Seven Evidence-Based Practice Habits: Putting Some Sacred Cows Out to Pasture

Abstract

Are we doing what is best for our patients with the current evidence available to us?Nursing has deeply rooted traditions. As far back as Florence Nightingale in the 19th century, nurses prided themselves on patient advocacy, infection control (before germ theory), and physical care of the entire body, not limiting the focus to management of disease or signs and symptoms.1 These early roots established the philosophy of nursing. Nurses labeled what they do as caring or the art of nursing.Critical care nurses find themselves in a unique situation. We have our feet deeply rooted in the art of nursing. Yet our hands and minds reach for the scientific basis that our highly technical, physiological, and pharmacological specialty requires. To base our practice on science, we must use research to answer questions, establish protocols, and promote critical thinking and decision making at the bedside. Doing so requires us to be willing and able to change practices, regardless of the tradition and commonly held beliefs, if validated, reliable, and useful evidence leads to such change. Nurses are at the forefront of evidence-based approaches.2The Institute of Medicine defines evidence-based practice (EBP) as “the integration of best research, clinical expertise, and patient values in making decisions about the care of individualized patients.”3 Research findings are a collection of facts. They become evidence when the findings are relevant and useful in particular clinical circumstances.4 Using research to guide clinical decision making is a shift in culture from basing decisions on opinion, past experiences, and precedents to basing decisions on science, research, and evidence.5 The Agency for Healthcare Research and Quality published Making Health Care Safer: A Critical Analysis of Patient Safety Practices.6 This document outlines 79 evidence-based practices and targets related to patient safety. The 11 recommendations with the strongest research support have a direct connection to critical care practice (Table 1).In this article, we cover 7 evidence-based practice (EBP) recommendations that clinicians should consider implementing into their practice. Much of this research is not new and has met with resistance at the bedside despite clear evidence that it represents best practice. We also address the traditional approach and offer recommendations for implementing the changes. Marianne Chulay addresses instillation of normal saline (physiological salt solution) with endotracheal suctioning and verification of nasogastric tube placement. Elizabeth Bridges reviews the current evidence and recommendations for accurate measurement of blood pressure and selection of electrocardiography leads. Kathleen Vollman delineates the research and recommendations for patients’ positioning and mobility. Richard Arbour discusses use of the Glasgow Coma Scale in neurological assessment and management of intracranial hypertension.Most hospital policies and procedures for management of artificial airways include instilling 5 to 10 mL of normal saline before endotracheal suctioning is done.7 This nursing and respiratory therapy routine was advocated as a way to improve oxygenation and removal of secretions by thinning thick secretions and stimulating coughing to assist with mobilization of secretions. Although instillation of normal saline is a long-practiced suctioning intervention, no research has ever documented the benefit of this practice, and some researchers have found the practice potentially harmful.In most experimental studies8–13 on the effect of instillation of normal saline before endotracheal suctioning, oxygen saturation or PaO2 was evaluated as the primary end point; in only a single study14 was mixed venous oxygenation evaluated. In these studies, oxygen saturation was significantly lower with instillation of saline than with no instillation of saline,8–10 or the results of the 2 methods (saline vs no saline) did not differ.11,12 In no studies to date did instillation of normal saline before suctioning improve oxygen saturation compared with suctioning without instillation of saline.An interesting finding in studies8–13 that showed decreases in oxygenation after instillation of saline before suctioning was that return to baseline oxygenation levels did not occur until at least 3 to 5 minutes after the suctioning procedure was finished. Although the decrease in oxygenation with instillation of normal saline may not be dramatic, it is far from a transient derangement.Several researchers9,12,15,16 have attempted to determine if more secretions are removed with suctioning when normal saline is instilled than when suctioning is done without instillation of saline. By weighing the volume of secretions removed during suctioning, the researchers hoped to quantify differences between the 2 methods of suctioning. However, in all but a single study, researchers did not take into account the weight of the saline instilled in their calculations, creating a serious flaw in the experimental design of the study and negating the results. In the one, small study16 (N = 12) in which the weight of the saline was taken into account, serious flaws in the study design (lack of randomization of the interventions) make the results invalid.Although an alleged benefit of instillation of saline is improvement in removal of secretions, to date no adequately reported scientific studies support that contention. This lack of research is no doubt partly due to the methodological issues associated with the measurement of secretion volumes in clinical studies, meriting further research to determine the best way to quantify removal of pulmonary secretions.17Although clinicians often believe that instillation of normal saline “thins” thick pulmonary secretions, no research has ever shown that this belief is correct. 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