Tipping (Sacred) Cows and Evidence-Based Practice Part I

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    How do you know if what you're doing for your patient is best practice or simply the most perpetuated practice?

    Tipping (Sacred) Cows and Evidence-Based Practice Part I

    I've heard of cow-tipping but I've never actually seen it done. Is it a real thing or are they just pulling my city-girl leg? I don't know. But..I do know what we can do- we can tip the Sacred Cows of Nursing. Sacred Cows are nursing practices we perpetuate because.... we've always done it that way.

    Do you ever wonder if you are following the most recent evidence-based care for your patients? Read here and find out. Caution-first and foremost, follow your facility's procedures and policies. If you discover that change is needed to provide your patients the best care, then be an agent for change and help to bring it about.

    "About 30% to 40% of patients do not receive care consistent with current scientific evidence." (Rauen, Chulay, Bridges,Vollman, & Arbour, (2008) p. 123)

    Guess what- we have the power and the responsibility to change nursing practice!

    Inflating Foley Balloon Prior to Insertion

    Catheter associated urinary tract infections (CAUTI) are the most common hospital-acquired infections (HAIs). CMS no longer reimburses for extra costs associated with CAUTIs. In addition, CAUTIs are considered a nursing-sensitive indicator of care- so it's on us, nurses.

    Pre-inflating the balloon is not necessary and can cause cause the balloon to crease, resulting in micro trauma to tissue.

    Practice Recommendation:
    Do not inflate balloon prior to insertion

    Additional best practices to reduce CAUTI:
    • Wash the periurethral area using soap and water or soap-containing wipes prior to insertion
    • Use a securement device to reduce friction
    • Assess regularly for necessity and remove as soon as possible
    • Use soap and water to clean the meatal surface around the catheter during daily routine catheter care. Cleaning the meatal surface with antiseptic solutions while a catheter is in place is ineffective for preventing CAUTI and not recommended

    Should Healthy Preoperative Adults Undergoing Elective Procedures be N.P.O. After Midnight

    A meta-analysis did not show smaller gastric volumes between patients who fasted more than 4 hours and patients who fasted 2-4 hours. This is very good news for the coffee drinkers

    Practice Recommendation:
    The American Society of Anesthesiologists published preoperative fasting guidelines of 6 hours for easily digested solids and 2 hours for clear liquids for healthy patients scheduled to undergo elective surgery. Fatty and fried foods takes longer to digest and should be eaten no less than 8 hours before surgery.

    Wet-to-dry Gauze Dressings For Clean Granulating Chronic Wounds

    Wet to dry dressings have traditionally been used to provide mechanical debridement.

    However, studies show they remove healthy, healing granulation tissue when the dressing dries out. The granulation tissue should not be disrupted in clean wounds healing by secondary intention.

    Gauze debridements actually impede healing and prolong the inflammatory process in clean granulating chronic wound. In chronic wounds with an adequate blood supply, a moist environment supports healing. Wet-to-dry dressings don't maintain a moist environment when they dry.

    In addition to impeding healing, wet-to-dry dressings are painful for the patient.

    Practice Recommendation:
    Moist environments promote wound healing. Avoid wet-to-dry dressings for clean granulating chronic wounds. Use moisture retentive dressings instead.

    Verifying Enteral Tube Placement for Initial and Ongoing Use

    It's extremely important to confirm the correct placement of feeding tubes prior to initiating feeding or administering medications. There are multiple methods used by nurses at the bedside to verify blind insertion, all of which have limited reliability.
    They include:
    • Auscultation of instilled air
    • Testing of pH
    • Visual assessment of gastric aspirate
    • Placing the tube in water, observing for water bubbles
    • Observing for signs of respiratory distress

    The gold standard for placement is radiographic confirmation.

    Practice Recommendation for initial placement:
    Verify placement with an X Ray. Immediately after radiographic confirmation, mark the tube with indelible marker or tape where it exits the nares to evaluate later for migration.

    Practice Recommendation for ongoing assessment:
    Check tube at 4 hour intervals. Inspect aspirate for changes. Compare tube markings Observe for a change in length of the external portion of the feeding tube by comparing tube markings. Review routine chest and abdominal X Rays.

    Best practice also includes avoiding constant pressure on the same nasal area and assessing skin for redness and breakdown. Alternate taping the tube toward the inner and outer side of the nose.

    Stopping Continuous Enteral Feedings Before Turning or Repositioning

    While feedings should be stopped when the head of the bed (HOB) will be lowered for an extended period of time, evidence does not support turning off feedings for short periods when lowering the head of the bed to reposition or when they'll be supine briefly.

    Of more concern is underfeeding patients receiving enteral nutrition. Minimize interruptions in enteral feedings.

    Practice Recommendation:
    Do not stop feedings when repositioning or lowering the HOB

    Trendelenburg to treat hypotension

    Evidence does not exist for this time-honored intervention used to treat hypotension. Trendelenburg has little positive effect on blood pressure or cardiac output. It can temporarily increase venous return but it's not lasting and outweighed by deleterious effects.
    Current data to support the use of the Trendelenburg position during shock are limited and do not reveal any beneficial or sustained changes in systolic blood pressure or cardiac output. Some deleterious effects have been documented. It can increase increase in intracranial pressure, engorged head and neck veins and cardiac compromise. It causes respiratory problems in obese patients.

    Practice Recommendation:
    Best practice is passive leg lift. Position your patient in the supine position, with lower legs elevated to promote right heart sided venous return.

    For more best practice, see Tipping Cows Part II for Use of sandbags to control bleeding post angioplasty; Fecal incontinence management and rectal tubes; Best practice in bathing; Instilling normal saline for endotracheal suctioning; and Use of gastric residual volumes to assess emptying and aspiration risk.

    For a related article please read Tipping (Sacred) Cows and Evidence-Based Practice Part II


    AACN 2016. AACN Practice Alert. Initial and Ongoing Verification of Feeding Tube Placement in Adults. Accessed January 2017 Initial and Ongoing Verification of Feeding Tube Placement in Adults - AACN

    American Association for Respiratory Care. (2010). AARC clinical practice guidelines: Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care, 55, 758-764. Accessed September 2016 via the Web at http://www.rcjournal.com/cpgs/pdf/06.10.0758.pdfJ

    American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495-511.

    APIC Implementation Guide: guide to preventing catheter associated urinary tract infections. 2014. http://apic.org/Resource_/Eliminatio...I_web_0603.pdf.

    Ayello EA, Baranoski S. Nursing 2014 survey results: wound care and prevention.

    Nursing 2014. 2014;44(4):34.

    Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for prevention of catheter-associated urinary tract infections, 2009. CDC - 29 CAUTI Guideline - HICPAC.

    Makic, M. B. F., VonRueden, K. T., Rauen, C. A., & Chadwick, J. (2011). Evidence-based practice habits: putting more sacred cows out to pasture.Critical Care Nurse, 31(2), 38-62.

    Hanrahan, K., Wagner, M., Matthews, G., Stewart, S., Dawson, C., Greiner, J., ... & Cullen, L. (2015). Sacred Cow Gone to Pasture: A Systematic Evaluation and Integration of Evidence‐Based Practice. Worldviews on Evidence‐Based Nursing, 12(1), 3-11.

    Metheny N. Turning tube feeding off while repositioning patients in bed. Crit Care Nurse. 2011;31(2):96-97.
    Stewart ML. Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice. Crit Care Nurse. 2014;34(4):14-22.

    Miller, J., Hayes, D. D., & Carey, K. W. (2015). 20 questions: Evidence-based practice or sacred cow?. Nursing2015, 45(8), 46-55.

    Rauen, C. A., Chulay, M., Bridges, E., Vollman, K. M., & Arbour, R. (2008). Seven evidence-based practice habits: putting some sacred cows out to pasture. Critical Care Nurse, 28(2), 98-123.
    Last edit by tnbutterfly on Jun 14, '18
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  3. by   RainMom
    My facility follows the npo guidelines above for elective surgeries which is great...as long as the pt doesn't get confused by it. One of the nurses calls the pt the day before to verify the time they need to arrive & when to stop eating, etc (also given in writing). Some pts, though, get totally befuddled at hearing that they can eat until one time, drink clears until another time. On top of that, many of the surgeons' offices will instruct the pt to be npo at midnight, causing further confusion (wish somebody would communicate here with the offices). About once a week, we have a surgeon's schedule get completely off track because a pt has to be delayed until later while staff tries to see if another pt can come in sooner.

    For some pts, it's just better to say npo at midnight, lol.
  4. by   LessValuableNinja
    Cow tipping is not only a real thing, but is required to graduate highschool in Wisconsin.
  5. by   Nurse Beth
    Quote from nicktexas
    Cow tipping is not only a real thing, but is required to graduate highschool in Wisconsin.
    I had heard that about Wisconsin
  6. by   LovingLife123
    Cow tipping is a very real thing.

    At my facility, cath care if performed every shift. We do not inflate balloons. And we do not use antiseptic to clean. Regular soap.

    I did not know people turn off feeds to reposition. Making sure we give adequate nutrition is becoming a big thing.

    I have noticed many of our docs going to strictly dry dressings. One of our surgeons got crappy about wound making their dressing wet to dry. I had to make sure for days nobody changed out their dressing to wet.

    Its nice to know we are using the latest evidenced based practice at my hospital. It's always changing though so next month we may be back to wet dressings!!!