Assignment: Recommending an Evidence-Based Practice Change
Assignment Recommending an Evidence-Based Practice Change
Evaluation Table
Use this document to complete the evaluation table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical Appraisal of Research
Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).**
The paper is based on the theory that increased intravascular volume can influence clinical and para-clinical aspects of patients. This could be possible because there is a mounting of the cardiac output when circulating volume are increased as a result of heightened preload. This can leaders to changes of patients’ clinical findings. The paper is based on the fact that both liberal fluids approach and restrictive fluids approach have shown their importance and limitations when administered to patients
with septic shock. The situation has made it difficult to discriminate the two interventions creating a clinical and scientific equipoise The paper asserts that it is not exactly known whether intravenous fluid
administration ameliorate or prevent injury despite being widely used in hospitals. This is because there is a limited understanding of the effects of the intravenous fluids
in the most vulnerable of patient groups.
The paper tend to theorize that anesthetists and postanesthesia nurses’ administration of intravenous (IV) fluid therapy during surgery and in the postanesthesia care unit might not be based on evidence
Design/Method
Describe the design and how the study was carried out (In detail, including inclusion/exclusion criteria). The study was conducted on trauma patient of Shahid Rajaei Hospital, Shiraz, Iran, during 2010-201. Only 84 of these patients remained for the study after excluding patients
younger than 16 and older than 60 years old, pregnant women, diabetic patients, those receiving blood transfusion, patients suffered from hepatic or cardiac failure, and subjects with coagulation abnormalities. The revised trauma score (RTS) was used to estimate injury severity of patients at a scale of 4 (mild=4). Patient examination was done by a general surgery resident where metabolic and coagulation markers such as complete
blood count (CBC), BUN, Sodium (Na), Potassium (K), venous blood gas (VBG), international normalized ratio (INR), prothrombin time (PT), and partial thromboplastin time (PTT) were checked and entered to designed
data form. Measurement and calculation clinical values such heart rate, blood pressure and respiratory rate then followed. One litter normal saline was then infused to
patients and the parameters checked after one hour and again after 6 hours. Then, the values of mentioned parameters were compared with baseline measures using repeated measures analysis of variance.
The authors first did a thorough literature reviews on studies on the two innervations – a liberal fluids approach that relies on a larger volume of initial IVF administration [often 50 – 75 ml/kg (4–6 liters in an
80 kg adult)]; and (2) a restrictive fluids approach consisting of a smaller volume of initial
IVF [often ≤30 ml/kg (≤2–3 liters)] and earlier use of vasopressors and compared the results obtain with an attempt of evaluating the better strategy. Thereafter, they developed a proposal called the
Crystalloid Liberal Or Vasopressor Early Resuscitation in Sepsis (COVER) which is a randomized clinical trial designed to compare two strategies. The paper is a mass up of may peer reviewed articles. The authors have done extensive literature review of these paper with regards to various aspects of intravenous fluid administration. The criteria used in the literature review and the exact number of articles reviewed have not been indicated. Generation, the paper does not capture methodology and sampling. In the study, two cohorts were chosen – Cohort 1 (n = 126) and cohort 2 (n = 130). This group member was randomly selected from patients in the hospital. A validating list was developed to help nurses to record data on the type and volume of fluid therapy. Analysis was done by comparing the frequency of given indication reasons for each IV fluid by surgical type.
Sample/Setting
The number and characteristics of
patients, attrition rate, etc. Trauma patients of Shahid Rajaei Hospital, Shiraz, Iran, during 2010-201 were chosen for the study. Among these those who were younger than 16 and older than 60 years old, pregnant women, diabetic patients, those receiving blood transfusion, patients suffered from hepatic or cardiac failure,
and subjects with coagulation abnormalities were excluded. This only left 84 patients eligible for the study.
No specific sampling method was used or proposed in the proposal. This is because it was a literature review. Still, there are not specific details on the number of papers reviewed or the criteria used to select the articles. No specific sampling method was used or proposed in the proposal. There is also no mentioning of the criteria used to sample the papers or their number. There was two samples Cohort 1 (n = 126) and cohort 2 (n = 130). These were patient from various hospitals
Major Variables Studied
List and define dependent and independent variables In this study, the independent variable was the infusion of one litter normal saline to
patients. The dependent variable was the effects it had on metabolic and coagulation markers such as complete
blood count (CBC), BUN, Sodium (Na), Potassium (K), venous blood gas (VBG), international normalized ratio (INR), prothrombin time (PT), and partial thromboplastin time (PTT) The paper was comparing the evidences of the effectiveness of either liberal fluids approach or restrictive fluids approach comparing the number of papers support either of the intervention and the reliability and integrity. The paper has touched on many aspects of intravenous fluid administration, thereby making hard to discern the dependent and independent variable in the paper. However, the paper creates emphasis on the ubiquity and the unknown impacts of the intravenous fluid administration to various patients. The independent variable was the indications of IV fluid needed for all surgeries. The dependent variable were the volume of intraoperative crystalloid fluids and volumes of both colloid and crystalloid fluids
Measurement
Identify primary statistics used to answer clinical questions (You need to list the actual tests done). Both SPSS statistical software version 18.0 was used in data analysis and analysis of variances (ANOVA) to compare the clinical and biochemical values of patients at one and six hours after fluid therapy with base line Neither the article nor the proposal within record any data collection method. The article records no data collection method. SPSS statistical software version 18.0 was used in data analysis
Data Analysis Statistical or
Qualitative findings
(You need to enter the actual numbers determined by the statistical tests or qualitative data). The results were; Hemoglobin (Hb) (df: 2; F=32.7; p<0.001), hematocrit (Hct) (df: 2; F=30.7; p<0.001), white blood cells (WBC) (df:
2; F=10.6; p<0.001), and platelet count (df: 2; F=4.5; p=0.01) showed the decreasing pattern following infusion of
one liter of normal saline. Coagulation markers were not affected during the time of study (p>0.05). The values of blood urea nitrogen (BUN) showed statistically significant decreasing pattern (df: 2; F=5.6; p=0.007). Pressure of carbon dioxide (PCO2) (df: 2; F=6.4; p=0.002), bicarbonate (HCO3) (df: 2; F=7.0; p=0.001), and base excess (BE) (df: 2; F=3.3; p=0.04) values showed a significant deteriorating changes following hydration therapy.
None The article records no data analysis method The volume of intraoperative crystalloid fluids was statistically different for patients with hip fracture surgery in cohort 2. Volumes of both colloid and crystalloid fluids were significantly higher for high-risk abdominal surgery in cohort 2.
Findings and Recommendations
General findings and recommendations of the research The study revealed that the pattern of BE, PCO2, and HCO3 following infusion
of one liter normal saline are worsening. As such the paper recommends monitoring and assessment of the changes in these values in patients with more severe injuries. The optimal dosing for IVF and timing for vasopressors are unknown. Literatures reveals that large volume fluid boluses of 4–5 L within the first 6 hours of treatment are more common that the earlier vasopressors
and less IVF during initial resuscitation for septic shock. Additionally, the literature also reports a highlighted potential
adverse effects from rapid, large-volume fluid boluses. The paper, therefore, recommends a shift towards earlier vasopressors and less IVF during initial resuscitation for improved outcome though there is no evidence to support the recommendation. As such, the researchers are loaning to execute the CLOVERS trial to generate empirical conclusion. The use of intravenous fluid as a foundational medical intervention is very complex. The understanding of its effects on the
most vulnerable of
patient groups is still not good despite being ubiquitous. Countless number of people are exposed to it on a daily basis worldwide. Those who use it for maintenance, haemodynamic optimization, and as a vehicle for drug administration can go up to millions daily. The use of the fluids give various results at different time, people, and places. The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines. Consequently, the paper recommends need of a stronger intervention to change practice to follow evidence-based clinical guidelines.
Appraisal and Study Quality
Describe the general worth of this research to practice.
What are the strengths and limitations of study?
What are the risks associated with implementation of the suggested practices or processes detailed in the research?
What is the feasibility of use in your practice? The paper has helped in providing empirical evidence that infusion of one liter normal saline causes a significant decrease in Hb, Hct, WBC, platelet, BUN, BE, HCO3, and
PCO2 in trauma patients with mild severity of injury and stable condition. However, it has not touched directly on the affects the intervention might have on severe traumas. Therefore, implementation of the intervention comes at the risk of not knowing the exact risk it might have on patients with severe traumas. But generally, the intervention is feasible due to the availability, easy accessibility and easy administration of normal saline. The paper established the clinical and scientific equipoise surrounding the use of liberal fluids approach and restrictive fluids approach administered to patients
with septic shock. This is becaiuse they both have their importance and limitations. The study have chosen the restrictive fluids approach as a better move though with no practical evidence. Therefore choosing one over the other come with risk of unverified
impacts or forgoing the better impacts that the abandoned option may offer. Generally, the interventions have been used for sometimes proving that they are feasible. The paper unravel the complexities that surround the use of intravenous fluids. The paper gives no specific findings with regards to the administration of intravenous fluids as there is a lot on inconsistency with the outcomes. Therefore the use of this strategies is unclothed with so much uncertainties. However, it is feasible since it is an intervention which very common and used by millions of people on a daily basis. The paper provide important information on administration of intravenous (IV) fluid therapy during surgery. The finding enlightens doctors not to administer fluids for patients with high-risk abdominal surgery and hip fracture patients
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The infusion of normal saline significantly affect Hb, Hct, WBC, platelet, BUN, BE, HCO3, and
PCO2 in trauma patients with mild severity of injury and stable condition The optimal dosing for IVF and timing for vasopressors are unknown. The use of intravenous fluid as a foundational medical intervention is very complex. The understanding of its effects on the
most vulnerable of
patient groups is still not well understood despite being ubiquitous Nurse anesthetists and nurses in the postanesthesia care unit rely more on basic static parameters than signing of inadequate tissue perfusion when they make decisions about fluid administration.
Outcomes
The infusion of one liter normal saline caused a significant decrease in Hb, Hct, WBC, platelet, BUN, BE, HCO3, and
PCO2 in trauma patients with mild severity of injury and stable condition Literatures reveals that large volume fluid boluses of 4–5 L within the first 6 hours of treatment are more common that the earlier vasopressors
and less IVF during initial resuscitation for septic shock. Additionally, the literature also reports a highlighted potential
adverse effects from rapid, large-volume fluid boluses The independent effects of fluid administration and fluid accumulation goes hand in hand with other markers of illness severity and aspects of the process of care. Fluid accumulation can result in organ injury, even when the fluid is being given to ameliorate or prevent such injury The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines
General Notes/Comments The paper show high level accuracy and professionalism in terms of data collection and analysis. The intervention is seeming simply, the finding can go a long in shaping the approaches traumas treatment. In an attempt to shed some light into the dilemmatic situation of the two treatments, the paper has just complication it further. This is because it has not just provided the evidence that the confusion is valid, but is also observed in empirical studies. The authors have done an exhaustive review of the literature. Their findings give a strong standing to the fact that the use and impacts of intravenous fluid administration is complex.
*These levels are from the Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide
Part 4B: Critical Appraisal of Research
For this assignment utilizing the Critical Appraisal Tool Worksheet Template was an exhalent way to identify the main points of peer-reviewed research for my area of interest. Finding the efficacy of aggressive intravenous fluid therapy on patients’ health. The observation from the research, aggressive IV fluid therapy in inpatient units; IVF is aimed at promoting hemodynamic stability & renal function; Effects on organ dysfunction- heart, kidney. The formulated PICOT question is; “Among critically ill patients, does the use of liberal IV fluid therapy, compared to restrictive IV fluid therapy result in more adverse events within a period of six months” The articles that are in the Critical Appraisal Template demonstrate both qualitative and quantitative, practice guidelines, and meta-analyses/syntheses are representative of the potential efficacy of the effect of aggressive intravenous fluid therapy on patients. Evidence-based practice depends on internal and external evidence. The implementation of evidence-based practice regarding aggressive intravenous fluid therapy is more detailed and the research is aiding in preventing weight gain, poor disease prognosis, and mortality among hospital patients, but adds more parameters to consider the deeper the research. Therefore, the support for this intervention is moderate. In general, intravenous fluid therapy on patients’ health outcome is yet to be more understood and needs more research due to the added details on different types of patients receiving IVF. The authors have done an exhaustive review of the literature. Their findings give a strong standing to the fact that the use and impacts of intravenous fluid administration is complex (Bunkenborg, Nørholm, & Foss (2019).
A study by Baumgarten et al., (2019) highlights Nurses do not follow set guidelines and use basic static parameters instead of signs of inadequate perfusion. Fluid therapies follow liberal and restrictive approaches. Increased fluid causes edema that impairs oxygen delivery and causes organ dysfunction (Self et al., 2018). The use of intravenous fluid as a foundational medical intervention is very complex. The understanding of its effects on the most vulnerable of patient groups is still not well understood despite being ubiquitous (Glassford & Bellomo, 2016). Thus, based on the hierarchy of evidence from research article appraisal, (Level I, II, and III); it does not supports the use of abundant IV fluid therapy, compared to restrictive IV fluid therapy for majority of in hospital patients depending on that patients situations and how they became ill. However, for effective implementation for liberal use of this practice this would entail certain parameters be determined by the organizational, individual and community level with the idea that more research analysis will be done for this type of practice.
Assignment: Evidence-Based Project, Part 5: Recommending an Evidence-Based Practice Change
The collection of evidence is an activity that occurs with an endgame in mind. For example, law enforcement professionals collect evidence to support a decision to charge those accused of criminal activity. Similarly, evidence-based healthcare practitioners collect evidence to support decisions in pursuit of specific healthcare outcomes.
In this Assignment, you will identify an issue or opportunity for change within your healthcare organization and propose an idea for a change in practice supported by an EBP approach.
To Prepare:
Reflect on the four peer-reviewed articles you critically appraised in Module 4.
Reflect on your current healthcare organization and think about potential opportunities for evidence-based change.
The Assignment: (Evidence-Based Project)
Part 5: Recommending an Evidence-Based Practice Change
Create an 8- to 9-slide PowerPoint presentation in which you do the following:
Briefly describe your healthcare organization, including its culture and readiness for change. (You may opt to keep various elements of this anonymous, such as your company name.)
Describe the current problem or opportunity for change. Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.
Propose an evidence-based idea for a change in practice using an EBP approach to decision making. Note that you may find further research needs to be conducted if sufficient evidence is not discovered.
Describe your plan for knowledge transfer of this change, including knowledge creation, dissemination, and organizational adoption and implementation.
Describe the measurable outcomes you hope to achieve with the implementation of this evidence-based change.
Be sure to provide APA citations of the supporting evidence-based peer reviewed articles you selected to support your thinking.
Add a lessons learned section that includes the following:
A summary of the critical appraisal of the peer-reviewed articles you previously submitted
An explanation about what you learned from completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template (1-3 slides)