1. Introduction
Central venous access devices are small catheters that are placed either directly or indirectly into the superior venacava or right atrium for the following purposes: drug administration, nutrition, dialysis of the kidneys, antibiotic therapy or transplantation of the bone marrows among other reasons. They are often used when the smaller veins are inaccessible or medications or nutrients cannot be administered via the smaller veins. The use of CVAD is often marred by two major problems: occlusion by thrombosis and infection. The patency of the catheter must be maintained. Nurses use normal saline or heparin in order to maintain the patency of CVADs. The debate on the efficacy of normal saline or heparin has given rise to several studies in an effort to come up with the best option. A systematic literature review of seven articles was carried out in order to determine the best solution to use for adult oncology patients.
There were varying opinions gathered from the articles. Normal saline is often used due to its cost effectiveness. The National Guide Clearing House on the other hand recommends the use of heparin citing its safety in reducing thrombosis in adult oncology patients . A comparison between the use of heparin and normal saline in a randomized double blinded study showed that there was no significant difference in flushing CVAD with heparin or flushing it with normal saline . In conclusion, it would be better to continue to use heparin instead of normal saline because the evidence from the reviewed articles does not show the merits and demerits of normal saline. The implementation of these research findings is necessary in order to improve efficiency and efficacy of the flushing of CVADs.
Evidence based practice(EBP) refers to a problem solving approach to making clinical decisions in a health care setting which is an integration of the best available scientific knowledge with the best experiential evidence. It involves making of clinical decisions after weighing the risk, the cost and the benefits of the research evidence prior to its application in the clinical set up . Evidence practice ensures that the nurses can implement the relevant intervention measures in a cost effective manner. It also allows for evaluation of the intervention measures that work and those that do not work. The patients therefore receive health care services are cost effective, are of better quality and are of known and manageable risks . A model is necessary in the application of findings. This thesis shall therefore describe a suitable evidence practice model for the implementation of the findings, the facilitators, the challenges and an evaluation plan for the model.
2. Implementation Model
An evidence based practice model that would be suitable for the implementation of the research findings described above would be an open system that is made up of components that are interrelated and which are influenced by both external and internal factors. Some of the external factors that influence the evidence based model include: accreditation bodies, legislative bodies, standards and regulations. Legislative bodies and regulatory bodies are responsible for enforcing laws that protect the interest of the public and promote fair access to the healthcare services . The current practice and the evaluation of the areas of need is done through the quality measures that have been put in place. Special interest groups, the media and community are also part of external factors that influence the model. The internal factors include: finance, library support, staffing needs, the environment and the culture of the organization to mention but a few .
For the open system evidence practice model to be effective, the following factors need to be in place: First, a supportive and dedicated leadership needs to be in place in order to allocate the necessary resources for the implementation of evidence based practice. These resources include: human resources, finances and technological support . Secondly, the organizational culture needs to be open towards ensuring that the patients receive optimal care at the health facility. Finally, knowledge of the population of the patients, the healthcare organization and health care organization are all critical components of the open system model of evidence based practice.
3. The Practice Question
The translation of evidence into practice in this case begins with the clear outline of the issue or practice question. The question is the utilization of heparin instead of normal saline for flushing central venous access device of adult cancer patients. Adult cancer patients may require having catheter venous access devices because of need to administer chemotherapeutic drugs or antibiotics. The occlusion of the catheters by thrombosis is quite common and can be eliminated through flushing using heparin or normal saline . Based on the evidence that has been gathered both normal saline and heparin have their merits. The synthesis of the evidence that was gathered reveals that there are inconsistent results regarding the substitution of heparin with normal saline for flushing of central venous access device. It can therefore be concluded that it may be presumptuous to substitute heparin with normal saline during flushing of catheter venous access devices among adult cancer patients.
4. The EBP committee
The implementation of this model is largely dependent on the members of the team who shall execute it. The team shall be comprised of the following professionals: Quality assurance committee, physicians, nurses and Standard of Care and Practice Committee and the hospital board members. The group shall be comprised of about 10 members because smaller groups are easier to manage than large groups. Prior to the commencement of its duties, the committee shall meet in order to come up with a timeline for the project and also draw up a strategy for the project. The initial task of the committee shall be the appraisal of the research evidence that is available regarding the utilization of heparin or normal saline for the flushing of catheter venous access devices.
There are four types of research evidence: aesthetic evidence is the evidence that is based on the nurses’ intuition. Personal evidence is based on the nurse’s personal interaction with the patients. Empirical evidence is evidence gathered as a result of scientific studies while ethical evidence is based on the nurse’s respect for the values and beliefs of the patient. All these types of evidence need to collected and appraised not only in isolation but also to draw up the relationships. Scientific evidence is given greater quality as compared to evidence that is non- scientific.
Evidence shall be obtained from: position statements that have been issued by organizations, research studies, expert opinions, patient surveys and EBP practice guidelines. It is recommended that a library specialist be assigned this duty in order to save on time . Once the evidence has been obtained, it shall be evaluated in order to determine whether it is relevant to the practice question or not. The medical librarian needs to evaluate the evidence obtained based on the following parameters: the author, the citation, the date and the person who reviewed the source of the evidence, the date and reason for the publication . The evidence obtained is then discussed by the team members who determine its quality and strength using an index after a consensus.
Scientific evidence is given greater quality as compared to evidence that is non –scientific. The evaluation of scientific evidence is pegged on the following: the design of the study, directness, consistency of the evidence and quality . However, scientific evidence in isolation is not sufficient to inform practice. It is therefore necessary to include non-research evidence in the search . This will allow for relevant filters to be put in place and ultimately come up with a conclusive answer to the practice question. Generation of evidence is important because; it allows for innovation therefore resulting in better outcomes in the practice of oncology nursing. It is also a cost effective strategy given that the strategies are evaluated on all aspects prior to implementation which is often a costly venture .
Having evaluated the evidence in order to determine the strength and the quality, the team can then come up with a set of recommendations that will affect the practice of oncology nursing at the hospital. The recommendations that are made are dependent on the quality and strength of the evidence that was obtained. High quality evidence based on qualitative and quantitative research can be used as a basis for changing the practice at a health care facility. In this case, the evidence obtained on the utilization of heparin instead of normal saline was weak and inconclusive. Therefore, the EBP team may opt for the use of what the health care facility had been using in the past for flushing of catheter venous access devices. If the evidence is mainly expert opinions and data on quality improvement, then the EBP team would have to make the recommendations for change judiciously. The team would have to carry out an analysis of the risks and benefits that would be associated with the changes prior to making such recommendations . A pilot study with a limited number of participants needs to be carried out prior to the commencement of the implementation of the changes.
The evidence based practice team needs to determine the feasibility of the proposed changes to the target setting. In this case, the team would have to determine whether it would be feasible to utilize heparin instead of normal saline for flushing catheter venous access devices. This is referred to as translation. This phase entails communication to the relevant stakeholders such as the clinicians, the pharmacists and the hospital board members . The stakeholders then provide feedback as to what they deem feasible and make recommendations as to how the changes can be custom made for the target setting (adult cancer patients in this case). It is also important for the evidence based practice team to obtain support from the health care facility in order to effect the proposed changes.
The team then comes up with an action plan for the implementation of the changes. Components of the action plan include: a set of guidelines for the protocol, the assignment of duties to the various team members and the members of the organization, a detailed timeline for the process and the soliciting of feedback from the relevant stakeholders. Once the action plan has been developed and approved, the process of implementing the change commences. It is important for the members of the organization to undergo training on change of protocol, the implementation and evaluation of the plan. It is also necessary for the EBP team to constantly evaluate the process of implementation as it goes on in order to identify areas that may need to be addressed in future. They should also be available to answer any question in the course of the implementation hence ensuring that the transition is smooth for the relevant stakeholders.
5. Possible Barriers and Challenges
The organization culture also plays a critical role in the implementation of evidence based practice. In a set up where availability of intervention measures, there could be resistance towards embracing the changes in implementation citing lack of the necessary tools for the implementation. In addition to this, the EBP could also meet resistance from the management of the hospitals therefore leading to prolonged periods of waiting for the resources that are necessary for the implementation of the change. If there is little value for research by the nurses and the organization, the implementation of evidence based practice could be hampered . The nurses may feel threatened or intimidated by the new body of knowledge being introduced citing the fact that they have had years of practice. The EBP team could also be constrained in terms of time. This is because the implementation of the necessary change takes time; it commences with several meetings, involves training of staff, collection of feedback, development of an action plan, implementation and evaluation. Depending on the set up of the health care facilities, the good will from the management of the hospital, the culture of the organization and resource availability, it may take quite some time to effectively implement the change. Given that the members of the team also have other functions to attend to at the hospital, further delays into the process of implementing EBP practice could be introduced.
The nursing curriculum does little to prepare the nurses for the utilization of research in making clinical decisions. The more educated a nurse is, the greater the likelihood of embracing evidence based practice. Most nurses however have a diploma in nursing and are therefore hesitant to embrace evidence based practice citing the fact that it was not part of their curriculum. The presentation of the concept of linking research and nursing is often presented a mystical concept that further scares the nurses from embracing evidence based practice . Finally, many health care facilities do not have a library, a medical librarian or the resources necessary for conducting a search for evidence. As a result, the nurses often have to make do with what they had previously learned in school at the expense of gaining information about what is happening in the world of research. The EBP team might find this as a barrier given that their work requires them to present evidence. It could prove costly to carry out a search with limited resources and they also have to hire a medical librarian which adds to the cost of conducting their duties.
6. The Evaluation of the EBP Model
The evaluation of the model is based on objectives of the EBP project. The EBP team is responsible for the implementation of the objectives needs to develop an evaluation criterion for the project. While positive outcomes are the mark of success for such a project, the negative outcomes of the project should also be taken into consideration. The evaluation criteria should not only encompass the results of the project but also evaluate the methods of implementation, the speed of implementation of change, the reasons for the implementation of change, the threats posed by the changes, the weaknesses and the opportunities that are presented as a result of the implementation of the change.
The unexpected outcomes also need to be evaluated. This is because they provide an opportunity for the organization to grow in the implementation of subsequent programs. Evaluation allows for the EBP team to set benchmarks and checkmarks for the process therefore allowing the organization to have a framework that could prove to be useful later on. Gaps in knowledge can also be closed as a result of the evaluation process which allows for introspection.
Works Cited
Anderson, B., Mitchell, M., Williams, K., & Umscheid, C. (2006). A comparison of heparin and saline flush to maintain the patency of central venous catheters. Nursing Times, 106.
Collins, S., Voth, T., DiCenso, A., & Guyatt, G. (2005 ). Evidence-based nursing: A guide to clinical practice. St.Louis: Mosby.
Fonteyn, M. (2005). The interrelationship among thinking skills, research knowledge and evidence based practice. Journal of Nursing education, 439.
Longest, B., & Darr, R. J. (2000). Managing health services organizations and systems . Baltimore : Health Professions Press.
López-Briz, E. Garcia, V., Cabello, B., Bort-Marti, Sanchis, R., & Burls, B. (2010). Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults. EvidenceBased medicine.
M.Kearney, Hodnet, E., & Gennaro, S. (2001). Making Evidence Based Practice a Reality in your institution: evaluating the evidence and using the evidence to change clinical practice . The American Journal of Maternal Health , 236-244.
Malone, J. R., Mccomarck, G. H., Estarbrooks, C., & Seers, K. (2002). Ingredients of change: revisiting a conceptual framework. Qual Saf Health Care , 174-180.
National Guideline Clearing House. (2006). Managing central venous access devices in cancer patients: a clinical practice guideline. Toronto: Cancer Care .
Robin P. Newhouse, Dearholt, S. L., Poe, S. S., Pugh, L. C., & Kathleen M. White. (2007). Johns Hopkins Nursing Evidence Based Practice Nursing Model and Gudelines. Indianapolis: Honor Society of Nursing.
Sams, L., Penn, B., & Facteau, L. (2004). The challenge of using evidence-based practice . Journal of Nursing Administration, 407-414.
Taylor-Seehafer, A., M., Abel, E., Tyler, D., & Sonstein, F. (2004). Integrating evidence-based practice in nurse practitioner education. Journal of American Academy of Nurse Practitioners, 520-525.
