Comparative Effectiveness Research in Nursing Care

[AHRQ]

Over the last several decades, advancements in research and health care have led to an overwhelming amount of information and increase in the number of treatments for many conditions and in a corresponding increase in journal articles reporting on these advancements. While it is essential for nurses to remain up-to-date with the latest clinical research, finding the time to read the huge amount of published articles can be difficult.

The Effective Health Care (EHC) Program of AHRQ wants to help. How do you stay on top of all of the research and know which treatment options you should share with your patients? How do you use the clinical research that is available to you so that you can engage your patients in constructive discussions about their health care?

Let's talk about ways the AHRQ EHC Program can make that easier for you. A good place to start is with a free continuing education activity on Understanding Comparative Effectiveness Research and Applicability to Practice.

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The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency within the U.S. Department of Health and Human Services charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans.

Comments from anyone outside of AHRQ do not imply an endorsement by the U.S. Department of Health and Human Services, AHRQ, or any other Federal agencies such as the National Institutes of Health, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Centers for Medicare & Medicaid Services, and the Health Resources and Services Administration.

[Esme12, ASN, BSN, RN]

Welcome to AN!

Great information!!!!

[Teresag_CNS]

We need CER on turning for pressure ulcer prevention. Has AHRQ considering funding an RCT of 2 versus 3 hour turning intervals in acute care? I know there is a large study by Bergstrom in long-term care on the topic. We need the question answered in acute care, because of the risk to nurses of moving patients, the opportunity cost of nurses' time (i.e. what else nurses could be doing with the time spent turning), the fact that most patients are not actually turned q2h, and the fact that turning is painful for many patients. The workload implications of frequent turning are huge, but it seems nurses' workload is not of much interest to funders. We need this research to use our human resources wisely.

[AHRQ]

Teresag_CNS, this is an excellent comment for a number of reasons. You've identified a real and important problem that nurses face every day, but more so, you described the full context and kept it patient-centered. You've described the topic in a way that researchers can actually study it. As you suggest, most research focuses on the patient outcomes and less on the workforce outcomes that go along with them. But I haven't answered your question yet...

I believe this would be an excellent question to suggest for new research. But at the same time, I'd suggest we first look at the body of literature. Fortunately, AHRQ recently published two systematic reviews on pressure ulcers (in May 2013). One focuses on assessment and prevention and the other focuses on treatment strategies. Since you focus on turning, I think that the assessment and prevention report is more relevant to the issue you describe. In this report, despite lots of studies, the evidence was sporifice for many interventions although turning (called "repositioning" in the report) "was an exception. The summary of repositioning was as follows...

"An exception was repositioning, for which there were three good- or fair-quality trials, although these reported somewhat inconsistent results. One trial found that a repositioning intervention was more effective than usual care in preventing pressure ulcers. Although other trials of repositioning did not clearly find decreased risk of pressure ulcers compared with usual care, the usual-care control group incorporated standard repositioning practices (i.e., the trials compared more intense repositioning vs. usual repositioning, not vs. no repositioning). A recently completed trial of repositioning, consisting of high-risk and moderate-risk arms that were randomized to repositioning at 2-, 3-, or 4-hour intervals, should provide more rigorous evidence on the effectiveness of repositioning." It goes on to say "Therefore, it would be inappropriate to conclude that standard repositioning, skin care, nutrition, and other practices should be abandoned, as these were the basis of usual-care comparisons."

There is obviously a need for a research study on repositioning and in addition to what is suggested in the systematic review, it seems wise to consider your suggestion to measure nursing and workforce outcomes as well.

Now I have a question for you and other readers... Would you like us to start a discussion topic on pressure ulcers, using these recent reports as a jumping-off point?

[herring_RN, ASN, BSN]

Teresag_CNS, this is an excellent comment for a number of reasons. You've identified a real and important problem that nurses face every day, but more so, you described the full context and kept it patient-centered. You've described the topic in a way that researchers can actually study it. As you suggest, most research focuses on the patient outcomes and less on the workforce outcomes that go along with them. But I haven't answered your question yet...

I believe this would be an excellent question to suggest for new research. But at the same time, I'd suggest we first look at the body of literature. Fortunately, AHRQ recently published two systematic reviews on pressure ulcers (in May 2013). One focuses on assessment and prevention and the other focuses on treatment strategies. Since you focus on turning, I think that the assessment and prevention report is more relevant to the issue you describe. In this report, despite lots of studies, the evidence was sporifice for many interventions although turning (called "repositioning" in the report) "was an exception. The summary of repositioning was as follows...

"An exception was repositioning, for which there were three good- or fair-quality trials, although these reported somewhat inconsistent results. One trial found that a repositioning intervention was more effective than usual care in preventing pressure ulcers. Although other trials of repositioning did not clearly find decreased risk of pressure ulcers compared with usual care, the usual-care control group incorporated standard repositioning practices (i.e., the trials compared more intense repositioning vs. usual repositioning, not vs. no repositioning). A recently completed trial of repositioning, consisting of high-risk and moderate-risk arms that were randomized to repositioning at 2-, 3-, or 4-hour intervals, should provide more rigorous evidence on the effectiveness of repositioning." It goes on to say "Therefore, it would be inappropriate to conclude that standard repositioning, skin care, nutrition, and other practices should be abandoned, as these were the basis of usual-care comparisons."

There is obviously a need for a research study on repositioning and in addition to what is suggested in the systematic review, it seems wise to consider your suggestion to measure nursing and workforce outcomes as well.

Now I have a question for you and other readers... Would you like us to start a discussion topic on pressure ulcers, using these recent reports as a jumping-off point?

Yes. I think many of us would like to discuss this.

May we add research that is not presented?

I would also like to know if AHRQ wants links and/or attachments of research articles from journals.

[AHRQ]

Given the interest, we'll start a discussion topic on pressure ulcers soon. You're always welcome to post any research and to include links to relevant resources.

[Teresag_CNS]

Thank you, Beth. I sat on a systematic review panel on pressure ulcer prevention recently; it may be the one you cited. It was done at Oregon Health & Science University. I was part of the initial team, then had to move on to other projects, so I wasn't an author. I think the conclusion is that we really don't yet know how often hospital patients should be turned.

Another topic of interest: What is the evidence base for nursing physical assessment in hospitalized people? Nurses spend a great deal of time checking pupils, listening to lungs, and feeling for peripheral pulses, yet there is very little evidence to support these practices. Nurses carry out frequent assessments because they are the facility's standard of care, and often physicians order frequent assessments without thinking of the workload they impose on the nurse, allowing those orders to stay in effect well after they are needed. I wonder if we could develop evidence-based physical assessment standards instead of the one-size-fits-all approach, saving time and resources. Patients may get better sleep with fewer interruptions, and their privacy will be enhanced if we aren't lifting the gown as often.

[AHRQ]

Hello Teresa,

Yes, we are thinking about the same systematic review. Thanks for your help on that! And I agree that we don’t yet know about the contribution of turning toward pressure ulcer prevention or treatment. It’s frustrating, right? The reality is that it’s difficult to prevent, treat and research pressure ulcers. Turning patients on a schedule is a time-consuming and often physically difficult task. If we just knew that it really worked, it would make it feel less frustrating. But the reality, as we know, isn’t that simple. We need to work with our colleagues, including physical therapists and nutritionists, as well as physicians and pharmacists, to tackle this issue together.

The question of turning is similar to your next suggestion regarding routine physical assessments. It’s a really good question. Perhaps there are others on this forum who would like to join you in a small project. There are several approaches that you could take. You could pick a couple common diagnoses or procedures and document all the findings from physical assessments for a month. Are there any patterns in those findings? Are they improved after 3 days post-op for example? If so, is there a physician who would be willing to change the order after 3 days to once a day? (again, just an idea – the data may show something different). Then continue to collect data and compare the outcome of once a day to tid (or whatever is standard).

A second approach would be to have a journal club on the topic and discuss what evidence does (or does not) exist. If you’re not used to journal clubs, maybe just start with a nurse-only group. Then ask an NP, CNS or physician if there is evidence that was missed. With evidence (or lack thereof), they may be open to changes in the protocol.

Good luck!

Beth