New Knowledge, Innovations & Improvements: Evidence-Based Practice NK3: Clinical nurses evaluate and use evidence-based findings in their practice. NK3b: Provide one example, with supporting evidence, of how clinical nurses used evidence-based findings to revise an existing practice to improve care. Introduction Evidence-based, relationship-based care is integrated into the professional practice model and is a high priority for all nurses at the Massachusetts General Hospital (MGH). Clinical nurses are encouraged to use scientific evidence to revise practices and policies. They are supported by a variety of resources within Nursing & Patient Care Services (N&PCS) that enable them to confidently propose practice changes to improve care. Participation in Collaborative Governance Committees, such as the Research and Evidence-Based Practice Committee (REBP), Policy, Procedures and Products Committee (now known as the Clinical Practice Committee (CPC), Quality and Safety Committee, and Staff Nurse Advisory Committee, offer clinical nurses the opportunity to question current practices, discuss practice with their peers across the institution, and review/revise/approve new and existing policies and procedures. Additionally, all nurses are encouraged to participate in professional nursing organizations and attend conferences where they can learn about existing standards and new evidence for practice. The Norman Knight Nursing Center for Clinical & Professional Development within the Institute for Patient Care is another resource that is dedicated to the professional development of all nurses and offers electronic and live courses related to evidence-based practice (EBP). The MGH also supports EBP through unit-based clinical nurse specialists/nursing practice specialists (CNS/NPS), nurse scientists affiliated with the Yvonne L. Munn Center for Nursing Research (Munn Center), and clinical librarians from the Treadwell Virtual Library. In June 2016, the Johns Hopkins Nursing Evidence-Based Practice Model was adopted and adapted for use in N&PCS. MGH s interdisciplinary evidence-based practice initiative is led by Nurse Scientist Meg Bourbonniere, PhD, RN, Nursing Practice Specialist Virginia Capasso, PhD, ANP-BC, CWS, and Social Worker Mary Susan Convery, MSW, LICSW. The first formal training course, Advancing Evidence-Based Practice, was held on June 28, 2016. More than 50 participants from disciplines across N&PCS attended the four-hour session delivered by Tam Nguyen, PhD, MSN, MPH, RN, an external faculty Nurse Scientist in the Munn Center and Assistant Professor of Nursing at Boston College, and Lisa Liang Philpotts, BSN, MSLS, Knowledge Specialist for Research & Instruction in the MGH Treadwell Virtual Library. From this course, ten EBP teams were formed. Each team was mentored by Bourbonniere, Capasso or Convery, who guided them through the EBP process. The following narrative describes the work of one of these teams representing the two Surgical Intensive Care Units (Ellison 4 and Blake 12) to prevent sacral pressure injuries.
Forming an Evidence-Based Practice Team The MGH has two surgical intensive care units. Blake 12 is an 18-bed unit that provides intensive care to surgical and transplant patients. Patients recuperating immediately after elective or emergency surgery and requiring intensive care receive care in the 20- bed Surgical Intensive Care Unit on Ellison 4. Both of these surgical intensive care units (SICUs) have high patient acuity that can include hemodynamic instability, organ failure, diminished sensory perception, and the use of multiple medical and mobility restricting devices that makes patients at extremely high risk for hospital-acquired pressure injury (HAPI). The SICUs often collaborate to standardize care related to common patient problems, like HAPI. In May 2016, the SICUs decided to partner on eliminating sacral pressure injuries among their patients and engaged internal skin and wound care expert, Capasso, to assist them in identifying additional strategies to reduce the HAPI risk for their critically-ill patient populations. From their past efforts to prevent HAPI, the clinical nurses on the SICUs engaged in evidence-based and effective HAPI prevention strategies. Examples include interventions that redistributed pressure, such as support surfaces and frequent repositioning, as well as other interventions, including the use of nutrition therapy and the effective management of moisture and incontinence. Clinical nurses on Blake 12, Laura Lux, RN, BSN, and Brittney Grazio, RN, BSN, along with clinical nurses on Ellison 4, Sharon Brackett, RN, BSN, CCRN, and Laura Prout, RN, BSN, RN-BC, indicated to Capasso that they and some of their colleagues were using a Mepilex silicone-coated foam sacral dressing for patients who were at highest risk for developing sacral pressure ulcers. These nurses also told Capasso that the practice of prophylactic use of sacral dressings as a prevention measure was gaining popularity in other settings outside MGH and that they thought this strategy was effective, but it was not a standard practice for all nurses who practiced in the SICUs. As part of the strategic goals of the organization to reduce costs, many products were undergoing cost/quality review. Capasso is a member of the Clinical Nurse Specialist/Nursing Practice Specialist Wound Care Task Force (WCTF). The WCTF had recently been engaged in trialing a new product, the Allevyn Life foam sacral dressing. This dressing was very similar to the Mepilex sacral dressing, but lower in cost. The new Allevyn product had been presented to the Collaborative Governance Policy, Procedure & Products Committee in December of 2016, and was targeted to replace Mepilex as current supplies dwindled. Capasso discussed this planned product change with Lux, Grazio, Brackett and Prout. The nurses, relying on their experiential evidence, expressed concern about the product change and questioned whether the Allevyn product would be as effective as the Mepilex dressing. Capasso suggested that the SICUs engage in an evidence-based practice project to examine the comprehensive evidence related to the use of prophylactic sacral dressings and recommended that a small group comprised of a clinical nurse, nursing practice specialist, and nursing director attend the educational program described above, Advancing Evidence-Based Practice.
On June 28, 2016, Lux and Grazio attended the EBP course described above with their Nursing Director, Mary McAuley, RN, MS, NE-BC, and Nursing Practice Specialist, Colleen Arsenault, RN, MSN (attachment NK3b.a). After the course, Lux, Grazio, McAuley, and Arsenault invited Sandra Muse, MSN, NP-C, Nursing Director from the Surgical Intensive Care Unit (Ellison 4) and two of her Clinical Nurses, Brackett and Prout, to join the team. The two SICUs joined together to evaluate the evidence comparing the effectiveness of Allevyn and Mepilex sacral foam dressings. Because of their longstanding collaboration with Capasso on pressure injury reduction, the team asked Capasso to serve as their EBP coach. The SICUs EBP team began meeting in July 2016 to discuss their EBP question. The team recognized that critical care patients were at high risk of developing HAPI and had been working diligently to maintain their HAPI rate below the NDNQI Critical Care-Adult Mean. They understood that their patient populations had risk factors including prolonged immobility, hemodynamic instability, vasopressor therapy, diminished sensory perception, organ failure, and use of medical devices that could all contribute to HAPI development. To develop their focused practice question to compare the two sacral foam dressings the team used the Population-Intervention-Comparison-Outcome (PICO) method they had learned in the June 2016 EBP educational program. Their question is outlined below. Population: Critical care patients Intervention: Mepilex foam sacral dressing Comparison: Allevyn Life foam sacral dressing Outcome: Sacral pressure injury prevention PICO Question: As compared to Mepilex foam dressings, are Allevyn Life foam dressings as effective at preventing sacral pressure injuries in critical care patients? Clinical Nurses Use Evidence-Based Findings In early August 2016, the SICUs EBP team provided librarian, Philpotts, with the PICO question and requested a comprehensive literature search. The results of Philpotts search yielded 31 articles (attachment NK3b.b). The SICUs EBP team reviewed the search results to determine the most relevant articles for their project and excluded international studies, trials of non-sacral pressure injuries, and bench studies that did not meet the dressing type criteria. This initial review left the team with seven relevant studies to analyze to answer their EBP question. In late August 2016, each team member was assigned a study to review and critique using the Hopkins EBP Model Research and Non-Research Evidence Appraisal Tools. Lux, Arsenault, and McAuley knew from their education that the literature review and critique could broaden or become narrower as they proceeded with the review of the articles that had been identified. They also learned that a discussion guided by an expert could help the entire team gain confidence in their skills. The team decided to
meet every two to three weeks from late August 2016 through January 2017. Capasso attended all meetings with the SICUs EBP team to coach them through the critique process and act as a resource at meetings where the strength and quality of each article was discussed and determined. As a result of these discussions, five additional studies were excluded for failing to relate to the PICO question or for reporting preliminary data. Four additional articles were identified using the reference lists of the assigned articles and added to the review (attachment NK3b.b). By late November 2016, the SICUs EBP team synthesized the evidence and developed their recommendation for practice. They had identified four high quality studies of foam dressings that were used prophylactically to prevent sacral pressure injuries. Two of the studies were judged at Level IA, having the strongest design and highest quality. These studies demonstrated lower incidence of sacral pressure injuries in critical care patients treated with prophylactic Mepilex foam dressings vs. patients with no dressings. The remaining two studies were rated lower, at Level IIB, but also revealed lower incidence of sacral pressure injuries in critical care patients treated with either Mepilex or Allevyn Life foam dressings vs. historical controls. (A historical control group is one that is chosen from a group of patients who were observed at some time in the past or for whom data are available through records. This type of control group is used for comparison with subjects being treated concurrently.) The team decided that the available evidence was limited, but supported the prophylactic use of either of the silicone-coated foam dressings for sacral pressure injury prevention. The team agreed that the Allevyn Life foam sacral dressing was an equivalent alternative to the Mepilex dressing. As the team progressed through their work to make recommendations for practice, it was noted that while several clinical nurses placed sacral foam dressings prophylactically on their high-risk patients to prevent sacral pressure injuries, it was not a consistently applied strategy in either SICU or beyond. This practice variation reinforced the need to revise nursing practice on preventing skin breakdown. The team identified the need to update the current Skin and Wound Care Guideline and subsequently, obtain approval from two committees, including the Clinical Practice Committee (formerly the Policy, Procedure & Products Committee) and the Wound Care Task Force. An educational awareness campaign on the revised guideline would inform clinical nurses of the practice change. Recognizing that practice is driven by evidence-based guidelines, clinical nurses, Lux, Grazio, and Brackett, worked with Capasso, the wound care specialist responsible for the Skin and Wound Care Guideline, to incorporate the recommendation for using the Allevyn Life foam dressing as a preventative measure for patients at high-risk for HAPI. With the support of the SICUs EBP team, Capasso took the revised guideline to a WCTF meeting, where she obtained feedback. She then discussed the feedback with Lux, Grazio, and Brackett and it was incorporated into the guideline. The updated guideline was presented at the April 11, 2017 meeting of the Collaborative Governance Clinical Practice Committee, where it was approved (attachment NK3b.c). Attachment NK3b.c also includes excerpts of the original and revised skin and wound care guideline
(copies of the complete guidelines are available on site for review) and the email notification sent to clinical nurses on May 1, 2017 citing that the newly-revised guideline was placed in Ellucid, the online policy management system, which is available to all clinical nurses. An example of the use of the newly-revised guideline is included in attachment NK3b.d, in which a clinical nurse from the Ellison 4 SICU documents the use of Allevyn on bony prominences to protect a patient at high risk for pressure injury. In addition, the SICU clinical nurses from Ellison 4 and Blake 12 and Capasso collaborated with the Research and Evidence-Based Practice Committee, to create a Did You Know? poster outlining the practice revision and to advocate for using Allevyn Life foam dressings prophylactically to prevent pressure injuries. The REBP Committee facilitated the poster production and distribution to Nursing Directors, CNS/NPSs, and clinical nurses. In addition, clinical units received a larger poster to display in a prominent place on each unit to further augment the educational awareness campaign. The Did You Know? poster (attachment NK3b.e) was distributed to all units the first week in May 2017, to describe the revised practice of prophylactically placing the Allevyn Life foam sacral dressing on patients with fragile or compromised skin around the sacral area. Clinical Nurse Specialists and Nursing Practice Specialists communicated the practice change to the clinical nurses directly and in their bedside consults. The awareness campaign was capped off during the Interactive Poster Session on Nursing Research Day, May 9, 2017, where Lux, Grazio, Brackett, and Capasso presented a poster of the SICUs EBP project. As a result of clinical nurses using evidence-based findings to revise an existing practice to improve care, the updated MGH Skin and Wound Care Guideline is available to all clinicians at MGH.