everett LQ. (Nov, 2003). Acute Pain Treatment for Older Adults Hospitalized       patients aged 65 and over,     amounts of analgesics              by review of the form by 3         recommendations for pain
With Hip Fracture: Current Nursing Practices and Perceived Barriers. [Journal     hospitalized with a hip        administered, frequency of         individuals with research          management are not being
Article. Research Support, U.S. Gov‘t, P.H.S.] Applied Nursing Research. 16       fracture. There were no        analgesics administered via        expertise in acute pain. The       adopted in practice and
(4): 211-27, 2003 Nov. UI 14608555                                                actual participants.           PCA or IM, patients with           tool was then pilot tested by      pain in elders continues to
                                                                                  Medical records were           dementia receiving same or         abstracting 10 records of          be undertreated. The study
                                                                                  randomly chosen from           different amounts of opioids,      elderly hip fracture patients      suggests more routinely
                                                                                  those that met the inclusion   PCA vs. IM injections differ       from a local health care           ordered analgesics versus
                                                                                  criteria. A total of 709       for patients with and without      facility. There were no            prn orders. Nurses need to
                                                                                  medical records comprised      dementia, frequency of nurses      significant problems with this     be aware of the harmful
                                                                                  the final sample.              administering prn analgesics,      study. There were no reasons       effects of Meperidine.
                                                                                                                 types and frequency patients       to doubt the findings in this      They can advocate for the
                                                                                                                 receive non pharmacological        study.                             patients with the results
                                                                                                                 pain interventions, and nurses                                        from this study. Further
                                                                                                                 perceived administration of                                           studies need to be




                                                                                                                                                                                                                     83
                    Population Studied         Results of Study             Threats to Validity of Study     Implications of Study
    Citation      (Who was studied? How    (What were the variables?         (Where there significant       (How can results help in
(in APA format)     many where in the       What did the researchers         problems with the study?        caring for patients? Is
                          study)                    find?)                  Where there reasons to doubt    more research required
                                                                                     findings?)               before we can draw
                                                                                                                  conclusions?)
                                          analgesics and perceived                                         conducted to study which
                                          barriers to optimal tx of acute                                  opioid provides the best
                                          pain in elders. Findings from                                    pain relief.
                                          this study show that
                                          interventions are needed to
                                          promote evidence-based
                                          practices of acute pain
                                          management in the elderly.
                                          They found that ―Meperidine
                                          use in the elderly should be
                                          avoided because of possible
                                          normeperidine toxicity,
                                          especially in the presence of
                                          coexisting heart failure and
                                          renal impairment‖.




                                                                                                                                       84
TRACK 6             EBP Team 18: Michelle Mann, Erika Rumble, Mary Sawyer, Chanda Vlanich, Paul Vlanich

Clinical Question: In adult patients with acute pancreatitis, which nutritional intervention, enteral or parenteral feeding, improves dietary intake, results in fewer
treatment complications, and decreases length of hospitalization?

              Citation                        Population Studied                          Results of Study                     Threats to Validity of Study                    Implications of Study
          (in APA format)                 (Who was studied? How many               (What were the variables? What           (Where there significant problems          (How can results help in caring for
                                              where in the study)                    did the researchers find?)                with the study? Where there            patients? Is more research required
                                                                                                                                reasons to doubt findings?)             before we can draw conclusions?)
Al-Omran, M; Groof, A; Wilke, D.        A total of 70 patients with acute         There was statistical evidence that      There were not enough trials/studies      There is a trend toward reduction of
(2008). Enteral versus parenteral       pancreatitis with clinical presentation   there was a reduction of length of       to come to a firm conclusion that         negative patient outcomes with enteral
nutrition for acute pancreatitis. The   and elevated serum amylase.               stay with enteral nutrition versus       enteral is better than parenteral         nutrition versus parenteral.
Cochrane Database of Systematic                                                   parenteral nutrition.                    nutrition.
Reviews. Vol. 4.                        Two randomized clinical trials were                                                                                          Enteral nutrition is cost effective and can
                                        considered in the review with a total     None of the other dependent                                                        be used with this patient population.
                                        of 70 participants.                       variables; mortality, systemic
                                                                                  infection, local septic complications,                                             More research is required for the
                                        One of the trials had a sample 38         and other local complications had                                                  conclusion that enteral nutrition is more
                                        patients and the other had 32.            significant statistical evidence to                                                beneficial in this patient population.
                                                                                  support enteral or parenteral
                                                                                  nutrition.

Louie, B. E. M.D., Noseworthy, T.,      Twenty-eight male and female              Researchers found enteral nutrition to   Problems included a very small            Put patients with acute severe
M.D., Hailey, D., PhD, Gramlich, L.     patients ranging in age from 59-65        be more cost effective, provide          sample related to difficulty obtaining    pancreatitis on enteral nutrition as soon
M., MD, Jacobs, P., PhD, &              years of age with severe pancreatitis     adequate nutrition, and secondarily      consent.                                  as possible to decrease the risk of sepsis,
Warnock, G. L., M.D. (2004). 2004       all had a ranson score>2.                 showed faster attenuation of                                                       improve nutritional status, and help
MacLean-Mueller Prize Enteral or                                                  inflammation and fewer septic            The study was underpowered and ran        decrease hospital length of stay.
parenteral nutrition for severe         Ranson score is a score based on          complications leading to a decreased     the risk of Type II error.
pancreatitis: a randomized controlled   criteria that is used to predict          length of stay.                                                                    The study recommends further research
trial and health technology             mortality in patients with acute                                                                                             be completed on this topic.
assessment. Canadian Journal of         severe pancreatitis.
Surgery, 48, (4), 299-306.

  McClave, S.A. (2007). Nutrition       The populations studied were              The analysis showed that there are       The threats to the validity of the        Initiating enteral nutrition in the first 48-
  Support in Acute Pancreatitis.        patients with severe acute                benefits in starting enteral nutrition   studies‘ results were the small           72 hours of diagnosis of acute
  Gastroenterology Clinics, 36, 1-7.    pancreatitis. This meta-analysis          in the first 48-72 hours of admission.   sample sizes included in the trials. In   pancreatitis can improve patient
                                        consisted of 15 prospective               These patients receiving enteral         addition, each trial used a different     outcomes, decrease disease severity, and
                                        randomized controlled trials and          nutrition have shorter LOS, fewer        definition of what constituted a          decrease mortality rates.
                                        included 2 meta-analyses.                 complications, and lowered mortality     complication of enteral feeding.
                                                                                  rates.




                                                                                                                                                                                                                     85
             Citation                         Population Studied                       Results of Study                      Threats to Validity of Study                  Implications of Study
         (in APA format)                  (Who was studied? How many            (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                              where in the study)                 did the researchers find?)                with the study? Where there            patients? Is more research required
                                                                                                                             reasons to doubt findings?)            before we can draw conclusions?)
  Marik, P. (2004). Meta-analysis       Six randomized control studies         The dependent variables were             The small number of patients that         Provided a comparison between enteral
  of parenteral nutrition versus        comparing enteral nutrition with       infections, complications other than     were included in each study. Of the      nutrition and perenteral nutritional
  Enteral nutrition in patients with    perenteral nutrition in 263 patients   infections, operative infections,        potentially relevant trials identified   supplementation.
  acute pancreatitis. British Medical   with acute pancreatitis were           length of hospital stay and mortality.   and screened for retrieval (n=117),
  Journal, 328, 1407-1412.              described. The six articles were       All studies included in the meta-        104 were considered not to be            Provided information about the need for
                                        screened from 117 articles and         analysis provided information on         randomized controlled trials. Four       additional nutritional support when
                                        included data extraction for this      length of hospital stay, which was       were excluded from the n of 13           patients present with acute onset of
                                        meta-analysis.                         significantly shorter in the enteral     retrieved for more detailed evaluation   pancreatitis.
                                                                               group ( mean reduction of 2.9 days,      as follows:
                                                                               range of 1.6 to 4.3 days).               TPN vs fluids (n=1), ENT vs fluids       Compiled tactical information when
                                                                                                                        (n=2), TPN vs ENT + PN (n=10).           caring for patients with acute pancreatitis
                                                                                                                                                                 in regard to the body‘s metabolism and
                                                                                                                        Trials included in meta-analysis         the increased need for nutritional
                                                                                                                        (n=6).                                   support.
                                                                                                                           The small sample size led to wide
                                                                                                                        confidence intervals.
                                                                                                                         The difference in severity of disease
                                                                                                                        may explain the heterogeneity in
                                                                                                                        length of stay between studies.

Siow, E. (2008). Enteral                The populaton studied was a total of    There was no difference in mortality    Small sample sizes in all 5 RCT          Gave useful recommendations for
  versus parenteral                     169 adult ICU patients with severe     between patients given enteral           studies.                                 providing appropriate route of nutritional
  nutrition for acute                   acute pancreatitis receiving enteral   nutrition versus parenteral nutrition.                                            support.
  pancreatitis. Critical                and/or parenteral nutrition for                                                 Lack of standardized outcome
 Care Nurse, 28(4), 19-31.              nutritional support.                   Complications (sepsis, nosocomial        parameters made it difficult to          Results showed enteral nutrition
                                                                               infection, catheter-related infection,   compare the studies.                     preferred over parenteral nutrition for
                                        Five randomized controlled trials      hyperglycemia) were higher among                                                  this population.
                                        (RCT) were reviewed in this meta-      those receiving parenteral nutrition     Tighter glucose controls reduced the
                                        analysis.                              than those given enteral nutrition.      relevance of some of the findings.       Encouraged use of scoring severity of
                                                                               Glucose control was difficult in both                                             pancreatitis using APACHE system
                                                                               parenteral and enteral patients, but                                              within 48 hours of admission.
                                                                               more so in those receiving parenteral
                                                                               nutrition.                                                                        Patients with pre-existing malnutrition
                                                                                                                                                                 who have severe acute pancreatitis
                                                                               Patients receiving enteral nutrition                                              should start enteral nutrition early to
                                                                               had a shorter hospitalization..                                                   prevent harmful catabolism.

                                                                               Enteral nutrition was preferred over
                                                                               parenteral nutrition as it wass more
                                                                               cost effective and resulted in fewer
                                                                               complications.




                                                                                                                                                                                                               86
          TRACK 6             EBP Team 21: Fran Trujillo, Mary Woods, Jeff Jeter, Edgar Paul

          Clinical Questions: What is the best pain management practice for post op patients: patient controlled analgesia (PCA) or conventional opiod analgesic?




Brown, EBBrown, Everett (2005). Differences in postoperative    Four public hospitals in the PCA and IM injections were the variables. Yielding inconsistent results on length of       The introduction of PCA analgesia
           opioid consumption in patients prescribed patient-   South Western region of      Researchers found no significant           hospital stay, side effects, postoperative      circumvents some of the barriers to
           controlled analgesia (PCA) versus intramuscular      Sydney, Australia during a differences between the demographic          complications, and cost of medications          effective postoperative pain management.
           injection. American Society for Pain Management      12-month period. 115 Male variables. There was significant difference usage. The retrospective design of this           PCA had a high degree of patient
           Nursing. 6(4),137-144.                               and female Patients aged 18- in the amount of opioid analgesia consumed study is acknowledged as a limitation. In       acceptance. Some evidence showed
dfdfdfdfdf                                                      65 years who received either during the 3 days of postoperative period. addition, because data collection was           overwhelming evidence indicating PCA
                                                                PCA or IM injection of       Mean total amount of opioid consumption dependent on medical records being                 provided superior analgesia. This study
                                                                opioid on a PRN basis.       was 136.89 mg for the PCA group and        supplied by the hospitals‘ administrative       also highlights that it is inadequate to
                                                                                             50.79 mg for the IM group.                 staff, it is not possible to be confident that  simply rely on patients to self-report their
                                                                                                                                        all eligible records were included in this      level of postoperative pain. Nurses need to
                                                                                                                                        sample.                                         be more vigilant in assessing postoperative
                                                                                                                                                                                        pain, particularly in patients who are
                                                                                                                                                                                        prescribed IM analgesia on an as-needed
                                                                                                                                                                                        basis. This vigilance needs to continue into
                                                                                                                                                                                        days 2 and 3 of the postoperative period.
                                                                                                                                                                                        The use of a pain assessment tool should
                                                                                                                                                                                        be included as part of routine assessment
                                                                                                                                                                                        for all patients in the postoperative period.
                                                                                                                                                                                        Continuing educational programs is pivotal
                                                                                                                                                                                        to good pain management.
          Carter-Snell, C., Fothergill- Bourbonnais, F.,       A final randomized sample Pain and satisfaction levels favored the           More patients excluded than anticipated Replication studies needed per conflicting
          Durocher-Hendriks, S. (1997). Patient controlled     of 73 pre-op patients to      patient controlled analgesia (P.C.A.) but no which reduced data collection because         results. Conflictions r/t analgesic
          analgesia and intramuscular injections: a comparison randomly assigned patient statistically significant difference in any of some planned major abdominal surgeries effectiveness in terms of PCA versus IM
          of patient pain experiences and postoperative        controlled analgesia (P.C.A.) the variables was noted; the variables         were changed to laparoscopic procedures (no accepted level of significance). PCA
          outcomes. Journal of Advanced Nursing (25(681- or intramuscular injection included comparing the following: amount which do not include major surgery.                        may be a fiscal advantage (patients may
          690).                                                (I.M.) pain control groups of pain and analgesia; degree of patient          Different forms of analgesia may have       use less pain meds with PCA) and/or be an
                                                               undergoing major abdominal satisfaction with pain control including          been used. Ambulation helps with pain       issue where patient satisfaction is a driving
                                                               surgery. Other inclusion      transitioning; length of time to ambulate; control; hysterectomy patients had              force. Other PCA modes have not been
                                                               criteria included ages        and length of stay (LOS). The P.C.A.           extended LOS and a delayed time to          compared i.e. epidural, subcutaneous.
                                                               between 16-70 years of age, patients took an average 4.5 hours longer ambulate. Patient motivation affects pain; Many factors and differences have been
                                                               not involved in any other     than the I.M. patients to ambulate post-       the more motivated, then the possibility of found to impact the patient‘s pain
                                                               study, and able to            operatively and the I.M. patients received ~ lesser pain and LOS with either PCA or experience. Some include knowledge and
                                                               comprehend using a P.C.A. 3X as much antiemetic. Locus of control conventional methods of pain control. Not attitudes (locus of control) towards pain,
                                                               in an area authorized to use was not found to be a major factor in           double –blinded. Confusing                  pharmacological differences in analgesics
                                                               them.                         satisfaction or pain levels. Other meta-       questionnaires. Revision to questionnaire. (sedation levels), LOS, first time to
                                                                                             analyses have also failed to yield significant Bulky PCA‘s affecting ambulation in the ambulate, patient satisfaction, and post-op
                                                                                             differences between I.M. and P.C.A. groups PCA group; thus, increasing time to first outcomes. Differing pain responses and
                                                                                             except in patient satisfaction.                ambulate. Differential attrition between analgesic requirements would support
                                                                                                                                            groups and a small sample size. Attrition individualized PCA dosages. Differing
                                                                                                                                            reduces the effectiveness of random         absorption rates per PCA versus               87
                                                                                                                                            assignment. This may create differences conventional i.e. IM. patients favor PCA
                                                                                                                                            in frequencies of types between groups. overall (no wait time, avoiding additional
                                                                                                                                Small sample sizes among the IM group. pain i.e. injection, sense of control,
                                                                                                                                This may have yielded insignificant          decreased sedation and anxiety. Findings
                                                                                                                                differences.                                 suggest no clear indication in favor of PCA
                                                                                                                                                                             versus IM in terms of patient outcomes.
Chang, A.M., Ip, W.Y., Cheung, T.H. (2004)          125 Chinese inpatient         PCA and IM were variables, Patients           The study evaluated the effectiveness of This study supports the use of patient
Patient-controlled analgesia (PCA) versus           women between the ages of satisfaction was better with PCA, activity PCA vs. IM, nurses did not follow the               controlled analgesia (PCA) more effective
conventional intramuscular injection (IM): a cost   18-7 2 in the first 24 hours level was high as compared to the patients protocol regarding administering IM              than conventional on demand
effective analysis. Journal of Advanced Nursing,    following elective            getting IM group. And Patients using PCA injection                                         intramuscular (IM) opioid injections as
46(5), 531-541.                                     gynecological surgery in      went home quicker.                                                                         proven by other studies.
                                                    Hong Kong, China.
Hudcova, J., McNicol, E.D., Quah, C.S., Lau, J.,    There were 52 inclusive       The dependent variable in the study was        Different inclusion criteria were           Subpopulations should be investigated
Carr, D.B. (2008). Patient controlled analgesia     RCT‘s involved in the         pain. The independent variables in the        employed among the studies per the           further as well as different types of
versus conventional opioid analgesia for            systematic review. 2,023      study were PCA administered analgesia or systematic review. Some studies used              surgeries. Less invasive approaches may be
postoperative pain (review). The Cochrane           randomly allocated patients conventional administration of analgesia. continuous infusions where others did not compared to post-operative analgesia with
Collaboration Issue 4.                              of all ages receiving         The results of the studies indicated PCA      including NSAIDS which may improve either conventional injections or
                                                    analgesia via PCA only        provided better pain control and greater      analgesic quality. Authors question the      intravenous PCA in order to characterize
                                                    without background infusion patient satisfaction than conventional          clinical significance between the PCA and clinical differences in efficacy or adverse
                                                    with abilities to operate PCA ―PRN‖ analgesia. PCA patients had shorter control group even though the PCA group events, if any. PCA for post-op pain
                                                    and rate pain intensity per length of stays (LOS) by 0.4 days. This is favored the pain control over the                 control has become an accepted pain
                                                    scale. 1,838 patients were    not clinically significant. PCA patients      conventional group. Data not supplied for control method in the U.S. and western
                                                    randomly allocated to the     consumed higher amounts of opioids than (LOS) between groups. Only 1 trial                 world despite lacking and convincing
                                                    control group which           controls although insignificant. The          reported that PCA patients were              advantages from previous reviews. This
                                                    received conventional pain systematic review provides evidence that discharged earlier. Other findings                   meta-analysis provides evidence that PCA
                                                    control such as               PCA is an efficacious alternative to          reported insignificance. Varying degrees provides better pain control compared to
                                                    intramuscular injections      conventional systemic analgesia for post- of surgical invasiveness among studies. conventional methods. Patients report
                                                    (I.M.), intravenous (I.V.),   operative pain control. There are an array of No stratification for example. Most          greater satisfaction with, and generally
                                                    subcutaneous (S.C.), or oral differences among previous studies that        patients had abdominal surgeries but other prefer PCA even though a slightly higher
                                                    (P.O.). Most of the patients have ranged from no differences to a           surgery types were included. The             opioid consumption occurs. Generally no
                                                    underwent abdominal           determination that the magnitude in           conversion of doses of opioid agonists       adverse side effects with the exception of
                                                    surgeries. All patients met difference is present albeit small. These       other than morphine to morphine              pruritis. LOS is similar between PCA and
                                                    inclusion criteria.           ranges include a strong patient preference equivalents may have affected results. All conventional pain control groups. Further
                                                                                  for PCA over conventional pain control        studies in the systematic review were not research needed utilizing RCT‘s.
                                                                                  methods.                                      blinded. This leads to bias. Some patients
                                                                                                                                may have had pre-operative chronic pain.
                                                                                                                                These patients should have been excluded
                                                                                                                                according to inclusion criteria established.




                                                                                                                                                                                                                       88
Yankova, Yankova, Z. (2008). Patients‘ Knowledge of patient      Each of the 6 research         All six research studies reviewed suggest      Limited trials were retrieved and           Based on the analysis of the research
          controlled analgesia (PCA) and their experiences of    studies had between 60-125     that although structured education about       methodological discrepancies were           findings, there is a clear need for further
          postoperative pain relief: a review of the impact of   patients. Patients over 16     PCA improved patients‘ knowledge about         identified in the selected studies. There   research. It was strongly believed that
          structured preoperative education. Journal of          years old of both sexes and    how and when to use the PCA device,            were discrepancies in the sampling          structured preoperative teaching about
          Advanced Perioperative Care, 3(3), 91-99.              all ethnic groups undergoing   overall, it did not contribute to a better     methods and in the experimental controls    PCA was the key towards better educated
                                                                 various surgical procedures    experience of pain relief. However, due to     and interventions.                          patients who would be able to obtain
                                                                 that required PCA post-op.     methodological discrepancies identified in                                                 optimal pain relief by using the PAC
                                                                                                the selected studies, no definite conclusion                                               device, but individual patients have
                                                                                                could be drawn.                                                                            different learning needs and styles.
                                                                                                                                                                                           Research to investigate the most
                                                                                                                                                                                           appropriate method of delivering
                                                                                                                                                                                           preoperative teaching on PCA and its
                                                                                                                                                                                           effect on postoperative outcomes might be
                                                                                                                                                                                           highly beneficial.




          TRACK 7             EBP Team 13: Veronica Armas, Janet Knappier, Candace McNeese, Sara Ralph

          Clinical Question: In the hospitalized patient age 65 years or older, what is the effect of the NICHE model of care on patient outcomes compared with a non-NICHE
          model of care?
                        Citation                         Population Studied                             Results of Study                    Threats to Validity of Study                     Implications of Study
                    (in APA format)                  (Who was studied? How many                  (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                                         where in the study)                       did the researchers find?)               with the study? Where there                   patients? Is more research
                                                                                                                                             reasons to doubt findings?)                required before we can draw
                                                                                                                                                                                                 conclusions?)
          Asplund, K., Gustafson,Y.,               413 total patients ages 70 years and         Independent variable: acute              Although the randomization                 Greater emphasis on early
          Jacobsson, C., Bucht, G., Wahlin, A.,    older; of these 190 on acute geriatric-      geriatric-unit ward (AGW)                procedure produced similar groups of       rehabilitation and discharge planning
          Peterson, J. (2000). Geriatric-based     based ward and 223 on general                Dependent variable: general              older patients within the two wards,       in the AGW shortened length of
          versus general wards for older acute     medical ward                                 medical ward                             patients admitted to the general           hospital stay and need for long-term
          medical patients: A randomized                                                        Findings: 71% of patients in the         medical ward had worse prognosis at        institutional care.
          comparison of outcomes and use of                                                     AGW could be discharged to home          admission, lived alone, and had
          resources. Journal of American                                                        compared with 64% of those treated       impaired cognitive and ADL                 More extensive education and
          Geriatrics Society, 48(11), 1381-                                                     in the general medical ward; length      function.                                  teamwork preparations could have
          1388.                                                                                 of stay was shorter in the AGW than                                                 been beneficial in facilitating a
                                                                                                the general ward.                        There were a limited number of beds        multidisciplinary approach.
                                                                                                                                         in the AGW.




                                                                                                                                                                                                                                         89
              Citation                          Population Studied                         Results of Study                  Threats to Validity of Study                Implications of Study
          (in APA format)                   (Who was studied? How many              (What were the variables? What         (Where there significant problems       (How can results help in caring for
                                                where in the study)                   did the researchers find?)             with the study? Where there              patients? Is more research
                                                                                                                              reasons to doubt findings?)            required before we can draw
                                                                                                                                                                             conclusions?)
                                                                                   At follow-up, case fatality, ADL
                                                                                   function, psychological well-being;
                                                                                   need for daily personal assistance,
                                                                                   drug consumption, need for
                                                                                   readmission to hospital, and total
                                                                                   health care costs after discharge did
                                                                                   not differ between the two groups.
Counsell, S., Holder, C., Liebenauer,     1521 community-dwelling patients,        Independent variable: Acute Care        Reports of outcomes and                 Improved process of care for
M., Palmer, R., Fortinsky, R.,            ages 70 or older, admitted for an        of Elders Unit (ACE)                    performance-based measure of            hospitalized older adults and their
Kresevic, D., et al. (2000). Effects of   acute medical illness between            Dependent variable: usual care unit     mobility may have been biased           satisfaction can be created through a
a multicomponent intervention on          November 1994 and May 1997               Findings: The composite outcome         because neither patients or data        multicomponent intervention, as well
functional outcomes and process of                                                 of ADL decline from baseline or         collectors could be blinded to          as potentially prevent decline in
care in hospitalized older patients: a                                             nursing home placement was less         treatment assignment.                   ADLs and/or nursing home
randomized controlled trial of acute                                               frequent in the intervention group at                                           placement at discharge without
care for elders (ACE) in a                                                         discharge and in the year following     At times, reports were not able to be   adverse effects or increased cost.
community hospital. Journal of                                                     the hospitalization.                    taken from patients, but rather from
American Geriatrics Society, 48,                                                                                           proxies.
1572-1581.                                                                         There was no significant group
                                                                                   difference in hospital length of stay
                                                                                   and cost, home health care visits, or
                                                                                   readmissions.
Covinsky, K., King, J., Quinn, L.,        650 medical patients ages 70 years or    Independent variable:                   Sample size limited the accuracy of     Caring for patients on a specialized
Siddique, R., Palmer, R., Kresevic,       older, randomly assigned to              intervention unit                       cost difference estimate between        unit increases patient outcomes
D., et al. (1997). Do acute care for      intervention unit (326) and usual care   Dependent variable: usual care unit     intervention and usual care subjects.   without increasing hospital costs.
elders units increase hospital costs?     unit (324)                               Findings: Cost per day for hospital
A cost analysis using the hospital                                                 was slightly higher in the              Nursing satisfaction was not taken
perspective. Journal of American                                                   intervention group, however average     into account which could result in
Geriatrics Society, 45(6), 729-734.                                                length of stay was shorter for the      increased cost due to turnover of
                                                                                   intervention group; therefore           staff.
                                                                                   resulting in similar costs for both
                                                                                   groups.
Landefeld, S., Palmer, R., Kresevic,      651 patients ages 70 years or older,     Independent Variable – Acute Care       The impracticality of blinding          Specific changes in the provision of
D., Fortinsky, R., Kowal, J., et al.      who were randomly assigned to            for Elders (ACE) program unit           patients and interviewers to the        acute hospital care can improve the
(1995). A randomized trial of care in     either an Acute Care for Elders          Dependent Variable – usual care in      treatment assignments may have          ability of acutely ill older patients to
a hospital medical unit especially        (ACE) program (327) or to usual care     another general medical unit            biased the reports of outcomes.         perform basic ADLs at the time of
designed to improve the functional        in another general medical unit (324)    Findings: A higher percentage of                                                discharge from the hospital and can
outcomes of acutely ill older patients.                                            patients at discharge in the            Reports given by proxies may differ     reduce the frequency of discharge to
The New England Journal of                                                         intervention group were classified as   from those given by patients.           institutions for long-term care.
Medicine, 332(20), 1338-1344.                                                      much better, in terms of performance
                                                                                   of ADLs.                                                                        Further evaluation of cost




                                                                                                                                                                                                              90
              Citation                           Population Studied                       Results of Study                  Threats to Validity of Study                  Implications of Study
          (in APA format)                    (Who was studied? How many            (What were the variables? What         (Where there significant problems       (How can results help in caring for
                                                 where in the study)                 did the researchers find?)             with the study? Where there                patients? Is more research
                                                                                                                             reasons to doubt findings?)              required before we can draw
                                                                                                                                                                               conclusions?)
                                                                                                                                                                  effectiveness and its long-term
                                                                                  Length of stay was shortened by one                                             effects is needed in order to test the
                                                                                  day in the intervention. Hospital                                               success of an ACE program in other
                                                                                  costs were similar in both groups.                                              settings

                                                                                  Fewer patients assigned to the
                                                                                  intervention group were discharged
                                                                                  to long-term care institutions as
                                                                                  compared to the usual care group.
Lopez, M., Delmore, B., Ake, J.,           73 elderly patients ages 70 years or   Independent variable:                   Study population in small.              The assessment tool, SHARING,
Kim, Y., Golden, P., Bier, J., et al.      older at NYU Medical Centers           specialized Geriatric Resource Nurse                                            used in the GRN model, effectively
(2002). Implementing a geriatric           admitted to a geriatric 34-bed         (GRN) model unit                                                                identified high-risk geriatric
resource nurse model. Journal of           medical unit                           Dependent Variable:                                                             syndromes, and created special
Nursing Administration, 32(11), 577-                                              conventional care unit                                                          protocols to address these issues.
585.                                                                              Findings: The GRN program
                                                                                  demonstrated insight and education                                              Further analysis of geriatric
                                                                                  about the crucial needs of the                                                  syndromes screening tools,
                                                                                  hospitalized elderly.                                                           readmission rates, staff turnover, cost
                                                                                                                                                                  effectiveness of the GRN model,
                                                                                                                                                                  patient and family satisfaction, and
                                                                                                                                                                  increasing efforts concerning elderly
                                                                                                                                                                  needs, regardless of setting are
                                                                                                                                                                  needed.
Mezey, M., Mia, K., Grossman, S.,          Coordinators at 103 active NICHE       Findings: The findings confirm the      Generalizability is limited because     Hospitals find NICHE useful for
Firpo, A., Fulmer, T., Mitty, E., et al.   programs                               crucial role of the NICHE               the survey was conducted solely in      educating nurses and creating nursing
(2004). Nurses improving care to                                                  coordinator in implementing and         active NICHE hospitals.                 services for older patients, therefore,
health system elders (NICHE):                                                     sustaining NICHE.                                                               increasing quality of care.
Implementation of best practice                                                                                           Responses to individual survey items
models. Journal of Nursing                                                        The study determined that hospitals     fluctuated between 82% and 100%.        Additional research is needed to
Administration, 34(10), 451-457.                                                  were more likely to use more than                                               more fully understand the NICHE
                                                                                  one NICHE tool.                                                                 coordinators role in improving
                                                                                                                                                                  outcomes for older patients.
Mezey, M., Quinlan, E., Fairchild, S.      14 staff RNs who worked on units       Independent variable: RNs with          Sample size of RNs was small.           The competencies allow for staff
& Vezina, M. (2006). Geriatric             with patients 65 years or older        geriatric preparation                                                           development educators to directly
compentencies for RNs in hospitals.                                               Dependent variable: RNS without         RNs were self-referred to the study     observe staff on the unit in
Journal for Nurses in Staff                                                       geriatric preparation                   rather than randomly selected.          relationship to recognizing recent
Development, 22(1), 2-10.                                                         Findings: The assessment                No self-evaluation was conducted for    onset of patient conditions or
                                                                                  instrument, Geriatric Competencies      RNs, making it difficult to determine   symptoms.
                                                                                  for RNs in Hospitals, can be utilized   overall success of the assessment
                                                                                  to make recommendations for staff       tool.




                                                                                                                                                                                                            91
              Citation                          Population Studied                       Results of Study                   Threats to Validity of Study                 Implications of Study
          (in APA format)                   (Who was studied? How many            (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                                where in the study)                 did the researchers find?)              with the study? Where there               patients? Is more research
                                                                                                                             reasons to doubt findings?)             required before we can draw
                                                                                                                                                                             conclusions?)
                                                                                 development.
                                                                                                                          Simulated patient methodology
                                                                                                                          differs from actual practice and may
                                                                                                                          not fully reflect the competency of
                                                                                                                          RNs in a real patient situation.

Palmer, R., Landefeld, S., Kresevic,      655 patients ages 70 years or older    Independent variable: Prehab             The study was completed 19 years         The implementation of a Prehab
D., & Kowal, J. (1994). A medical         admitted to the University Hospitals   Program (a comprehensive                 ago.                                     Program on an ACE unit, combined
unit for the acute care of the elderly.   of Cleveland for acute medical         intervention that integrates geriatric                                            with the principles of geriatric
Journal of American Geriatrics            illnesses                              assessment into the optimal medical                                               assessment, will facilitate guidelines
Society, 42(5), 545-552.                                                         and nursing care of patients in an                                                for optimal medical and nursing care
                                                                                 interdisciplinary environment) for the                                            of patients in an interdisciplinary
                                                                                 Unit for Acute Care of the Elderly                                                environment.
                                                                                 (ACE)
                                                                                 Dependent variable: usual care on
                                                                                 a medical service unit
                                                                                 Findings: A loss of independent
                                                                                 physical functioning often occurs in
                                                                                 elderly patients during the course of
                                                                                 an acute illness requiring
                                                                                 hospitalization.

                                                                                 The ACE Unit fosters the
                                                                                 independent functioning of patients,
                                                                                 thereby alleviating the need for
                                                                                 restrictive targeting of patients.
Siegler, E., Glick,D., & Lee, J.          Key personnel on 18 Acute Care of      Findings: Nurse to patient staffing      30-40 units were planned in the          ACE units differ in size and
(2002). Optimal staffing for acute        the Elderly (ACE) units                ratios (when combining RN and            initial study, but only personnel from   admission criteria, however they
care of the elderly (ACE) units.                                                 LPN) average 1:5.6, 1:6.1, and 1:7.0     18 ACE units were polled for this        share common goals in their focus on
Geriatric Nursing, 23(3), 152-155.                                               for days, evenings, and nights.          study.                                   functional improvement, reduction in
                                                                                                                                                                   length of stay, and staff/patient
                                                                                 Nursing assistant staffing ratios are                                             satisfaction.
                                                                                 more variable but generally larger,
                                                                                 reflecting a focus on acuity of care.                                             Optimal staffing in ACE units
                                                                                                                                                                   improves outcomes for hospitalized
                                                                                                                                                                   elders.




                                                                                                                                                                                                            92
              Citation                        Population Studied                         Results of Study                  Threats to Validity of Study                    Implications of Study
          (in APA format)                 (Who was studied? How many              (What were the variables? What         (Where there significant problems         (How can results help in caring for
                                              where in the study)                   did the researchers find?)             with the study? Where there                  patients? Is more research
                                                                                                                            reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                conclusions?)
Swauger, K. & Tomlin, C. (2002).        Elderly patient ages 65 and older        Findings: Together We Improve           The study was preliminary.                Variations to the NICHE model can
BEST CARE for the elderly at            admitted to Forsyth Medical Center       Care of the Elderly (TWICE), a                                                    be adapted to meet the needs of
forsyth medical center. Geriatric                                                modified program of the NICHE                                                     geriatric patients specific to a
Nursing, 23(3), 145-150.                                                         model, resulted in reduced length of                                              hospital‘s unit.
                                                                                 stay by 1 day; decreased incidences
                                                                                 of nosocomial infections; decreased                                               Study showed need for more nurses
                                                                                 use of restraints.                                                                with advanced degrees in geriatric
                                                                                                                                                                   nursing.




TRACK 7            EBP Team 14: Sarah Glenn, Laurel Hadsell, Candice Harper, Whitney Kindell

Clinical Question: In the community dwelling elderly population, ages 60 years and older, does purposeful cardiovascular exercise at least two times a week, compared
to no exercise at all, result in a constant or increase of mental and physical health?

              Citation                        Population Studied                         Results of Study                  Threats to Validity of Study                    Implications of Study
          (in APA format)                 (Who was studied? How many              (What were the variables? What         (Where there significant problems         (How can results help in caring for
                                              where in the study)                   did the researchers find?)             with the study? Where there                  patients? Is more research
                                                                                                                            reasons to doubt findings?)               required before we can draw
                                                                                                                                                                               conclusions?)
Carvalho-Bastone, A., & Filho, W. J.    This study determined the                No significant difference was found     Some methodological problems              This study shows that exercise does
(2004). Effect of an exercise           effectiveness of a 6-month program       between the groups at baseline in       relevant to the evaluation of the         cause benefits in the elderly so an
program on functional performance       of regular exercises for the             relation to age, but compared to the    effects of an exercise program have       exercise program should be
of institutionalized elderly. Journal   improvement of functional                exercise group; the no exercise group   not been considered in this study.        implemented for them. Some of
of Rehabilitation Research &            performance of the elderly living in a   had a significantly longer              First, owing to resource limitations, a   these benefits include functional
Development. 41(5), 659-668.            nursing home. The 40 subjects aged       institutionalization time. When         blind observer did not assess the         improvement, reduction in depressive
                                        60 to 99 who took part in this trial     comparing the means of the              exercise group, and therefore,            symptoms and prevention of decline
                                        were assigned either to a comparative    differences obtained subtracting        observer bias possibly may have           in mental status. However, to
                                        group or an exercise group. The          baseline from follow-up values of the   intervened. However, post study           conclusively confirm these benefits,
                                        following variables were measured:       exercise and no exercise groups, we     measurements were made without            investigators need to conduct
                                        functional performance with the use      found that the exercise group           reference to baseline values. A need      randomized control studies with large
                                        of an obstacle course, a lower-limb      performed significantly better in all   exists to include control                 subject samples and better
                                        function test, and a 6-minute walk       the tests, except for the               interventions, which mimic the            assessment conditions.




                                                                                                                                                                                                           93
             Citation                       Population Studied                           Results of Study                      Threats to Validity of Study                  Implications of Study
         (in APA format)                (Who was studied? How many                (What were the variables? What             (Where there significant problems         (How can results help in caring for
                                            where in the study)                     did the researchers find?)                 with the study? Where there                patients? Is more research
                                                                                                                                reasons to doubt findings?)              required before we can draw
                                                                                                                                                                                 conclusions?)
                                      test (gait velocity); isometric strength   proprioception. The results suggest         exercise program as close as
                                      of the knee extensors; proprioception      that an exercise program can produce        possible, except for the exercise
                                      of the lower limbs; mental status          benefits with regard to functional          program itself. In this particular
                                      through the Mini- Mental State             improvement, reduction of                   study, a control group with an
                                      Examination (MMSE); and                    depressive symptoms, and prevention         intervention that mimics the exercise
                                      depression symptoms with the use of        of decline in mental status in the          program only in the social aspects
                                      the Geriatric Depression Scale             institutionalized elderly, thus             was not accomplished.
                                      (GDS). Among the nursing home              contributing to a better quality of life.
                                      residents who had been referred to
                                      the exercise program, 40 were
                                      selected to participate in this study
                                      after a personal interview. Subjects
                                      were assigned either to an exercise
                                      group, those who wanted to attend
                                      the exercise sessions, or to a
                                      comparative group, those who did
                                      not want to attend the exercise
                                      sessions but who volunteered to
                                      participate in the study.
                                      The subjects were consenting and
                                      informed volunteers, mentally
                                      capable of understanding and
                                      performing the tests proposed, and
                                      ambulatory with and without aids.
Houde, S.C. & Melillo, K.D. (2002).   The article is a review of literature on   The quantity and type of physical           The threats to validity of the study or   The implications of the study are
Cardiovascular health and physical    physical activity and its relationship     activity that should be recommended         reasons to doubt findings include that    clear that more research is needed to
activity in older adults: An          to cardiovascular risk factors and         to bring about positive effects on          the study was conducted from 1990-        be able to clearly identify what type
integrative review of research        mortality in older adults, to clarify      cardiovascular health is unclear            2000 and was published in 2002 and        and amount of physical activity is
methodology and results. Journal of   the specific benefits and optimal          however there is support that an            that with the recent physical activity    necessary to achieve the positive
Advanced Nursing. 38(3):219-234.      level of physical activity for             active lifestyle decreases mortality.       goals of Healthy People 2010 there        effects of physical activity in the
                                      cardiovascular health in the older         All 12 studies that had a dependent         may have been more research done          elderly. Physical activity is
                                      adult population. An integrative           variable of mortality showed an             within the 6 years from when the          considered an important factor in the
                                      review of the literature using the         increase in mortality in those who          article was published.                    quality of life of older adults but
                                      MEDLINE and CINAHL database                had a sedentary lifestyle in                                                          there is a concern about the lack of
                                      form 1990-2000 and forty-four              comparison to those who were                                                          clarity regarding optimal level of
                                      articles research articles were            physically active. Despite                                                            physical activity for the elderly. The
                                      reviewed.                                  differences in the measurement of                                                     results are clear that more evidence is
                                                                                 physical activity and variation in the                                                needed in order for healthcare
                                                                                 way mortality was identifies, study                                                   providers to provide their older
                                                                                 outcomes do overwhelmingly reflect                                                    patients with an appropriate exercise




                                                                                                                                                                                                                 94
             Citation                       Population Studied                         Results of Study                   Threats to Validity of Study                   Implications of Study
         (in APA format)                (Who was studied? How many              (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                            where in the study)                   did the researchers find?)              with the study? Where there                 patients? Is more research
                                                                                                                           reasons to doubt findings?)               required before we can draw
                                                                                                                                                                             conclusions?)
                                                                               the benefits of physical activity on                                              recommendation that includes a
                                                                               mortality.                                                                        tailored exercise prescription.




Kalapotharakos, V., Michalopoulos,    42 inactive healthy older adults, age    All measurements took place the          A limitation of the current study was    Although the declines in physical and
M., Strimpakos, N..,                  60-75yrs, voluntarily approached         week before the exercise program         the small size of the sample in both     neuromotor performance have been
Diamantopoulos, K.., & Savvas         through telephone, friends, and          started (pretest) and the week after     groups, and the results must be          attributed primarily to aging, an
P. (2006). Functional and             advertisement in the community.          the end of the program (posttest) and    carefully interpreted. Moreover,         inactive lifestyle contributes further
neuromotor performance in older       Participants were inactive based on      were made by the principal               although the participants of the study   to this direction. The results of the
adults: Effect of 12 wks of aerobic   physical activity score of <9.4,         researchers during a 12 week             were randomly allocated in the two       present study suggest that an aerobic
exercise. American Journal of         independent, non-smokers, free of        exercise program. Baseline               groups, this was not a double-blind      exercise program can maintain or
Physical Medicine & Rehabilitation.   medications, no cognitive                information of the physical health of    clinical trial because the assessors     even reverse the decline in physical
85(1):61-67.                          impairments (MMSE >24), no               the patients were evaluated through:     were aware of group allocation.          and neuromotor performance in
                                      depressive symptoms, no history of       Muscle strength, mobility and            Findings are limited to a healthy        inactive older adults. Patients could
                                      cardiovascular disease, no orthopedic    capacity of functional exercise (6-      inactive elderly population and may      benefit in the performance of aerobic
                                      history, neuromuscular disease,          MWT), chair rising performance           not apply to a frail population.         exercise in daily routine. Allocating
                                      HTN, or other chronic conditions. No     time, and reaction time to visual                                                 specific times and durations for
                                      cardiovascular or respiratory distress   signal (WBRT). The aerobic exercise                                               exercise into a patient‘s schedule can
                                      noted during exercise test. 19 were      group exercised three times per week                                              improve muscle strength, mobility,
                                      excluded, leaving 23 active              for 12 wks on nonconsecutive days.                                                and reaction time of an individual.
                                      participants. 12 participants in         Aerobic exercise consisted of                                                     Further research is required to
                                      aerobic exercise and 10 as control       walking on a treadmill. All exercise                                              determine the effects of various types
                                      subjects.                                sessions began with a 5-min warm-                                                 of exercise (such as bicycling,
                                                                               up and ended with a 5-min cool                                                    flexibility, and balance exercises) or
                                                                               down at the heart rate corresponding                                              physical activity programs (such as
                                                                               to 40% of maximal heart rate.                                                     walking and dance) on physical and
                                                                               Exercise intensity and duration were                                              neuromotor performance in healthy
                                                                               progressively increased within a 12-                                              and frail older adults. Moreover,
                                                                               wk period. During the first 3 wks, the                                            studies need to examine the
                                                                               intensity of the exercise was set at                                              mechanisms that the different types
                                                                               50% of the maximal heart rate and                                                 of exercise recruit to the physical and
                                                                               the Although the declines in physical                                             neuromotor performance of older
                                                                               and neuromotor performance have                                                   adults.
                                                                               been attributed primarily to aging, an
                                                                               inactive lifestyle contributes further
                                                                               to this direction. Duration was set at
                                                                               20 minutes. Thereafter, the intensity
                                                                               of heart rate of the exercise and the




                                                                                                                                                                                                           95
              Citation                       Population Studied                         Results of Study                    Threats to Validity of Study                 Implications of Study
          (in APA format)                (Who was studied? How many              (What were the variables? What           (Where there significant problems        (How can results help in caring for
                                             where in the study)                   did the researchers find?)               with the study? Where there               patients? Is more research
                                                                                                                             reasons to doubt findings?)             required before we can draw
                                                                                                                                                                             conclusions?)
                                                                                duration were gradually increased
                                                                                until the last week, whereupon the
                                                                                experimental group exercised at 80%
                                                                                of the maximal heart rate for 40
                                                                                minutes.
                                                                                  Aerobic exercise improved
                                                                                significantly the 1-RM knee
                                                                                extension strength by 12%, the 1-RM
                                                                                flexion strength by 19%, the 6-MWT
                                                                                distance by 17%, the chair-rising
                                                                                time by 8%, and the WBRT by 20%
                                                                                after the exercise period. No
                                                                                significant differences in 1-RM knee
                                                                                extension (1.4%) and flexion (0.7%)
                                                                                strength, in 6-MWT distance (0.9%),
                                                                                in chair-rising time (2.5%), and in
                                                                                WBRT (0.3%) were observed in the
                                                                                control group after a 12-wk period.

Purath, J., Buchholz, S.W., & Kark,    The purpose of the exploratory,          Physically active older adults had        The small volunteer sample size          Physical fitness measures give
D.L. (2008). Physical fitness          cross-sectional study was to (1)         significantly better upper and lower      limits generalizability for the study,   primary care providers objective
assessment of older adults in the      assess physical fitness measures in a    body strength, aerobic endurance,         however, results show promise for        information to develop a physical
primary care setting. Journal of the   group of community-dwelling older        and dynamic balance. Older adults         further research. Other fitness test     activity program for their patients.
American Academy of Nurse              adults in the outpatient setting (2)     who reported better general health        batteries that were not evaluated in     This study and other research support
Practitioners. (21):101-107.           examine the relationships between        and had fewer chronic conditions          this study are available for older       the need for healthcare providers to
                                       these physical fitness measures and      scored better on the physical fitness     adults.                                  provide social support for physical
                                       demographic characteristics, general     test. This study and other work note                                               activity
                                       health and well being, social support,   that older adults with increased levels
                                       and physical activity and (c) assess     of physical activity have enhanced
                                       feasibility of measuring physical        health and well-being. Social
                                       fitness in the outpatient setting.       support had a significant correlation
                                       The study was conducted in two U.S.      with physical activity in the elderly.
                                       clinics in midsized cities: one in the
                                       Northwest and one in the Midwest.
                                       Thirty four persons older than 60
                                       years completed self-reported
                                       measures and the Senior fitness test.




                                                                                                                                                                                                           96
              Citation                         Population Studied                         Results of Study                    Threats to Validity of Study                  Implications of Study
          (in APA format)                  (Who was studied? How many              (What were the variables? What           (Where there significant problems       (How can results help in caring for
                                               where in the study)                   did the researchers find?)               with the study? Where there                patients? Is more research
                                                                                                                               reasons to doubt findings?)              required before we can draw
                                                                                                                                                                                 conclusions?)
Uffelen, J., Chin A.P., Marijke, J.M.,   Age of study ranged from 55-95 yrs       Of the 15 studies among cognitively       The poor methodological quality and     Changes in aerobic fitness contribute
Hopman-Rock, M., & Mechelen, W.          in cognitively healthy populations       healthy subjects, 6 consisted of          the predominantly small sample sizes    to the changes in cognitive
(2008). The effects of exercise on       and 67-99 yrs in populations with        aerobic exercise. In 1 of these studies   of the included studies are the most    performance. Indeed, in the present
cognition in older adults with and       cognitive decline. Sample size           aerobic exercise was combined with        important limitations of the review.    review, beneficial effects of aerobic
without cognitive decline: A             varied from 30- 210 subjects in the      flexibility exercise. Five programs       Treatment allocation and blinding of    exercise were observed in subjects
systematic review. Clinical Journal      15 studies among cognitively healthy     covered strength exercise, which was      subjects and exercise trainers          with and without cognitive decline.
of Sport Medicine. 18(6):486-500.        subjects, and 20-152 in the 8 studies    combined with balance exercise in 1       especially were not well described.     Implementing physical fitness
                                         among subjects with cognitive            of these studies. Of the remaining 4      Studied populations with and without    program of mild intensity into the
                                         decline. Healthy, community              studies, 3 examined the combination       cognitive decline were determined on    lives of patients 65 years and older in
                                         dwelling, free from cardiovascular       of aerobic, strength, and flexibility     the basis of description of the         a community setting could help
                                         disease, free from HTN, free from        exercise and 1 study compared             population or mean MMSE scores in       maintain or improve cognitive
                                         diabetes, normal findings on ergo        aerobic, strength, and balance            the absence of a description. This      functioning. More high-quality trials
                                         meter stress test, no self-reported      exercise. Intensity of aerobic exercise   was the most feasible method to         are needed to assess the effects of
                                         ailments or impairments, mild to         was operationalized in various ways:      discriminate between groups on the      different types of exercise (content,
                                         moderate cognitive deterioration         30%-70% of heart rate reserve or          basis of available information in the   intensity, frequency, and duration) on
                                         (Less than 25 on MMSE), physically       ventilatory threshold. Five studies       included studies. The applied cut-off   cognitive function in older adults
                                         capable for regular mild exercise, not   examined progressive resistance           point for the MMSE of 24 is             with and without cognitive decline.
                                         a participant in regular exercise.       exercise.                                 commonly used to distinguish
                                                                                      In cognitively healthy adults,        subjects with and without cognitive
                                                                                  improvements were observed in             decline for research purposes, but in
                                                                                  memory (Corsis block-tapping test,        reality the distinction is not that
                                                                                  Rey-Osterrieth figure, face               clear. To illustrate this, the study
                                                                                  recognition, digit span), information     population in which the mean MMSE
                                                                                  processing abilities (organization,       was 25 was qualified as cognitively
                                                                                  auditory processing), and executive       healthy. However, considering the
                                                                                  function (word fluency). Effective        standard deviation of 5 points, this
                                                                                  interventions in this group included      study may have included subjects
                                                                                  aerobic exercise strength exercise        with cognitive decline as well. It is
                                                                                  alone or combined with balance            also likely that the study population
                                                                                  exercise; and all-round exercise          of Dorner et al, which was
                                                                                  including aerobic, strength, balance,     categorized as ―cognitive declined,‖
                                                                                  and flexibility training. In subjects     also included cognitively healthy
                                                                                  with cognitive decline, improvements      subjects given the mean MMSE
                                                                                  were observed in general cognitive        score of 21. Because cognitive
                                                                                  function (MMSE) and executive             decline is often associated with a
                                                                                  functions (category fluency, trail        decline in memory, it is remarkable
                                                                                  making, clock drawing). Effective         that no effect of exercise on memory
                                                                                  interventions among subjects with         was found in studies among subjects
                                                                                  cognitive decline included aerobic        with cognitive decline. Memory was
                                                                                  exercise and strength exercise            extensively assessed in only 2 of the




                                                                                                                                                                                                              97
    Citation          Population Studied               Results of Study                 Threats to Validity of Study                  Implications of Study
(in APA format)   (Who was studied? How many    (What were the variables? What        (Where there significant problems         (How can results help in caring for
                      where in the study)         did the researchers find?)            with the study? Where there                patients? Is more research
                                                                                         reasons to doubt findings?)              required before we can draw
                                                                                                                                          conclusions?)
                                               combined with flexibility or balance   studies in elderly patients with
                                               exercise                               cognitive decline.
                                                                                         Because of the diversity in exercise
                                                                                      programs, measures of cognition, and
                                                                                      study populations in included studies,
                                                                                      it is impossible to draw valid
                                                                                      conclusions about which type of
                                                                                      exercise program is most effective,
                                                                                      for what aspect of cognition, and for
                                                                                      which specific population.




                                                                                                                                                                      98
TRACK 8            EBP Team 6: Margaret Smith, Rachel Schupp, Kimberly Pritchard, Tracie Summers, Leslie Oakes

Clinical Question: What are the negative health effects of infants when exposed to bottles that contain varying concentrations of Bisphenol-A?
              Citation                        Population Studied                         Results of Study                    Threats to Validity of Study                    Implications of Study
          (in APA format)                 (Who was studied? How many              (What were the variables? What           (Where there significant problems         (How can results help in caring for
                                              where in the study)                   did the researchers find?)               with the study? Where there                  patients? Is more research
                                                                                                                              reasons to doubt findings?)               required before we can draw
                                                                                                                                                                                  conclusions?)
 Calafat, A., Weuve, J., Ye, X., Jia,   Forty-two infant diapers from two       Variables: The plastic medical             Problems:                                 More research is needed to know the
 L., Hu, H., Ringer, S., Huttner, K.,   Boston area hospitals were tested for   devices, feeding tubes, ventilators, age   The study did not know which              adverse health effects that could
 & Hauser, R. (2009). Exposure to       BPA in the urine. Two types of          of infant, breast/formula feeding status   babies were breastfed and which           occur with BPA exposure in
 Bisphenol A and other phenols in       BPA were studied: free and              and length of hospital stay.               were bottle-fed so this could cause a     premature infants. Therefore, it is
 neonatal intensive care unit           conjugated BPA.                         The researchers found different levels     misrepresentation of BPA in the           important for hospitals to know what
 premature infants. Environmental                                               of BPA in all 42 urine samples. The        infants urine.                            products contain BPA and how to
 Health Perspectives, 117(4), 639-                                              results were 10 times higher than                                                    limit infant exposure.
 644. Retrieved April 1, 2009, from                                             previously reported for adults and         Findings: This was the first study
 http://www.ehponline.org/members                                               twice as high from children 6-11 years     testing exposure to BPA in
 /2008/0800265/0800265.pdf.                                                     old.                                       premature infants, therefore, this is a
                                                                                                                           landmark study proving that BPA is
                                                                                                                           higher than previously thought in
                                                                                                                           premature infants.
 Davis, M., Foulds, J., Freeman, A.,    Ten new polycarbonate baby bottles      Variables                                  Simulation of washing of the bottles      More research is needed. We know
 Khatter, K., Polyzou, C., Robinson,    including six popular brands (listed         Water Temperature: room              instead of repeated washing               that polycarbonate plastic baby
 J., Schade, M., Smith, R., & Vom-      below) were purchased from a                  temperature and 80º C                                                          bottles can leach BPA when heated.
 Saal, D. (2008). Baby's toxic bottle   variety of major retailers (listed           Type of bottle : Glass and           Study could have been more specific       We need to know and understand the
 (Rep.). Retrieved February 22,         below) from Canada and nine states            Plastic                                                                        negative health effects this can have
 2009, from                             in the US. The baby bottles ranged in        Size of bottles                      Only studied the water not milk or        on infants.
 http://www.environmentcalifornia.o     sizes from 4 oz – 9 oz.                      Then brands of bottles               juice
 rg/uploads/wm/HH/wmHHMjKT2                    Bottle Brands: Avent,                Amount of time water was in                                                    This information can help us as
 OLz4Nc4kXzynQ/Toxic-Baby-                      Disney/The First Years, Dr.           the bottle                                                                     nurses educate their patients for their
 Bottles.pdf.                                   Brown‘s, Evenflo, Gerber,            The simulation of the bottles                                                  safety and the safety of their
                                                Playtex                               being used and washed d                                                        newborns.
                                               Retailers: Babies‖R‖Us,
                                                CVS, Target, Toys‖R‖Us,         The controls were water in glass
                                                Walgreens, Wal-mart             bottles untreated and treated ―spiked‖
                                                                                with BPA (8.5ng/ml) were run as
                                                                                negative and positive controls

                                                                                Bottles did not show notable levels of
                                                                                leaching at room temperature but
                                                                                when bottles did show significant
                                                                                levels of leaching in the range of 5-9
                                                                                ng/ml when heated.




                                                                                                                                                                                                               99
            Citation                       Population Studied                           Results of Study                    Threats to Validity of Study               Implications of Study
        (in APA format)                (Who was studied? How many                (What were the variables? What           (Where there significant problems      (How can results help in caring for
                                           where in the study)                     did the researchers find?)               with the study? Where there             patients? Is more research
                                                                                                                             reasons to doubt findings?)           required before we can draw
                                                                                                                                                                           conclusions?)

                                                                               The bottles were tested brand new and
                                                                               after a polycarbonate plastic bottle
                                                                               goes through repeated washing can
                                                                               start to degrade the plastic and the
                                                                               amount of BPA leached can increase

                                                                               Indicates polycarbonate plastics
                                                                               degrade over time.
Gibson, R. (2007). Toxic baby        Studied: Five brands of baby              Variables: Temperature of the water        Problems with the study: They used     The results can help inform parents
bottles (Rep.). Retrieved February   bottles: Avent, Dr, Brown‘s,              in each bottle, five different types of    a small sample size, there was only    and hospitals about the leaching of
22, 2009, from                       Evenflo, Gerber and Playtex. Three        baby bottles, which could be five          water used to simulate BPA             BPA in baby bottles and will give
http://www.environmentcalifornia.o   bottles of each brand were chosen         different composites of plastic, time of   leaching, not milk which is what       them the choice to use plastic bottles
rg/uploads/wm/HH/wmHHMjKT2           from different retail stores across the   24 hours for each bottle to leach BPA.     babies usually drink from bottles,     or to use glass bottles to feed their
OLz4Nc4kXzynQ/Toxic-Baby-            state of California. There were three                                                and they only studied the leaching     infants. More research is required
Bottles.pdf.                         negative controls: glass baby bottles     Findings: BPA does leach from baby         effects from a 24-hour period.         before we can determine the effects
                                     to control against introduction of        bottles when exposed to hot water to                                              BPA has on the health of our
                                     Bisphenol-A during technical              simulate 50-75 dishwashing cycles.         Reasons to doubt findings: No, it is   children.
                                     handling and three positive controls:     The amount of BPA leached from             a good study to demonstrate that
                                     Lexan® polycarbonate sport water          each of the baby bottles follows:          BPA leaching does occur in baby
                                     bottles known to release Bisphenol-       Avent bottle 1: 7.74 ppb, Avent bottle     bottles when exposed to hot water
                                     A                                         2: 8.29 ppb, Avent bottle 3: 10.07 pbb     that simulates 50-75 dishwashing
                                                                               Dr. Brown‘s bottle 1: 6.07 ppb, Dr.        cycles to sanitize baby bottles.
                                     In the study there were a total of 15     Brown‘s bottle 2: 6.29 ppb, Dr.
                                     baby bottles.                             Brown‘s bottle 3: 7.07 ppb
                                                                               Evenflo bottle 1: 8.17 ppb
                                                                               Evenflo bottle 2: 8.91 ppb
                                                                               Evenflo bottle 3: 8.16ppb
                                                                               Gerber bottle 1: 6.99 ppb
                                                                               Gerber bottle 2: 7.34 ppb
                                                                               Gerber bottle 3: 6.18 ppb
                                                                               Playtex bottle 1: 4.58 ppb
                                                                               Playtex bottle 2: 5.96 ppb
                                                                               Playtex bottle 3: 5.79 ppb

                                                                               Negative controls- glass bottles: less
                                                                               than 0.05 ppb

                                                                               Positive controls- sport bottles: 5-7
                                                                               ppb




                                                                                                                                                                                                          100
             Citation                       Population Studied                       Results of Study                    Threats to Validity of Study                Implications of Study
         (in APA format)                (Who was studied? How many            (What were the variables? What           (Where there significant problems     (How can results help in caring for
                                            where in the study)                 did the researchers find?)               with the study? Where there              patients? Is more research
                                                                                                                          reasons to doubt findings?)           required before we can draw
                                                                                                                                                                         conclusions?)
Lang, I. A., Galloway, T. S.,         The study included                    Variables included were race/ethnicity     The study included                    This research is a starting point in
Scarlett, A., Henley, W. E.,          noninstitutionalized US adults aged   (from self-description and categorized     noninstitutionalized US adults aged   proving that BPA is related to
Depledge, M., Wallace, R. B., &       18- 74 years.                         into Mexican American, other               18- 74 years.                         cardiovascular disease and diabetes.
Melzer, D. (2008). Association of                                           Hispanic, non-Hispanic white, non-                                               Research hopefully can lead to
urinary Bisphenol A concentration     The study sample included 694 men     Hispanic black, and other race             The study sample included 694 men     halting the use of different products
with medical disorders and            and 761 women for a total of 1455.    [including multiracial]), education        and 761 women for a total of 1455.    with BPA in them. These would
laboratory abnormalities in adults.                                         (categorized as <high school, high                                               include linings of food and beverage
The Journal of the                                                          school diploma [including General                                                containers and in polycarbonate
American Medical Association,                                               Education Development], and >high                                                plastic in many consumer products.
300(11), 1303-1310.                                                         school);
                                                                                                                                                             More research is needed to draw
                                                                             annual household income (in 3                                                   conclusions. Independent replication
                                                                            approximately equal-sized categories                                             is needed to confirm these findings
                                                                            [<$25,000, $25,000- $55,000, and                                                 to provide evidence on whether
                                                                            >$55,000], plus a fourth category for                                            associations are casual.
                                                                            missing values [n=92];

                                                                            smoking (from self-reported status
                                                                            and categorized as never smoked,
                                                                            former smoker, smoking some days,
                                                                            and smoking every day, plus
                                                                            unknown, because the questions were
                                                                            asked those aged ≥ 20 years [n=177];

                                                                            body mass index (BMI) and
                                                                            categorized as underweight [<18.5],
                                                                            recommended weight [18.5-24.9],
                                                                            overweight [25.0-29.9], obese I [30.0-
                                                                            34.9], or obese II [≥35.0], with a final
                                                                            category for participants with missing
                                                                            values [n=25];

                                                                            waist circumference (in quintiles, with
                                                                            n=60 in a group with missing values);
                                                                            and urinary creatinine concentration in
                                                                            mg/dL.

                                                                            The researchers found that higher
                                                                            BPA concentrations were associated
                                                                            with diagnoses of cardiovascular




                                                                                                                                                                                                     101
             Citation                        Population Studied                         Results of Study                   Threats to Validity of Study                 Implications of Study
         (in APA format)                 (Who was studied? How many              (What were the variables? What          (Where there significant problems        (How can results help in caring for
                                             where in the study)                   did the researchers find?)              with the study? Where there               patients? Is more research
                                                                                                                            reasons to doubt findings?)             required before we can draw
                                                                                                                                                                            conclusions?)
                                                                               disease and diabetes. Also found were
                                                                               associations between higher BPA
                                                                               concentrations and clinically abnormal
                                                                               concentrations of the 3 liver enzymes
                                                                               examined, GGT, alkaline phosphate,
                                                                               and lactate dehydrogenase.
Le, H. H., Carlson, E. M., Chua, J.    Drinking Bottles (with water inside     Variables:                                Data presented is representative of at   The higher temperatures elevated the
P., & Belcher, S. M. (n.d.).           under various conditions)               - New or used polycarbonate drinking      least 3 experiments or quantitative      rate of BPA migration. This is
Manuscript submitted for               -    new polycarbonate (PC)             bottles and high density polyethylene     determinations.                          similar to the exposure that can be
publication, Department of                  obtained from national             bottles.                                                                           anticipated through drinking bottles
Pharmacology and Cell Biophysics,           recreation supply retailer                                                   Less extreme temperatures could be       and infant bottles and can serve as a
University of Cincinnati College of    -    high density polyethylene          Dependent Variable                        more relevant than autoclaving at        source of BPA contamination which
Medicine. Retrieved February 20,            (HDPE) bottles obtained from       - Standard washing and rinsing            120-125°C. This may be above             can contribute to the total amount of
2009, from National Institutes of           national recreation supply         procedure. Autoclaved pipet tips used     typical washing but may mimic            endocrine disrupting compounds.
Health Public Access.                       retailer                           for all liquid transfers.                 household practice such as boiling to
                                       -    Used PC bottles- all donated       - Cerebellar cultures from neonatal       sterilize infant feeding bottles.
                                            bottles were described as have     rats were used to obtain granule cells
                                            been used under normal             used in the wash/rinse process.
                                            conditions for between 1-9
                                            years.                             - Detectable levels of BPA were
                                       -    3 replicate experiments for        identified in all water samples
                                            each bottles were conducted        collected from either the new or used
                                       -    Primary cerebellar cultures        PC bottles.
                                            prepared from neonatal female      The concentration of BPA from these
                                            rats.                              bottles increased with time. The
                                                                               concentration of BPA in each sample
                                                                               was found to be at least double the
                                                                               value accumulated unheated samples.
                                                                               Higher amounts of BPA leached into
                                                                               the water from exposure of
                                                                               polycarbonate heated water. HDPE
                                                                               bottle water samples contained much
                                                                               lower levels of BPA.
Polyzou, C., Khatter, K., Freeman,     Nine new plastic baby bottles were      Variables:                                Room temperature was never               This study implicates that high levels
A., Foulds, J., Smith, R., Saal, F.    purchased from a variety of retailers   -     Temperatures for the baby           specifically defined in terms of         of leaching occur when baby bottles
V., & Stone, C. (2008). Toxic baby     in Toronto and Ontario. Selected              bottles were first conducted at     degrees. This effects the amount of      are heated at 80°. From this, nurses
bottles in Canada (Rep.). Retrieved    were the most popular, easily                 room temperature and then in an     leaching that can possibly result in     and caregivers can change practice
February 08, 2009, from                available brands. Three Gerber                oven at 80°.                        higher or lower leaching                 to help reduce negative effects that
http://www.toxicnation.ca/files/toxi   bottles in different sizes of the       -     Different brands of baby bottles.   concentrations depending on specific     result from leaching BPA.
cnation/report/ToxicBabyBottleRep      ComfortHold Premium feeding             Results:                                  room temperature.




                                                                                                                                                                                                           102
               Citation                      Population Studied                         Results of Study                 Threats to Validity of Study                  Implications of Study
           (in APA format)               (Who was studied? How many              (What were the variables? What        (Where there significant problems        (How can results help in caring for
                                             where in the study)                   did the researchers find?)            with the study? Where there                patients? Is more research
                                                                                                                          reasons to doubt findings?)              required before we can draw
                                                                                                                                                                           conclusions?)
ort.pdf.                               system bottle packages, three Avent   -    Laboratory test detected 5-          The different sizes in baby bottles      This study also implies that leaching
                                       Natural bottles with extra soft            8ng/ml bisphenol A leached           effects the amount of leaching that      of BPA can cause harmful effects to
                                       silicone nipples, and three Playtex        from all bottles when heated at      can be produced due to different         newborns.
                                       Avance bottles from the Bubble-free        80°                                  surface areas. The study did not take
                                       system were selected to conduct the   -    The results of Avent brand           in consideration that some bottles
                                       study.                                     bottles showed the overall           were larger/smaller than other bottles
                                                                                  highest levels of bisphenol A        when results were recorded.
                                                                                  leaching, while Playtex brand
                                                                                  bottles showed the overall
                                                                                  lowest leaching levels of
                                                                                  bisphenol A.
                                                                             -    The levels of bisphenol A
                                                                                  leaching increased exponentially
                                                                                  when the bottles were heated,
                                                                                  with higher concentrations
                                                                                  reported from Avent brand
                                                                                  bottles.
Welshons, W., Nagel, S., & Vom         Review of literature and research     Variables:                                Specific lab tests were not              Although some may argue that
Saal, F. (2006). Large Effects from    involving animal and human studies.   -    Different levels of exposure         consistently identified.                 research conducted in laboratory
Small Exposures. III. Endocrine                                              Results:                                   Multiple methods were used under        animals are insufficient and do not
Mechanisms Mediating Effects of                                              -    Increase in number and               different conditions.                    correlate with humans, these
Bisphenol A at Levels of Human                                                    hyperplasia of prostate gland                                                 startling effects caused from BPA
Exposure. Endocrinology, 147(6),                                                  after administration                                                          should encourage the need for more
S56-S69. Retrieved February 22,                                              -    A 10 ug/kg dose of BPA                                                        research and studies. Consumers
2009, from                                                                        produced permanent changes in                                                 should be educated about possible
http://endo.endojournals.org/cgi/rep                                              male reproductive organs such                                                 adverse effects and what findings
rint/147/6/s56.                                                                   as a decrease in sperm                                                        have been made concerning
                                                                                  production.                                                                   exposures to bisphenol A.
                                                                             -     Early onset of puberty was
                                                                                  reported after 2.4 ug/kg dose of
                                                                                  BPA
                                                                             -    BPA was shown to cross the
                                                                                  placenta and cause harmful
                                                                                  effects to the fetus even at low
                                                                                  doses.
                                                                             -    Significant effects caused in rats
                                                                                  and mice after exposure to BPA
                                                                                  include: structural and
                                                                                  neurochemical changes
                                                                                  throughout the brain associated




                                                                                                                                                                                                        103
              Citation                           Population Studied                        Results of Study                  Threats to Validity of Study              Implications of Study
          (in APA format)                    (Who was studied? How many             (What were the variables? What         (Where there significant problems     (How can results help in caring for
                                                 where in the study)                  did the researchers find?)             with the study? Where there            patients? Is more research
                                                                                                                              reasons to doubt findings?)          required before we can draw
                                                                                                                                                                           conclusions?)
                                                                                       with behavioral changes such as
                                                                                       hyperactivity, learning deficits,
                                                                                       increased aggression, increased
                                                                                       likelihood for drug dependency,
                                                                                       abnormalities in male sperm
                                                                                       production, changes in
                                                                                       reproductive systems and in
                                                                                       infertility of males and females,
                                                                                       immune disorders, increased
                                                                                       growth rate and early sexual
                                                                                       maturation.




TRACK 8            EBP Team 9: Kristina Hammon, Jenna Noland, Amanda Wells, and Jennifer York

Clinical Question: Is a urine specimen from a urethral catheter compared to a sterile bag equally effective for accurate diagnosis of a UTI in a symptomatic child
under 5 years?
                Citation                            Population Studied                       Results of Study                 Threats to Validity of Study               Implications of Study
            (in APA format)                     (Who was studied? How many            (What were the variables? What            (Where there significant           (How can results help in caring
                                                    where in the study)                 did the researchers find?)          problems with the study? Where          for patients? Is more research
                                                                                                                            there reasons to doubt findings?)        required before we can draw
                                                                                                                                                                             conclusions?)
American Academy of Pediatrics. (2007,         A guideline that provides criteria    Recommends urethral                    No significant findings, as this     Recommends urethral
April). Urinary Tract Infection. Retrieved     and symptoms of UTI in children.      catheterization for infants and        provides a guideline for clinical    catheterization for infants and
on March 29, 2009, from                                                              children less than 2 years of age      practice of diagnosing, obtaining    children less than 2 years of age
http://www.aap.org/publiced/BR_UTI.htm                                               who are febrile and need immediate     urine specimens, and the treatment   who are febrile and need immediate
                                                                                     antibiotic treatment.                  of UTIs in children.                 antibiotic treatment.

                                                                                     Recommends the bag method of                                                Recommends the bag method of
                                                                                     collection be used with infants and                                         collection be used with infants and
                                                                                     children who are afebrile and                                               children who are afebrile and
                                                                                     asymptomatic, but a catheterized                                            asymptomatic, but a catheterized
                                                                                     specimen be obtained immediately                                            specimen be obtained immediately
                                                                                     if urinalysis is positive for                                               if urinalysis is positive for




                                                                                                                                                                                                       104
                Citation                         Population Studied                     Results of Study                   Threats to Validity of Study                   Implications of Study
            (in APA format)                  (Who was studied? How many          (What were the variables? What              (Where there significant               (How can results help in caring
                                                 where in the study)               did the researchers find?)            problems with the study? Where              for patients? Is more research
                                                                                                                         there reasons to doubt findings?)            required before we can draw
                                                                                                                                                                              conclusions?)
                                                                                 leukocytes or nitrite.                                                           leukocytes or nitrite.

Gilljam, B., Svensson, M. (2008). In-Out    61 children ages 0-24 months with    In-out catheterization is a reliable    The bagged specimen technique is         In-out catheterization is a reliable
Catheterization of Young Children with      suspected UTIs.                      method to use to confirm UTIs in        not distressing, but well tolerated.     method to correctly diagnose young
Suspected Urinary Tract Infection: A                                             children 0-24 months.                   The bag method causes some pain          children with suspected UTI. To
Retrospective Journal Study. Pediatric                                                                                   when the bag is removed because of       lend weight to this argument, further
Nursing 34 (3), 241-245. Retrieved on                                                                                    the adhesive.                            research is needed.
March 21, 2009, from the Ovid Database.




Lau, A., Wong, S., Yip, K., Fong, K., Li,   98 children: 82 boys and 16 girls,   Independent variables:                  This study was not planned to find       For a definite diagnosis of UTI in
S. P., Que, T. (2006). A comparative        below 2 years of age without known   The independent variables of this       out the sensitivity and specificity of   uncircumcised male infants,
study on bacterial cultures of urine        to have UTIs.                        study are urine samples obtained by     urine culture in diagnosing UTI          suprapubic aspiration urine culture
samples obtained by clean void technique                                         clean void technique versus urethral    since no patients with genuine UTI       is best to obtain sample.
versus urethral catheterization. Acta                                            catheterization.                        (true-positives) were included. Both
Paediatrica, 96, 432-436. Retrieved                                                                                      collection methods were prone to         In patients who are ill enough to
February 21, 2009, from Ovid database.                                           Dependent variables:                    yield false-positive culture results.    warrant immediate antimicrobial
                                                                                 The dependent variable of this study                                             treatment, transurethral bladder
                                                                                 is the rate of urine contamination.                                              catheterization should be performed
                                                                                                                                                                  immediately. In patients who are
                                                                                 Uncircumcised boys, both with                                                    stable, clean-catch void sample is
                                                                                 clean voided urine and catheter                                                  recommended.
                                                                                 urine were prone to contamination.

                                                                                 Catheter produced less false
                                                                                 positive than the clean voided urine.
Loane, V. (2005, November). Obtaining       44 non-potty trained children:       Independent variables:                  Small sample study.                      The best practice to obtain a urine
urine for culture from non-potty trained    community based patients.            The independent variables of this                                                culture is by clean catch method.
children. Paediatric Nursing, 17 (9), 39-                                        study are the various urine             Contamination rate in pad samples        Even though it is not the most
42. Retrieved March 21, 2009, from                                               collection methods (bag, pad, clean     was thought to be associated with        convenient method, it gives more
Academic Search Elite database.                                                  catch) obtained by nurses and           prolonged contact between the wet        reliable results when compared with
                                                                                 trained technicians.                    pad and perineal flora.                  the pad.

                                                                                 Dependent variables:                    Contamination was higher in              Catheterization should be used only
                                                                                 The dependent variable is the rate of   samples obtained from trained            for the very ill children.
                                                                                 urine contamination of samples.         technicians.




                                                                                                                                                                                                          105
                Citation                           Population Studied                       Results of Study                    Threats to Validity of Study                   Implications of Study
            (in APA format)                    (Who was studied? How many            (What were the variables? What               (Where there significant               (How can results help in caring
                                                   where in the study)                 did the researchers find?)             problems with the study? Where              for patients? Is more research
                                                                                                                              there reasons to doubt findings?)            required before we can draw
                                                                                                                                                                                   conclusions?)
                                                                                     Clean catch sampling is not the          White cells become embedded in
                                                                                     most practical but is least invasive.    the fibers of the pad thus lowering
                                                                                     This evidence shows that clean           the count.
                                                                                     catch is the most accurate method
                                                                                     when obtaining a urine culture.

                                                                                     Suprapubic and catheterization is
                                                                                     the most reliable for a urine
                                                                                     collection when the children are
                                                                                     very ill.
Long, E., Vince, J. (2007). Clinical         Clinical review of various samples      Independent variables:                   In the MSU collection, the mothers        SPA and CSU are rapid and
Review: evidence behind the WHO              comparing supra-pubic aspiration        The independent variables of this        were unsupervised with cleaning.          accurate methods of obtaining urine
guidelines: hospital care for children:      (SPA), catheter-specimen urine          study are the various urine              CCU was collected by parents of           samples from infants who are
what are appropriate methods of urine        (CSU), bag-specimen urine (BSU),        collection methods.                      young children who are not                unable to void on command. In
collection in UTI? Journal of Tropical       clean-catch urine (CCU), and mid-                                                sufficiently unwell to require            older children and infants who do
Pediatrics. Retrieved February 21, 2009,     stream urine (MSU).                     Dependent variables:                     immediate antibiotic therapy. Lack        not require immediate antibiotic
from Ovid database.                                                                  The dependent variable of this study     of expertise and parental concerns        treatment, CCU or MSU are the
                                                                                     is the rate of urine contamination.      regarding complications from these        methods of choice for obtaining a
                                                                                                                              relatively invasive methods may           urine sample. BSU samples cannot
                                                                                     SPA is the ―gold-standard‖ of urine      limit their use.                          be recommended in diagnosing a
                                                                                     collection; CSU samples proved an                                                  UTI.
                                                                                     accurate diagnosis of UTIs; BSU
                                                                                     has a false-positive 50% and a false-
                                                                                     negative rate of 9%; CCU there
                                                                                     were 2 false-positive results in study
                                                                                     that would be considered
                                                                                     contaminated; MSU had 90% of
                                                                                     samples with intermediate growth.
McGillivary, D., Mok, E., Mulrooney, E.,     Study of 303 non-toilet-trained         Independent variables:                   The consequence of ―catheterize           Formal decision and cost-benefit
Kramer, M.S. A head-to-head                  children under 3 years of age at risk   The independent variables of this        all‖ strategy for all nontoxic-           analysis of this versus other
comparison: ―Clean-void‖ bag versus          for urinary tract infection who         study are bag versus catheter urine      appearing children with fever             strategies might be helpful to
catheter urinalysis in the diagnosis of      presented to the children‘s hospital    samples.                                 without source may have the               compare alternative approaches.
urinary tract infection in young children.   emergency department. Compared                                                   potential to lead to test resistance by   Further studies with larger numbers
(2005). Journal of Pediatrics 147, 451-      bag and catheter samples from each      Dependent variables:                     nurses, physicians, and parents who       are needed to confirm this study‘s
456. Retrieved February 21, 2009, from       child.                                  The dependent variable of this study     are concerned about a painful             findings obtained for children less
Ovid database.                                                                       is the rate of urine contamination.      procedure and the unknown risk of         than 3 months of age.
                                                                                                                              introducing infection.

                                                                                     Catheterization samples had less




                                                                                                                                                                                                              106
                Citation                         Population Studied                      Results of Study                   Threats to Validity of Study                Implications of Study
            (in APA format)                  (Who was studied? How many           (What were the variables? What              (Where there significant            (How can results help in caring
                                                 where in the study)                did the researchers find?)            problems with the study? Where           for patients? Is more research
                                                                                                                          there reasons to doubt findings?)         required before we can draw
                                                                                                                                                                            conclusions?)
                                                                                  contamination rates compared to
                                                                                  bag samples.
National Guideline Clearinghouse (NGC).    Evidence-based care guideline for      States suprapubic aspiration and        No significant findings, as this       A high-quality clean catch urine
(2009, Feb). Guideline synthesis:          medical management of urinary          urethral catheterization are the most   provides a guideline for clinical      sample is the preferred method for
diagnosis and management of pediatric      tract infection in children 12 years   sensitive methods of urine              practice of diagnosing, obtaining      urine collection. If unable to obtain
urinary tract infection (UTI). Retrieved   of age or less.                        collection.                             urine specimens, and the treatment     specimen by clean catch, urine
March 27, 2009, from                                                                                                      of UTIs in children.                   samples collected by catheter or
http://www.guideline.gov                                                          Recommends suprapubic needle                                                   SPA (if age-appropriate) are
                                                                                  aspiration or catheterization for the                                          recommended.
                                                                                  most accurate sample in children
                                                                                  where UTI is suspected and the
                                                                                  need for antibiotic treatment is
                                                                                  immediate.

                                                                                  The bag collection method has a
                                                                                  false-positive rate of 85-99%.
Orifi, F., McGillivray, D., Tange, S.,     7,584 children less than 24 months     Independent variables:                  Because the vast majority of urine     Study recommended catheterized
Kramer, M. S. (2000). Urine culture from   that needed outpatient urine           The independent variables of this       cultures obtained in the PTC are       urine sample to be obtained in all
bag specimens in young children: Are the   cultures. Samples from the             study are bag specimens and             ordered b private office based         febrile infants less than 3 months of
risks too high?. Journal of Pediatrics,    Emergency center and pediatric test    catheter specimens of urine             community pediatricians, data on       age and in older children who are
137 (2), 221-226. Retrieved February 21,   center were obtained from these        obtained from the emergency center      clinical outcomes are incomplete for   not toilet trained that have other
2009, from the Ovid database.              areas.                                 and a pediatric test center.            these cultures.                        factors associated with a high risk of
                                                                                                                                                                 UTI, such as toxic appearance, UTI
                                                                                  Dependent variables:                    Adverse clinical outcomes under the    symptoms, history of UTI, known
                                                                                  The dependent variable of this study    study were significantly more          renal anomalies or urologic
                                                                                  is the rate of urine contamination.     common in urine specimens              instrumentation.
                                                                                                                          obtained by the bag technique.
                                                                                  Contamination rates were 62.8%                                                 Non toilet trained children should
                                                                                  and 9.1% in bag versus catheter         Bag specimens had higher               have a bagged specimen if they are
                                                                                  specimens.                              contamination rates from the PCT       at low risk of infection.
                                                                                                                          because of the transportation.
                                                                                  Emergency department had a                                                     If white blood cells are higher or a
                                                                                  contamination rate 56.4% and the        Did not study several additional       positive dipstick test then the
                                                                                  pediatric test center had a 69.25%      potential adverse outcomes such as     children should be catheterized,
                                                                                  contamination rate.                     the emotional and economic aspects
                                                                                                                          of unnecessary or prolonged
                                                                                                                          treatment, investigation, admission,
                                                                                                                          and recall to the ED and the medical
                                                                                                                          consequences of delayed diagnosis
                                                                                                                          or treatment.




                                                                                                                                                                                                          107
                Citation                            Population Studied                       Results of Study                   Threats to Validity of Study                  Implications of Study
            (in APA format)                     (Who was studied? How many            (What were the variables? What              (Where there significant              (How can results help in caring
                                                    where in the study)                 did the researchers find?)            problems with the study? Where             for patients? Is more research
                                                                                                                              there reasons to doubt findings?)           required before we can draw
                                                                                                                                                                                  conclusions?)
Schroeder, A.R., Newman, T.,                  A total of 3066 infants aged 0-3        Independent variables:                  Bagged urine specimens were more        Both urine cultures and urinalysis
Wasserman, R.C., Finch, S.A., Pantell,        months with temperatures of 38          The independent variables of this       likely to have two organisms, to        are more accurate in catheterized
R.H. (2005). Choice of Urine Collection       degrees Celsius.                        study are the various urine             have nonpathogenic bacteria, and to     specimens; the magnitude of
Methods for the Diagnosis of Urinary                                                  collection methods.                     have an ambiguous result.               difference is small but should be
Tract Infections in Young, Febrile Infants.   A total of 219 patients from within                                                                                     factored into clinical decision
Arch Pediatr Adolesc Med 159, 915-922.        the Pediatric Research in Office                                                                                        making.
Retrieved February 21, 2009, from Ovid        Settings‘ network, including 44         Dependent variables:
Database.                                     states, the District of Columbia, and   The dependent variable of this study
                                              Puerto Rico.                            is the rate of urine contamination.

                                                                                      Infection rates were similar in bag
                                                                                      and catheterized specimens.
Vaillancourt, S., McGillivray, D., Zhang,     350 toilet-trained children who         Independent variables:                  Although written instruction were       Urine contamination rates are higher
X., Kramer, M. (2007). To Clean or Not        were between the ages 2-18 years of     The independent variables for this      given to the child and the parent, it   in midstream urine that is collected
to Clean: Effect on Contamination Rates       age and had a midstream urine           study were the cleaning and not         is difficult to verify that either      from toilet-trained children when
in Midstream Urine Collections in Toilet-     sample requested.                       cleaning of the urinary areas of        cleaning or midstream collection        obtained without perineal/genital
Trained Children. Journal of the                                                      children.                               was accurately performed.               cleaning. Cleaning may reduce the
American Academy of Pediatrics 119 (6),                                                                                                                               risk for returning for repeat cultures
1288-1293. Retrieved on February 23,                                                  Dependent variables:                                                            and for receiving unnecessary
2009, from the Ovid Database.                                                         The dependent variable for this                                                 antibiotic treatment and
                                                                                      study was the rate of urine                                                     investigations.
                                                                                      contamination of clean and not
                                                                                      cleaned children.

                                                                                      The rate of contamination in the
                                                                                      cleaning group was 7.8% and 23.9%
                                                                                      in the non cleaning group. Children
                                                                                      who were randomly assigned to
                                                                                      cleaning were less likely to have a
                                                                                      positive urinalysis than those in the
                                                                                      non cleaning group.




                                                                                                                                                                                                               108

								
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