Evidence-Based Practice (EBP) can be termed as the integration and option of best research evidence with clinical expertise, skill and patient values. It seeks to improve the care process and the care outcomes based on the evidence collected over time and tailoring that to the needs of the patients within a particular setting. The EBP process is aimed at improving judgment and decision making but this is also based on the experience of the nurse in understanding the research evidence and relating the same to specific scenarios within the clinical setting. It is a process that is facilitated by consultation and team work as well as utilization of feedback between the involved groups. The EBP process is characterized by four major steps; the first step is the identification of the clinical question or problem that we seek to address; the second step is the detailed search for evidence that can answer the question by making a systematic and methodical review of literature (Melnyk, Fineout-Overholt, Stillwell & Williamson, 2010). The third step is to assess the acquired literature and evidence to determine its relevance to the set out question as well as the quality and possibility of bias. The fourth step is the delicate process of making clinical judgments and decisions based on the combination on relevant literature, client preferences and the policies within the clinical setting (Melnyk, Fineout-Overholt, Stillwell & Williamson, 2010).
Defining the problem/rationale and question
The utilization of intravenous cannulas (IVCs) in clinical situations is one of the most important elements that have helped manage patients in need of fluids. However, the risk of infection during insertion or during removal as well as in the cases of management of the IVCS remains a major problem for the healthcare providers. These IVCs find their use mostly in the acute care settings and the surgical units where the level of accuracy required is high but the risk of errors and misses and subsequent infections is equally high (Wu & Casella, 2013). Currently, there exist no standard policies or guidelines that determine the appropriate insertion, removal or change of the IVCs. It is apparent that once an IVC is inserted, it could pose significant benefits to the recovery of the patient while on the other hand, it could pose significant dangers to the health of the patient. Hospital acquired illnesses are a high possibility in the use of IVCs especially in the event where the safety and quality measures and protocols are not well defined or even so well implemented (Wu & Casella, 2013).
Question: For hospitalized patients in need of IVCs, should the replacement of IVCs be based on physiologic needs or should it be based on the standard- time intervals?
Locate the evidence
The following three databases were determined for search of literature; CINAHL, Medline and PubMed. The key words used to make the search included peripherally inserted intravenous (IV) catheters, intravenous cannulas (IVCs), replacement of catheters and time/physiologic need. The search was .limited to the last five years as well as eliminating any of the articles that did no contain full text. The abstracts were thus eliminated. The results yielded a total of 8 articles in which five were expert analysis that were deemed unsuitable for this study. Two articles were ultimately utilized to analyse the clinical situation as had been presented. This decision was based on the detailed nature and the specificity of the articles on the issue at hand and the clinical question (Melnyk, Fineout-Overholt, Stillwell & Williamson, 2010).
Appraisal of evidence
Palese, A., Cassone, A., Kulla, A., Dorigo, S., Magee, J., Artico, M., & Nadlišek, B. (2011). Factors influencing nurses' decision-making process on leaving in the peripheral intravascular catheter after 96 hours: a longitudinal study. Journal of Infusion Nursing, 34(5), 319-326.
In this study, the authors sought to explore the factors that influence the decision making and judgment of the nurses in regard to the replacement of the peripheral IVCs after the recommended period of 96 hours. In a study of 166 participants, the researchers identified that the majority of the decisions on replacement of IVCs is based on medical necessity. However, there was notable agreement that the determination of medical necessity is solely based on the experience of the nurse or the ability of the nurses to work together as a team. In the absence of experience, nurses should be afforded a platform where communication can be enhanced and the nurses can consult to reach an amicable solution that does not compromise the quality of care and safety of the patient.
Castro-Sánchez, E., Charani, E., Drumright, L. N., Sevdalis, N., Shah, N., & Holmes, A. H. (2014). Fragmentation of care threatens patient safety in peripheral vascular catheter management in acute care–a qualitative study.PloS one, 9(1), e86167.
In this study, the researchers sought to establish the factors/influences that the care behaviors in PVC and their impact on safety of the patient. The study indicates that over the course of time, there have been quality improvement initiatives that have been formulated to reduce the occurrence of adverse events in the use of PVC. However, nurses have not been well informed of these specific issues that influence the decisions and judgments in clinical use of PVCs. In this study, the researchers utilized qualitative interviews of ten clinical pharmacists, ten doctors and 18 nurses as well as midwife. Thematic analysis of the responses was done. The results indicated that fragmented management of care characterized by poor communication, lack of specific standards tailored to the facility, insufficient knowledge/skill or experience, resentment and frustration of nurses due to workload as well as ambiguity of the responsibilities within the organization all lead to poor decision making in the use of PVCs.
Summary of recommendations (best practice)
There are two major issues that arise from this case; on one hand is the lack of appropriate communication channels within the facility. Secondly, there is a lacking case of standardization of policies and guidelines in regard to delicate care processes and in this particular case the timing of change of IVCs. On the issue of communication, Emily’s dilemma is a typical example of the situations that lead the nurses to a situation where they are forced to overlook or even forego some policies and guidelines and therefore compromise the quality of care and the safety of the patient. Emily on the realization that the workload is significantly high even amidst her relative inexperience decides to consult her colleagues. Apparently, the most viable solution would have been to report to a senior colleague or the supervisor or the ward manager on the workload that is awaiting Emily rather than making a decision to compromise on the safety of the patient.
The supervisor was apparently not present and there had been poor monitoring of the workload and scheduling which once more indicates poor communication within the facility had the communication been effective, the supervisor and the Emily would have recognized the workload ahead in time and therefore put in place a fallback option such as standby nurses who will help Emily as the workload increases. The occurrence of a situation in which the there were undetected or unpredictable workload and poor scheduling is all part of confirmation that the communication within the facility is at an all time low and could even get worse (Melnyk, Fineout-Overholt, Stillwell & Williamson, 2010).
The second issue that emanates from this case is the lack of standardization of policies within the facility. There is an aspect within the organization in which the policies are just provided in their general format. In this era of evidence based practice, nurses are required to develop regulations and policies that are tailored to their workplace. This is within the realization that different facilities or units have different needs and there is some specificity attached to each facility/unit. In Emily’s case, the nurses are aware that there is a policy that demands a change of the IVCs on a daily basis. This policy has been formulated in a generalized form in that the nurses have not been informed nor trained on the actual aspects that they should observe in the determination of change of the IVCs. This could mean that there are many cases in which the IVCs are changed without any medical necessity such as when they do not pose any danger or harm to the patient (Wu & Casella, 2013).
In such cases, then there are cases of wastage of resources which could have otherwise been utilized otherwise. The policy should specify for instance that all IVCs that have been inserted in the patient for a period of more than 24 hours or so should be replaced or as evidence guides. This should be backed up by evidence to suggest that beyond this time there is a high risk on the safety of the patient. Further, the facility has to set out bedside monitoring reports for patients with IVCs which indicate and record the time of the day when the last IVC replacement was done. This would ensure consistency and improve communication among the nurses especially in consideration of the personnel changes during shifts (Melnyk, Fineout-Overholt, Stillwell & Williamson, 2010).
Conclusion
The impact of HAIs within the healthcare settings has called for greater detail on the management of cases that place high risk of occurrence of infections for hospitalized patients. The costs of care for these HAIs are managed and catered for by the respective healthcare facility. The use of IVCs poses significant risk of HAIs. However, effective management can assure of minimal cases of HAIs. However, IVCs need be replaced over time and the decision to make regular replacements can be informed by timing or physiologic need for change. Timing implies the change of IVCs over a particular period of time irrespective of whether it causes harm to the patient of not while the physiologic perspective is based on the assessment of possible harm that the IVCs can pose to the patient past a certain time. EBP has its focus on costs effectiveness and safety of the patient in equal priority as they all affect the outcomes. In that case, there is sufficient evidence to sustain the replacement of IVCs based on physiologic need as opposed to timing. The recommended time after which IVCs can be replaced is 96 hours subject to which the nurses and the care team can reassess the risk to the patient. However, all decisions regarding the change or replacement of IVCs are primarily more effective when the feedback and communication channels within the care team and the facility are working optimally (Wu & Casella, 2013).
References
Castro-Sánchez, E., Charani, E., Drumright, L. N., Sevdalis, N., Shah, N., & Holmes, A. H. (2014). Fragmentation of care threatens patient safety in peripheral vascular catheter management in acute care–a qualitative study.PloS one, 9(1), e86167.
Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: step by step: the seven steps of evidence-based practice. AJN The American Journal of Nursing, 110(1), 51-53.
Palese, A., Cassone, A., Kulla, A., Dorigo, S., Magee, J., Artico, M., & Nadlišek, B. (2011). Factors influencing nurses' decision-making process on leaving in the peripheral intravascular catheter after 96 hours: a longitudinal study. Journal of Infusion Nursing, 34(5), 319-326.
Wu, M. A., & Casella, F. (2013). Is clinically indicated replacement of peripheral catheters as safe as routine replacement in preventing phlebitis and other complications?. Intern Emerg Med, 8, 443-4.
