Evidence-based Practice Improvement Project Research Articles

Malignant Hyperthermia Preparedness Training: Using Cognitive Aids and Emergency Checklists in the Perioperative Setting

PurposeThe purpose of this project was to prepare perioperative staff at a military ambulatory surgical center to respond to a malignant hyperthermia crisis effectively with the assistance the Stanford emergency manual cognitive aid. DesignThis is an evidence-based practice improvement project. MethodsMultidisciplinary perioperative staff at a military ambulatory surgical center participated in an in-service about the Stanford emergency manual cognitive aid tool, and a simulation exercise was conducted to practice using the tool during a malignant hyperthermia crisis. Preproject and postproject implementation surveys were to used to measure staff perceptions of and willingness to use cognitive aids/emergency checklists during perioperative emergencies. FindingsStaff positive perception of and willingness to use the Stanford emergency manual cognitive aid improved after implementation of an education session and simulation exercise with the checklist tool. ConclusionsIntroduction of the Stanford emergency manual cognitive aid to multidisciplinary perioperative staff with an in-service and simulated malignant hyperthermia scenario improved staff perception of cognitive aid use during emergencies. Use of cognitive aid checklists during simulated perioperative emergencies was shown to reduce missed critical treatment steps.

Implementation of Enhanced Recovery After Surgery in a Community Hospital: An Evidence-Based Approach

Enhanced recovery after surgery (ERAS) is an evidence-based practice protocol that has been shown to reduce cost, decrease length of stay (LOS), and improve surgical outcomes. An evidence-based practice improvement project with a multidisciplinary team translated the ERAS protocol into practice at a community hospital. The evidence-based practice improvement design allows integration of evidence into projects to improve clinical outcomes for patients. Small tests of change using the Plan-Act-Study-Do methodology were used to evaluate the process of implementing one surgical service at a time to ensure effective outcomes. After the process was determined to be effective, patient outcomes (eg, LOS) were measured. On average, LOS was decreased from 3.2 to 1.7days. Surgical readmission rate decreased from 3% to 1%. There has been positive feedback and nursing workload has decreased with consistent processes. The ERAS order set continues to be modified based on the evidence and feedback from anesthesia and registered nurses. Monthly reports ensure consistency.

Fitting Square Theories Into Round Projects

Colleagues, the time has come for me to stand on my soapbox and proselytize about the difference between the kinds of end products/projects/dissertations we expect from PhD, DNS, DNSc, EdD, and DNP students. More than that, however, is the need to provide appropriate learning experiences regarding that difference. I have tried to be diplomatic and not create too many waves (e.g., a tsunami) among some of my colleagues, but the time has come for me to speak out regardless of how wet I get.What has spurred this transition? I have been involved in developing and teaching in three different DNP programs during the past several years and have noticed important differences among programs. One of these has to do with the faculty's understanding of the difference between research and evidence-based practice (EBP) improvement projects. EBP improvement projects are geared to improving health care in a specific organization or agency. In contrast, research is geared toward discovering new knowledge. I have seen the differences among programs in approach, courses, and learning experiences. More to the point, I was in the midst of evaluating the presentations of several DNP students in one of these agencies while beginning this column and experienced the difficulty students have with differentiating between research and EBP. One part of this challenge has to do with the type of content courses they are receiving and how these courses prepare DNP students for the real world of practice improvement, not to mention their capstone projects.Let us begin with how we determine the differential content in or scientific underpinnings courses between research and practice doctorates. When we conduct research, having a theoretical or conceptual framework or model is important for a deductive study. When we are conducting practice improvement projects; however, what is far more important are the models we use to guide our approach to implementing innovative projects for real clinical problems. When there are theory courses in a DNP curriculum that focus on old nursing models or theories to be tested (e.g., Roger's science of man or Orem's of self-care deficits), this course does not facilitate the DNP students' project development. They become confused. And the students try to fit square theories into round projects.So what do we need to include in the theory course for DNP students versus the traditional content we include in research doctorates? There are numerous EBP, PI, and EBPI models out there that need to have the floor in theoretical/conceptual models courses for DNP students. Here are some examples:* The Advancing Research and Clinical Practice through Close Collaboration (ARCC) model (Levin, Fineout- Overholt, Melnyk, Barnes, & Vetter, 2011)* The PARIHS model (Rycroft-Malone, 2010)* The IOWA model (Titler, 2010)* The Evidence-Based Practice Improvement (EBPI) model (Levin et al., 2010)* The Clinical Microsystems model (Nelson, Batalden, & Godfrey, 2007)These are the kinds of models or frameworks that are helpful in directing practice improvement projects.We might also wish to include theories related to the major concepts of the DNP curriculum in such a course. In addition to EBP, these concepts may include primary care, interprofessional collaboration, leadership, and/or quality and safety. …

Developing Guidelines for Clinical Protocol Development

During the 2-year period from 2007 through 2009, the Visiting Nurse Service of New York (VNSNY) conducted the Renfield Evidence-Based Practice Improvement (EBPI) Fellows Program1 (hereinafter referred to as the Renfield Program). This program was cosponsored by the Department of Education and Clinical Development within the larger Departments of Quality Management Services (QMS) and Research. The Evidence-Based Practice Improvement (EBPI) model designed by the first author in conjunction with the VNSNY for conducting a clinical practice improvement project was the guiding framework for the program (Levin et al., 2010). The purposes of the Renfield Program were to * provide participants with the knowledge and skills to identify a clinical issue within an organizational context, search for the best and most relevant evidence, and appraise a variety of evidence from the literature; * guide participants in the development of a body of evidence related to a selected clinical problem (a) using evidence-based methods to evaluate the evidence relevant to the selected clinical problem, (b) evaluating the appropriateness of the evidence base for practice implementation, and (c) determining the need for small tests of change; * provide participants with the knowledge and skills to develop the EBPI project plan; and * facilitate participants' design of an EBPI project plan. Both quantitative and qualitative outcomes of this program demonstrated the fellows' growth in their beliefs about and their confidence in incorporating evidence- based practice into their daily work as well as their actual implementation of EBPI. Using Melnyk, and Fineout-Overholt's EBP Beliefs and Implementation Scales (2008), fellows' beliefs about EBP increased from baseline (mean = 55.8; SD = 3.0) to 12 months (mean = 56.5; SD = 3.2), but the increase was not significant (p = .37). Evidence-based practice implementation scores increased from 23 (SD = 18.3) to 30 (SD = 16.5) with higher scores showing more experience with EBP tasks (p = .13). Although the sample size is small (15 nurses completed baseline tools and 11 at follow-up) to show significant differences on these scales, the evaluation results demonstrate positive trends. Interestingly, group cohesion improved significantly from 16.7 (SD = 5.3) at baseline to 13.5 (SD = 5.8) at 12 months (p = .04). In addition, fellows commented very positively on their participation in this program and how the program helped them to view their practice through a different lens. Two EBPI projects, conducted by two different teams of fellows, led to important information that could help VNSNY improve clinical practice. One interesting aspect of the Renfield Program was to mentor selected individuals in the QMS department to become future educators of EBPI within the agency. The faculty-in-training during this project, Lorraine Ferrara and Bonnie Lauder, were mentored by the visiting faculty member from Pace University and the visiting scholar from the University of Pennsylvania. They have embraced and internalized all this learning, and have been teaching others in the QMS Department as well as participating with the first author in the evidence-based practice doctoral course she taught at Pace University and the workshops (described in the following texts) that she and Dr. Kathy Bowles, visiting scholar from University of Pennsylvania, have given at VNSNY. Building on the success of the Renfield EBPI Fellows Program, a series of workshops was conducted for the entire QMS staff on EBPI. Feedback from QMS participants was very positive. The next step in going forward and putting to use the information gleaned by workshop participants was the formation of a committee to develop Guidelines for Clinical Protocol/Guidelines/Procedures Development within VNSNY in an effort to standardize the process for such protocol development and incorporate an EBPI approach (see Figure 1). …