Evidence Based Practice

SoldierNurse22, BSN, RN · Jan 25, 2014

I'll give you a real-life example of EBP.

Back in my oncology days, we spent a lot of time getting blood cultures on patients who spiked fevers while neutropenic (their immune systems were shot from chemotherapy). For example: I'd come in at 0700, they'd spike a fever at 0800, we'd get cultures, give them Tylenol, and then their fever would predictably return after the Tylenol wore of about 6-7 hours later. Frequently, repeat cultures were ordered when the fever returned (as is customary for each time a patient spikes a new fever), but the nurses were aware that the fever wasn't a new one--it was simply returning as the Tylenol wore off.

Despite this, we'd have to report it to the doc and they'd frequently order another set of cultures. Sometimes, especially if a fever was detected at 1600, Tylenol given at 1700, and the fever returned on the next shift around 2300, another draw was pretty much inevitable. As you can imagine, on a different shift and with a different covering physician, the patient is going to be woken up from their already fragile sleep pattern for 2+ peripheral sticks (getting blood from these patients, whose counts were already in the toilet, was rarely an easy task to boot) as well as cultures of any central lines.

As you can imagine, this whole process had a few problems. In order of my complaints:

1. Patients are being tested multiple times--sometimes for days at a time--for the same fever.

2. The majority of patients with neutropenic fevers will come back without any bacteria to treat on their cultures, so drawing cultures over and over again is pretty silly.

3. These patients are already immunocompromised. To poke them multiple times a day, sometimes for days at a time, heightened their risk for infection.

4. These patients' blood counts were already low. Cultures (especially if a patient had a central line) required about 40cc of blood minimally. Over the course of the day for a patient who is already receiving blood products to bolster their counts, that's a lot of blood if you're drawing cultures 2-3 times.

5. The physicians aren't looking at the patient's notes hard enough to see that this is the same fever. Nurses and physicians need to be educated to prevent this endless process from adversely affecting patient outcomes.

I took it upon myself to look up the treatment standards for patients in our population. The guidelines very clearly stated that unless the fever was new, cultures shouldn't be drawn more than once in a 24- hour period. They specifically indicated that one needs to note any anti-pyretics that were given and take into account that they could be making it seem like the fever was "new" when it really wasn't.

I wrote a policy for the floor that ensured that:

1. Our nurses were educated about the proper policy for cultures.

2. Our nurses were able to refuse orders when given inappropriately by a physician.

3. Our nurses understood the reason behind drawing cultures and were able to balance the need for this procedure with the risk.

I left my previous duty station just as my policy was put into effect (go figure), but that's just one way that a faulty practice can be changed by evidence-based research and an evidence-based policy.

Hope that helps! Sorry for the book. :)

akanini, MSN, RN · Jan 25, 2014

Soldier Nurse,

Thank you for the book!!!! That's a perfect example!!!

SoldierNurse22, BSN, RN · Jan 25, 2014

Glad to help! I know EBP can be presented as really lofty and complicated, but really, it boils down to this: we don't do things in nursing anymore just because "that's how it's always been done". We do things based on research. It sounds like a really easy concept and it's hard to imagine how someone could go against it, but tradition and the "that's how we've always done it" mentality can be really tough to break.

The tendency to over-treat in medicine to avoid lawsuits is also rampant, and unfortunately, there is very little available to put the brakes on such behavior unless a treatment/procedure (like the one above) poses a significant risk to the patient. Even then, it occasionally takes a nurse/nurses or a physician/physicians to point it out, do the research and present the correct course of action, often in the form of a protocol or policy.

This will get easier as you move along in your practice. Soon, you'll be able to spot things right off the bat that don't seem supported by evidence. There is no shame and absolutely nothing wrong with asking for evidence if you're curious as to the validity of a treatment, either. I'd argue that if you're worried, you have a duty to act on behalf of the patient in your care.

Just don't make the mistake of falling into complacency, where you get used to a certain way that things are and you aren't willing to change. Nursing and medicine change all the time, which is why EBP is so important. Best practice always utilizes the most up-to-date, reliable research to guide it, and it will change frequently to reflect these new discoveries.

nurseprnRN, BSN, RN · Jan 25, 2014

Here's another. It's technically related to a medical diagnosis, but the management is all nursing practice.

I heard a great presentation by an ER nurse specialist who realized that they were getting slammed with people in CHF on Wednesdays and wondered why. A little digging and she discovered they didn't know about monitoring their daily weights; after a weekend of being a little looser on their sodium and fluid restrictions, they were short of breath from the extra fluids load. But all the internal med docs' offices were booked full (and Wednesdays were half days for the internal med guys), so when they called the doc office they got told to go to the ER. Lather, rinse, repeat, ad infinitum.

So she got a grant and bought 100 bathroom scales, developed a patient teaching sheet in weighing and recording, inserviced the staff on how to teach this concept and give away the scales to CHF patients...and CHF admissions dropped like a shot. The docs took credit for it, but this, my friends, was nursing at its finest.

And it's all because a nurse realized that everybody had to understand the concept of fluid balance and how to monitor it right.

I also recommend you cruise on over to Amazon and check out a book called (I think) Ritualistic Practices in Nursing. It's from the 1960s but it's a classic in the field and will give you all sorts of ideas of how to think about these problems in the way your faculty is suggesting.