Evidence Based Practice

Big questions. I find that a lot of nurses think EBP is another form of torture, or some educator is needing to justify his/her existence. Then, when I can put it in to dollars and show how it benefits them, they may come around. I was an easy convert because I have worked in Medical and Legal areas and know that it is always easier and cheaper to do things the right way first. The big deal is agreeing on what is "right". Our local schools teach EBP and my STT chapter promotes it. I send emails every Friday to our hospital staff on short blurbs or abstracts regarding new or controversial study results. Some tell me they appreciate it, but I believe most delete it immediately.

I tend to think one of the biggest obstacles is time. I now can rush around and do things by routine, almost without thinking in an extremely time efficient manner. The alternative takes time, in both education, and changing the manner in which things are done. We replaced our pyxis with an accudose machine, and everyone hated it (I still do.) No more rushing and letting my hands and fingers fly around, I have to stop, move slowly and focus more. And this interferes with my ability to multitask. Plus, I don't know about your education departments, but ours wastes a lot of time educating us on complicated things we never do, but may, one day and things we do all the time. I really hate spending any more time with the education people. They seem really out of touch. Aside from that,I think it would be great. Especially if it improves pt care/outcomes. I just think that any institutionalized change anywhere will always be a fight for the above reasons.

I agree with ThrowEdNurse. Seems like a lot of wasted time. But, as an Educator, I am challenged with JCAHO, OSHA and corporate requirements for documentation that the education was at least presented. I was in a meeting yesterday and asked by Directors to create another module for nurses. I knew right then it was not going to be a hit with the nurses, but-------------------------

1. What is the biggest obstacle in your facility in implimenting Evidence Based Practices?

2. Do your staff nurses understand what EB is?

3. How did you go about changing attitudes?

Continuing education should be made attractive while feasabile. This could be rectified through appropriate staffing and introducing changes in piecemeal fashion so that staff members have a chance to absorb it and implement it. Perhaps linking EBP to 'continuing Ed credits' might help encourage practitioners to seek remediation.

Also, consideration should be given to the fact that everyone implements change at different rates. Outcome measurement should be planned accordingly.

4. Did you get support from your hospital and administration?

5. Do you believe in evidence based practice?

Take for example good old Vancomycin. Everyone I know has had this drilled into their heads in school - "any and all patients receiving Vancomycin should be monitored for urine out put because Vancomycin is a nephrotoxic drug". During our careers, we've often seen clinicians and "pharmacy committees" order Vanco-trough levels on pts. receiving the drug for any period over 3 days.

But just how toxic is Vanco?

A quick search at NIH reveals the following:

There have been 28 reports of vancomycin-associated ototoxicity published in the medical literature since 1958. It remains unclear whether any diminution in hearing is permanent or reversible. Few patients in the literature had follow-up audiometry and the hearing impairment tends to be at higher frequencies. Several authors reported peak serum vancomycin concentrations, but the exact time these were drawn with respect to the last dose is mostly unclear. In other reports, the 'peak' concentrations noted 3 to 6 hours after the last dose are probably indicative of much higher concentrations because of vancomycin's rapid phase of distribution. More than half the 57 cases of reported nephrotoxicity due to vancomycin occurred within the first 6 years of the drug's use. Many of these patients also had pre-existing renal dysfunction or were concomitantly receiving other nephrotoxic agents. It is unclear whether the coadministration of aminoglycosides produces a synergistic toxicity. The exact incidence of nephrotoxicity is uncertain, but is probably less with the current, relatively pure, product. The correlation of nephrotoxicity with certain serum vancomycin concentrations remains to be clarified. Other aspects also require clarification, such as when to draw samples to determine peak serum concentrations and whether or not routine measurements are necessary at all.

Although monitoring serum vancomycin concentrations in clinical practice is commonplace, the data supporting this practice are meager. The rationale for monitoring these concentrations is to improve the effectiveness and/or reduce the toxicity of the drug. However, there are no data to suggest that monitoring serum vancomycin concentrations improves the effectiveness of therapy. In addition, despite many case reports of vancomycin-associated nephrotoxicity and ototoxicity, it is unclear whether this agent truly causes such conditions. Moreover, there is no evidence that adherence to specific ranges of vancomycin concentrations will preclude these events. Finally, vancomycin pharmacokinetics are sufficiently predictable that adequate serum drug concentrations can be obtained with dosing methods that take into account the patient's age, weight, and renal function. Safe and effective vancomycin dosage regimens can be constructed with these empirical dosing methods, whereas monitoring vancomycin levels increases the cost of therapy without improving the safety or efficacy of treatment.

Vancomycin-associated nephrotoxicity is rare in neonates, even with serum peak concentrations >40 microg/mL.

6. Were you an instnt convert to EB or did it take time to convince you one way or the other?

7. Are the nursing schools in your area preparig students in understanding what eb means and is?

cheers,