Practical Application Of Clinical Evidence System Research Articles

Hand hygiene adherence among healthcare providers working in radiation therapy center

Background Good hand hygiene is a crucial measure for preventing the spread of antimicrobial resistance and healthcare-associated infections (HCAIs). The factors contributing to the rise of HCAIs in patients with cancer may include an increase in antimicrobial resistance and the treatment effects of radiation and chemotherapeutic agents. Infection control and prevention practices such as proper hand hygiene practice could decrease infection rates among patients with cancer. Hence, in order to minimize cross-transmission of HCAIs, it is essential that healthcare providers working in the radiation therapy center practice proper hand hygiene technique. Aims This project aimed to improve adherence of hand hygiene practices among healthcare providers working in a radiation therapy center using the six steps hand hygiene techniques together with the “My five moments for hand hygiene” concept. Methods The team utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice program to conduct pre- and post-implementation audit using evidence-based criteria, and implement the change. The project was implemented from July 2011 to November 2011, in three different phases. Results The post-implementation results showed an improvement for all criteria except Criterion 5. Adherence rate for Criterion 2 showed a slight improvement of 28% (36% to 64%). There was a remarkable improvement of 73% (0 to 73%) in Criterion 3. Another remarkable improvement in adherence of 72% (10% to 82%) was observed for Criterion 4. Criterion 5 showed a 12% reduction in adherence (100% to 88%). Criteria 1 and 6 showed no change in adherence rate. Conclusion The improvement of adherence in five out of the six criteria in hand hygiene could be attributed to teamwork and dedication of the project team. The team had also gained knowledge and skills in enhancing their leadership roles in conducting this project. Sustaining the outcomes is an ongoing challenge, and the team had come up with different strategies to maintain the positive outcomes.

Bed bathing among adult patients in a private oncology ward within an acute care hospital

Bed bathing cleanses the skin, removes odor, and enhances personal hygiene, leading to higher self-esteem. Therefore, it is essential to perform bed bathing based on the best available evidence, so that hospitalized patients are receiving high quality care. The aims of this project were to ensure bed bathing is performed according to the best available evidence, provide a pleasant bed bathing experience for patients, and promote evidence-based practice within clinical culture. The project was implemented in three phases using a system of audit and feedback. JBI PACES (Practical Application of Clinical Evidence System) was utilized to set up a team, data collection, data analysis, GRIP process (Getting Research into Practice) and report writing. GRIP was used for barriers identification, formulation of strategies, and resource identification. There was 100% and 90% improvement of criteria 1 and 2 respectively. There were 21 sub criteria in criteria 1. The 21 sub criteria were detailed steps to follow when performing a bed bath. Criterion 2 referred to evidence of bed bathing and documentation in the patient's file. This project has successfully introduced evidence-based practice in relation to bed bathing among the assistant nurses. They have increased levels of confidence in performing high quality care, and are better prepared to be ambassadors for evidence-based practice among their colleagues.

Implementation of best practice in fall prevention in an adult acute medical ward

Aims/Objectives The aim of this project was to implement best practice evidence to reduce incidence of falls in an acute care ward. Methods This project was conducted in a 44-bed acute care ward in a 935-bed acute care tertiary hospital from December 2010 to May 2011. This project utilized the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES), a pre- and post-implementation audit strategy, and the Joanna Briggs Institute Getting Research Into Practice (JBI GRIP) programs. The audits included three out of eight criteria recommended by the Joanna Briggs Institute. The process involved reviewing patients' medical records, verifying implementation of targeted fall preventive interventions, and fall risk assessment training for ward nurses. Results The findings of the post-implementation audit showed small to significant improvement in all three criteria, indicating compliance with best practice. After nurses had attended the education and training programs on fall risk assessment, accuracy in fall risk assessment has improved by 43%, patient and family education documentation showed an improvement of 31%, and targeted fall prevention interventions achieved a 4% improvement. Conclusion This project found that implementing evidence-based practice of the fall prevention criteria has raised awareness, improved knowledge, and reduced rate of falls. For inpatient fall prevention to be effective in the hospital, creating awareness, education, and communication to every staff member and patient and/or caregiver are essential. The pre- and post-implementation clinical audit is a useful method for evaluating the effectiveness of implementing evidence-based clinical practice.

Skin tear prevention and management among patients in the acute aged care and rehabilitation units in the Australian Capital Territory: a best practice implementation project

A skin tear is a traumatic wound that results from the separation of the skin layers due to shearing forces, friction or blunt trauma that affects all people. Numerous preventative measures aim to reduce the skin tears and minimise conditions that predispose the epidermis to injury. With the increasing elderly population in acute aged care, implementation of an evidence-based guideline is critical as changes to ageing skin integrity make this population more susceptible to skin tear. The aim of this project was to ensure the practice of skin tear assessment, prevention and management among acute aged care causes and rehabilitation patients was performed according to best available evidence. This project utilised a pre- and post-implementation audit design using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs. The project was conducted from June to November 2010 with the audits conducted in the acute aged care and rehabilitation units of two public hospitals in the Australian Capital Territory involving a sample size of 96 patients at pre-audit and 95 patient at post-audit admitted during the audit period. A convenience sample of 20 nurses also consented to be observed. The audits were conducted after obtaining ethics approval and consent from patients and nurses. The results showed a significant change in compliance to the skin tear guidelines at post-implementation audit. Staff education in particular had a dramatic increase from 20% to 98% and the point prevalence rate of hospital-acquired skin tear decreased from 10% to 0.15%. This project emphasised the importance of education of all personnel involved in patient care and that a simple assessment of skin integrity is critical in preventing and managing skin tear especially among the susceptible elderly population.

Utilization Report

In Brief Background Diabetic patients are routinely referred by doctors to Advanced Diabetic Clinic for education and advice if they present with an HbA1c of greater than 10%. The patients were followed up every month for a duration of 6 months, during which they were provided with information on managing their diabetes. The role of diabetic nurse educator is pivotal in preventing complications such as diabetic foot ulcer. Aims/Objectives The aims of this project were to educate diabetic nurse educators to implement the technique of foot assessment among diabetic patients, to establish an evidence-based patient pathway system, to promote foot care knowledge among diabetic patients, and to promote patients' compliance of routine outpatient visits thereby preventing diabetic foot ulcers among diabetes mellitus patients. Methods The implementation of a Best Practice project utilizing audit and re-audit implementation cycle. The Joanna Briggs Institute Practical Application of Clinical Evidence System was used, with four Evidence-based audit criteria developed to determine compliance with best practice. The Getting Research Into Practice was then used to improve practice. Such as patients completed the questionnaires on diabetes foot care knowledge and practice, had foot examination for neuropathy, peripheral pulses and deformity, foot risk was classified, and patients with feet at risk of ulceration attended a tailored education program. Results The results of this project showed that the level of compliance increased by 70% in all four of the audit criteria. Discussion/Conclusion It was a very good exercise because evidence-based practice will now be established among staff in UKMMC and the delivery of care for patients will be based on evidence. Patient compliance has ultimately improved significantly following this utilization project. A diabetic foot education program at a primary health clinic in Kuala Lumpur: a best practice implementation project

Implementation of best practice for chemotherapy-induced nausea and vomiting in an acute care setting

Chemotherapy-induced nausea and vomiting is the commonest side-effect for patients undergoing cancer treatment with chemotherapy. These symptoms can lead to nutritional deficiencies, dehydration and electrolyte imbalance, and negative impacts on quality of life. However, wide gaps exist between clinician and patient perceptions of nausea and vomiting. Effective communication about these symptoms is essential for proper treatment. We conducted a recent chart review to identify gaps in practice regarding chemotherapy-induced nausea and vomiting assessment and documentation. The goal of this project was to improve local practice in the management of chemotherapy-induced nausea and vomiting in patients with cancer. This study used one pre- and two post-implementation audit strategies utilising the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) module. The study was conducted in the 33-bed oncology ward of a large acute care hospital in Korea from February 2010 to June 2010. To facilitate evidence-based nursing practice, audit-feedback-re-audit cycles strategies were used. The audits included four criteria recommended by the Joanna Briggs Institute. There were statistically significant improvements in all four criteria. The first post-implementation audit showed that all four audit criteria rated >50% in compliance. At the second follow-up audit, all four audit criteria rated 100% compliance, indicating excellent compliance with best practice. The differences between the pre- and post-data were statistically significant (P < 0.001) for all four audit criteria. The results indicate that the pre- and post-implementation audits are an effective method in improvement of assessment, documentation and evidence-based nursing implementation for cancer symptom management.

General pain assessment among patients with cancer in an acute care setting

Aims This project sought to determine improve local practice in managing patients with cancer. It involved by: educating Registered Nurses on the importance of pain assessment, and ensuring this practice is done according to the current best available evidence and monitoring compliance with the audit criteria. Methods This project utilised a pre- and post-implementation audit strategy using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research Into Practice programs. It was implemented in three phases over a 6-month period, from September 2009 to February 2010. The audits utilised three out of 10 criteria recommended by The National Health Service Quality Improvement Scotland. The audits took place in a 24-bed oncology ward in a large acute care setting in Singapore involving a sample size of 24 patients and Registered Nurses. It involved going through the clinical charts and medical records of the cases, and educating Registered Nurses on pain assessment for patients with cancer. Results The post-implementation audit findings indicated a modest to significant improvement in all the three criteria: first, an improvement of 33% through using a pain assessment tool to assess pain in patients with cancer; second, a 75% increase in the number of Registered Nurses who received education on pain assessment; and third, a 46% increase in accuracy in the assessment and documentation of pain. Conclusion The project had shown that pre- and post-implementation audits represent a useful method for translating evidence into practice. The conduct of this project showed that achieving change in clinical practice was challenging. It also showed that positive audit results were achieved through the enthusiasm, commitment and dedication of every member of the project team, the use of champions who were involved in direct patient care and performance feedback.

General pain assessment among patients with cancer in an acute care setting: a best practice implementation project

This project sought to determine improve local practice in managing patients with cancer. It involved by: educating Registered Nurses on the importance of pain assessment, and ensuring this practice is done according to the current best available evidence and monitoring compliance with the audit criteria. This project utilised a pre- and post-implementation audit strategy using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research Into Practice programs. It was implemented in three phases over a 6-month period, from September 2009 to February 2010. The audits utilised three out of 10 criteria recommended by The National Health Service Quality Improvement Scotland. The audits took place in a 24-bed oncology ward in a large acute care setting in Singapore involving a sample size of 24 patients and Registered Nurses. It involved going through the clinical charts and medical records of the cases, and educating Registered Nurses on pain assessment for patients with cancer. The post-implementation audit findings indicated a modest to significant improvement in all the three criteria: first, an improvement of 33% through using a pain assessment tool to assess pain in patients with cancer; second, a 75% increase in the number of Registered Nurses who received education on pain assessment; and third, a 46% increase in accuracy in the assessment and documentation of pain. The project had shown that pre- and post-implementation audits represent a useful method for translating evidence into practice. The conduct of this project showed that achieving change in clinical practice was challenging. It also showed that positive audit results were achieved through the enthusiasm, commitment and dedication of every member of the project team, the use of champions who were involved in direct patient care and performance feedback.

Implementation of a glucose management protocol to prevent hypo- and hyperglycaemia in critically ill patients

Background Many healthcare providers acknowledge the importance of encouraging health professionals to base their practice on current evidence. There is a plethora of evidence supporting tight glucose control in critically ill patients to reduce mortality and morbidity and many studies have shown that hyperglycaemia in critically ill patients has been associated with an increased susceptibility to infection and impaired immune response. Methods This project aimed to improve current practice in the prevention and management of hypo- and hyperglycaemia in critically ill patients based on the best available evidence. The setting for the project was a large public hospital in Brisbane, Queensland, with an 11 bed tertiary referral intensive care unit (ICU) for critically ill adult patients. A pre-implementation audit using a set of evidence-based criteria from a systematic review on tight glucose control in critically ill patients was undertaken. The Joanna Briggs Institute on-line audit and feedback software, paces (Practical Application of Clinical Evidence System), was used to analyse the data to determine ICU's current compliance with established best practice in glucose management. These initial audit results were used to develop an action plan to improve glucose management practice within the unit. This included the development and implementation of a glucose management protocol, the identification of barriers and facilitators and education of clinical staff. Following the implementation of this protocol a post-implementation audit was conducted using the same criteria as in the initial audit. Results The post audit findings indicated improvement in most areas of glucose management practice within the ICU. Conclusion The success of this project is not only evident through improved ICU glucose management practice over 12 weeks, but also through clinicians gaining experience in the process of utilising evidence-based recommendations in all areas of practice.

Implementation of a glucose management protocol to prevent hypo- and hyperglycaemia in critically ill patients

Background Many healthcare providers acknowledge the importance of encouraging health professionals to base their practice on current evidence. There is a plethora of evidence supporting tight glucose control in critically ill patients to reduce mortality and morbidity and many studies have shown that hyperglycaemia in critically ill patients has been associated with an increased susceptibility to infection and impaired immune response. Methods This project aimed to improve current practice in the prevention and management of hypo- and hyperglycaemia in critically ill patients based on the best available evidence. The setting for the project was a large public hospital in Brisbane, Queensland, with an 11 bed tertiary referral intensive care unit (ICU) for critically ill adult patients. A pre-implementation audit using a set of evidence-based criteria from a systematic review on tight glucose control in critically ill patients was undertaken. The Joanna Briggs Institute on-line audit and feedback software, paces (Practical Application of Clinical Evidence System), was used to analyse the data to determine ICU's current compliance with established best practice in glucose management. These initial audit results were used to develop an action plan to improve glucose management practice within the unit. This included the development and implementation of a glucose management protocol, the identification of barriers and facilitators and education of clinical staff. Following the implementation of this protocol a post-implementation audit was conducted using the same criteria as in the initial audit. Results The post audit findings indicated improvement in most areas of glucose management practice within the ICU. Conclusion The success of this project is not only evident through improved ICU glucose management practice over 12 weeks, but also through clinicians gaining experience in the process of utilising evidence-based recommendations in all areas of practice.

Implementation of best practice in advance care planning in an ‘ageing in place’ aged care facility

Background For many older people, a residential aged care facility is home, a place where they should have the choice to die comfortably with a sense of control of care and treatment. An advance care plan describes the process of planning end-of-life care while a person is still able to make decisions with the aim of using this information should a person become unable to communicate their wishes. In the residential aged care setting, an advance care plan should be based on discussions involving the resident, family members and caregivers regarding the beliefs, values and goals of the resident and their family. It is not limited to the final days and weeks before dying, it can encompass a positive and open attitude towards death and dying. Aim The aim of this project was to examine the process of how residents' end-of-life care wishes is recorded and to ensure that the implementation of an advance care plan is performed according to the best available evidence. Method There were four stages to the project. The first stage involved interpretation of the five audit criteria. The criteria related to involving residents and their families in an advance care plan, providing them with appropriate information about end-of-life issues, and ensuring that staff are appropriately trained about an advance care plan. Next, the records of staff and resident were audited using JBI-PACES, the Joanna Briggs Institute's Practical Application of Clinical Evidence System. The next stage (Getting Research into Practice, GRIP) involved a process of situational analysis, action planning and action taking to improve compliance with best practice, followed by a post-implementation audit. Results Initially, compliance with an advance care plan best practice was fairly poor - less than 50% for each audit criterion. The GRIP phase highlighted seven barriers which were addressed during the implementation part of the project. These barriers included deficits related to the knowledge and education of residents, families and staff members, and issues related to administration and documentation, and concerns that any implementation process would not be sustainable. The post-implementation compliance was greater than 75% for each criterion. Conclusion The project highlights the ongoing challenges of educating residents and families, as well as staff on the importance of discussing/completing an advance care plan. Several improvements were made to the facility's documentation and records keeping processes, including the identification of resident's wishes regarding end-of-life treatment. Residents and their families expressed a high level of satisfaction with these changes. Indeed, an increase in completed advance care plans at the facility had a clear benefit in improving care for residents towards the end of their life.

Reducing and/or minimising physical restraint in a high care, rural aged care facility

Background This report takes you through a journey of implementing evidence-based best practice guidelines in relation to physical restraint in an aged care facility. It describes the processes involved in making changes to an existing system, introducing evidence-based guidelines and collaboratively achieving compliance with best practice. The project formed part of a combined initiative between the Joanna Briggs Institute and the Commonwealth Department of Health and Ageing, called the Aged Care Clinical Fellowship Program. The Joanna Briggs Institute Practical Application of Clinical Evidence System, an online audit-based tool that includes an action research process Getting Research Into Practice was used to facilitate audit data collection and analysis. This report demonstrates that effective clinical leadership and evidence-based research, combined with a strategy of audit, feedback and re-audit, can become an effective change agent to improve clinical practice in residential aged care facilities. Aims/objectives The aims of this project were to increase staff knowledge and awareness of restraints, improve practices in restraint assessment and usage, reduce or minimise the amount and type of restraints used and ensure the least restrictive device possible was utilised in a rural aged care facility. Methods A system of audit, feedback and re-audit was performed using the Joanna Briggs Institute Practical Application of Clinical Evidence System software. This was completed in a series of stages over a period of 6 months. The first stage was to apply defining characteristics to each of the evidence-based audit criteria to determine compliance. A team of staff was set up to assist with the project. An initial audit was conducted, followed by a situational analysis of the findings. From this an action plan for improvement using Getting Research Into Practice was developed. The action plan was then implemented and the criteria re-audited and reviewed. Results The initial audit confirmed non-compliance as expected in two criteria. All criteria showed improvement in the re-audit. Those criteria with the least compliance in the initial audit showed the most improvement in the re-audit. Conclusion Effective change processes can be achieved when there is an identified reason or need for change, and when staff are aware of that need. With clinical leadership and education attitudes, fears and myths can be dispelled and improved performance will come out.

Advance care planning for residents in aged care facilities: what is best practice and how can evidence-based guidelines be implemented?

Background Advance care planning in a residential care setting aims to assist residents to make decisions about future healthcare and to improve end-of-life care through medical and care staff knowing and respecting the wishes of the resident. The process enables individuals and others who are important to them, to reflect on what is important to the resident including their beliefs/values and preferences about care when they are dying. This paper describes a project conducted as part of the Joanna Briggs Institute Clinical Aged Care Fellowship Program implemented at the Manningham Centre in metropolitan Melbourne in a unit providing services for 46 low and high care residents. Objectives The objectives of the study were to document implementation of best practice in advance care planning in a residential aged care facility using a cycle of audit, feedback and re-audit cycle audit with a clinical audit software program, the Practical Application of Clinical Evidence System. The evidence-based guidelines found in 'Guidelines for a Palliative Approach in Residential Aged Care' were used to inform the process of clinical practice review and to develop a program to implement advance care planning. Results The pre-implementation audit results showed that advance care planning practice was not based on high level evidence as initial compliance with five audit criteria was 0%. The barriers to implementation that became apparent during the feedback stage included the challenge of creating a culture where advance care planning policy, protocols and guidelines could be implemented, and advance care planning discussions held, by adequately prepared health professionals and carers. Opportunities were made to equip the resident to discuss their wishes with family, friends and healthcare staff. Some residents made the decision to take steps to formally document those wishes and/or appoint a Medical Enduring Power of Attorney to act on behalf of the resident when they are unable to communicate wishes. The post-implementation audit showed a clear improvement as compliance ranged from 15-100% for the five audit criteria. Strong leadership by the project team was effective in engaging staff in this quality improvement program. Conclusion The outcomes of the project were extremely positive and demonstrate a genuine improvement in practice. All audit criteria indicate that the Manningham Centre is now positively working towards improved practice based on the best available evidence. It is hoped that as the expertise developed during this project is shared, other areas of gerontological practice will be similarly improved and more facilities caring for the older person will embrace evidence-based practice.

Maintaining oral hydration in older adults living in residential aged care facilities

Background The Clinical Fellowship program was developed to address the need for best practice in aged care and therefore improve outcomes for residents in Residential Aged Care. The project chosen for this program was Oral Hydration with the aim of improving the hydration status of Nursing Home residents and management of those at risk of dehydration. Method The clinical audit tool used was the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES). This tool allows measurement of current practice against best practice. The Getting Research into Practice program was then used to address non-compliance with best practice. This program requires consultation with key stakeholders to identify limitations to achieving best practice and plan action to address these limitations where possible. Conclusion While 100% compliance with all audit criteria was not achieved, strategies to improve current practice were identified and are in the process of being implemented. The tools developed by The JBI have been beneficial in identifying, measuring and implementing best practice. The process has the potential to contribute to improved resident outcomes and best practice in residential aged care through clinical audit and feedback.

Improving the oral health of older adults with dementia/cognitive impairment living in a residential aged care facility

Background Studies conducted in Residential Aged Care Facilities (RACFs) indicate that high levels of oral diseases and conditions are prevalent in older adults who have dementia. Poor oral health impacts on eating ability, weight, speech, hydration, severity of behavioural problems, appearance and social interactions. This study looked at a group of older adults with dementia in a RACF site in the northern suburbs of Adelaide, South Australia. It is known that in nursing home residents with dementia dental pain and problems are under-detected and under-treated. Strategy An audit was conducted to assess the level of compliance of the RACFs oral hygiene care practices with established best practice. The audit questions were based on current best practice as identified from a rigorous international systematic review of the subject. A clinical audit software program (The Joanna Briggs Institute, Practical Application of Clinical Evidence System (JBI PACES)) was used to manage the audit. An audit, feedback, re-audit cycle was followed. Stakeholders of the project were identified from which a Project team was formed. The Project team analysed the results of the first audit, conducted a situational analysis and formulated and implemented a strategic plan to target specific criteria for a change management process. Short-term and longer-term strategies were identified. Those criteria targeted as achievable in the short term were then re-audited after 6 weeks to determine the effectiveness of the change management process. Findings The criterion Daily cleaning and night-time removal of dentures are documented was re-audited and although there was a slight increase in compliance across the site this increase was not statistically significant. The criterion Resident's dentures are individually marked was re-audited and showed a large increase in compliance across the site, this increase was statistically significant.