EBP 4
Herealshi
CriticalApprasalpart3.pdf
By Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP,
FNAP, FAAN, Susan B. Stillwell, DNP, RN, CNE, and Kathleen M.
Williamson, PhD, RN
In September’s evidence- based practice (EBP) article, Rebecca R., our hypotheti cal staff nurse, Carlos A., her hospi- tal’s expert EBP mentor, and Chen M., Rebecca’s nurse colleague, ra- pidly critically appraised the 15 articles they found to answer their clinical question—“In hospital- ized adults (P), how does a rapid response team (I) compared with no rapid response team (C) affect the number of cardiac arrests (O) and unplanned admissions to the ICU (O) during a three-month period (T)?”—and determined that they were all “keepers.” The team now begins the process of evaluation and syn thesis of the articles to see what the evidence says about initiating a rapid re- sponse team (RRT) in their hos- pital. Carlos reminds them that evaluation and synthesis are syn- ergistic processes and don’t neces- sarily happen one after the other. Nevertheless, to help them learn, he will guide them through the EBP process one step at a time.
STARTING THE EVALUATION Rebecca, Carlos, and Chen begin to work with the evaluation table
they created earlier in this process when they found and filled in the essential elements of the 15 stud- ies and projects (see “Critical Ap - praisal of the Evidence: Part I,” July). Now each takes a stack of the “keeper” studies and system- atically begins adding to the table any remaining data that best re - flect the study elements pertain- ing to the group’s clinical question (see Table 1; for the entire table with all 15 articles, go to http:// links.lww.com/AJN/A17). They had agreed that a “Notes” sec- tion within the “Appraisal: Worth to Practice” column would be a good place to record the nuances
of an article, their impressions of it, as well as any tips—such as what worked in calling an RRT— that could be used later when they write up their ideas for ini- tiating an RRT at their hospital, if the evidence points in that direc- tion. Chen remarks that al though she thought their ini tial table con- tained a lot of information, this final version is more thorough by far. She appreciates the opportu- nity to go back and confirm her original understanding of the study essentials.
The team members discuss the evolving patterns as they complete the table. The three systematic
Critical Appraisal of the Evidence: Part III The process of synthesis: seeing similarities and differences across the body of evidence.
This is the seventh article in a series from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician exper- tise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.
The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we’ve scheduled “Chat with the Authors” calls every few months to provide a direct line to the experts to help you resolve questions. See details below.
Need Help with Evidence-Based Practice? Chat with the Authors on November 16!
On November 16 at 3 PM EST, join the “Chat with the Au -thors” call. It’s your chance to get personal consultation from the experts! Dial-in early! U.S. and Canada, dial 1-800-947-5134 (International, dial 001-574-941-6964). When prompted, enter code 121028#.
Go to www.ajnonline.com and click on “Podcasts” and then on “Conversations” to listen to our interview with Ellen Fineout- Overholt and Bernadette Mazurek Melnyk.
[email protected] AJN ▼ November 2010 ▼ Vol. 110, No. 11 43
44 AJN ▼ November 2010 ▼ Vol. 110, No. 11 ajnonline.com
Ta bl
e 1.
F in
al E
va lu
at io
n Ta
bl e
Fi rs
t A ut
ho r
(Y ea
r) Co
nc ep
tu al
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am ew
or k
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aj or
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ie d
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ei r
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in iti
on s)
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su re
m en
t D
at a
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ly si
s Fi
nd in
gs A
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th to
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n PS
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l. A
rc h
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rn M
ed
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6
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rp os
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nl y
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2)
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on tro
l gr
ou p
or
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ro l p
er io
d an
d 3)
h os
pi ta
l m
or ta
lit y
w el
l de
sc rib
ed a
s ou
tc om
e •
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ud ed
5
stu di
es th
at m
et
cr ite
ria d
ue to
no
re sp
on se
to
e- m
ai l b
y pr
im ar
y au
th or
s
N =
1 8
ou t o
f 14
3 po
te nt
ia l
stu di
es
Se tti
ng : a
cu te
ca
re h
os pi
ta ls;
13
a du
lt, 5
p ed
s
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ra ge
n o.
be
ds : N
R
A ttr
iti on
: N R
IV : R
RT
D V1
: H M
R (in
cl ud
in g
D N
R,
ex cl
ud in
g D
N R,
no
t t re
at ed
in
IC U
, n o
H M
R de
fin iti
on )
D V2
: C R
RR T:
w as
th e
M D
in vo
lv ed
?
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R: o
ve ra
ll ho
sp ita
l d ea
th s
(s ee
d ef
in iti
on )
C R:
c ar
di o
an d/
or p
ul m
o -
na ry
a rr
es t;
ca rd
ia c
ar re
st
ca lls
• Fr
e -
qu en
cy •
Re la
tiv e
ris k
13 /1
6 stu
di es
re
po rti
ng te
am
str uc
tu re
7/ 11
a du
lt an
d 4/
5 pe
ds
stu di
es h
ad s
ig -
ni fic
an t r
ed uc
- tio
n in
C R
C R:
• In
a du
lts ,
21 %
–4 8%
re
du ct
io n
in
C R;
R R
0. 66
(9
5% C
I, 0.
54 –0
.8 0)
• In
p ed
s, 3
8%
re du
ct io
n in
C
R; R
R 0.
62
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C I,
0. 46
–0 .8
4)
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R: •
In a
du lts
, H
M R
RR
0. 96
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C
I, 0.
84 –
1 .0
9)
• In
p ed
s,
H M
R RR
0.
79 (9
5%
C I,
0. 63
– 0
.9 8)
W ea
kn es
se s:
• Po
te nt
ia l m
is se
d ev
i- de
nc e
w ith
e xc
lu si on
of
a ll
stu di
es e
xc ep
t th
os e
w ith
c on
tro l
gr ou
ps •
G re
y lit
er at
ur e
se ar
ch
lim ite
d to
m ed
ic al
m ee
t- in
gs •
O nl
y in
cl ud
ed H
M R
an d
C R
ou tc
om es
•
N o
co st
da ta
St re
ng th
s: •
Id en
tif ie
d no
. o f a
ct iv
a- tio
ns o
f R RT
/1 ,0
00
ad m
is si on
s •
Id en
tif ie
d va
ria nc
e in
o ut
co m
e de
fin iti
on
an d
m ea
s u re
m en
t ( fo
r ex
am pl
e, 1
0 of
1 5
stu d-
ie s
in cl
ud ed
d ea
th s
fro m
D
N Rs
in th
ei r m
or ta
lit y
m ea
su re
m en
t)
C on
cl us
io n:
•
RR T
re du
ce s
C R
in
ad ul
ts, a
nd C
R an
d H
M R
in p
ed s
Fe as
ib ili
ty :
• RR
T is
re as
on ab
le to
im
pl em
en t;
ev al
ua tin
g co
st w
ill h
el p
in m
ak in
g de
ci si on
s ab
ou t u
si ng
RR
T •
Ri sk
/B en
ef it
(h ar
m ):
be ne
fit s
ou tw
ei gh
ri sk
s
[email protected] AJN ▼ November 2010 ▼ Vol. 110, No. 11 45
M cG
au gh
ey J,
et
a l.
C oc
hr an
e D
at ab
as e
Sy st
Re v
20 07
;3 :
C D
00 55
29
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(C oc
hr an
e re
vi ew
)
Pu rp
os e:
e ffe
ct o
f RR
T on
H M
R •
Se ar
ch ed
6
da ta
ba se
s fro
m
19 90
–2 00
6 •
Ex cl
ud ed
a ll
bu t
2 RC
Ts
N =
2 s
tu di
es
A cu
te c
ar e
se t-
tin gs
in A
us tra
lia
an d
th e
U K
A ttr
iti on
: N R
IV : R
RT
D V1
: H M
R H
M R:
A us
tra lia
: ov
er al
l h os
pi ta
l m
or ta
lit y
w ith
- ou
t D N
R
U K:
S im
pl ifi
ed
A cu
te P
hy si ol
- og
y Sc
or e
(S A
PS ) I
I de
at h
pr ob
ab il-
ity e
sti m
at e
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O R
of A
us -
tra lia
n stu
dy ,
0. 98
(9 5%
C I,
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–1 .1
6)
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of U
K stu
dy ,
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(9 5%
C I,
0. 32
–0 .8
5)
W ea
kn es
se s:
• D
id n’
t i nc
lu de
fu ll
bo dy
of
e vi
de nc
e •
C on
fli ct
in g
re su
lts o
f re
ta in
ed s
tu di
es , b
ut n
o di
sc us
si on
o f t
he im
pa ct
of
lo w
er -le
ve l e
vi de
nc e
• Re
co m
m en
da tio
n “n
ee d
m or
e re
se ar
ch ”
C on
cl us
io n:
•
In co
nc lu
si ve
W in
te rs
B D
, et
a l.
C rit
C
ar e
M ed
20
07 ;3
5( 5)
: 12
38 -4
3
N on
e SR Pu
rp os
e: e
ffe ct
o f
RR T
on H
M R
an d
C R
• Se
ar ch
ed 3
da
ta ba
se s
fro m
19
90 –2
00 5
• In
cl ud
ed o
nl y
stu di
es w
ith a
co
nt ro
l g ro
up
N =
8 s
tu di
es
A ve
ra ge
n o.
be
ds : 5
00
A ttr
iti on
: N R
IV : R
RT D
V1 : H
M R
D V2
: C R
H M
R: o
ve ra
ll de
at h
ra te
C R:
n o.
o f i
n- ho
sp ita
l a rr
es ts
Ri sk
ra tio
H M
R: •
O bs
er va
- tio
na l s
tu di
es ,
ris k
ra tio
fo r
RR T
on H
M R,
0.
87 (9
5%
C I,
0. 73
– 1.
04 )
• C
lu ste
r R C
Ts ,
ris k
ra tio
fo r
RR T
on H
M R,
0.
76 (9
5%
C I,
0. 39
– 1.
48 )
C R:
• O
bs er
va -
tio na
l s tu
di es
, ris
k ra
tio fo
r RR
T on
C R,
0.
70 (9
5%
C I,
0. 56
– 0.
92 )
• C
lu ste
r R C
Ts ,
ris k
ra tio
fo r
RR T
on C
R,
0. 94
(9 5%
C
I, 0.
79 –
1. 13
)
St re
ng th
s: •
Pr ov
id es
c om
pa ris
on
ac ro
ss s
tu di
es fo
r S
tu dy
le ng
th s
(ra ng
e,
4 –8
2 m
on th
s) Sa
m pl
e si ze
(r an
ge ,
2, 18
3– 19
9, 02
4)
C
rit er
ia fo
r R RT
in iti
a- tio
n (c
om m
on : r
es pi
ra -
to ry
ra te
, h ea
rt ra
te ,
bl oo
d pr
es su
re , m
en ta
l sta
tu s
ch an
ge ; n
ot a
ll stu
di es
, b ut
n ot
ew or
- th
y: o
xy ge
n sa
tu ra
tio n,
“w
or ry
”) •
In cl
ud es
id ea
s ab
ou t
fu tu
re e
vi de
nc e
ge n-
er at
io n
(c on
du ct
in g
re se
ar ch
)— fin
di ng
o ut
w
ha t w
e do
n’ t k
no w
C on
cl us
io n:
•
So m
e su
pp or
t f or
R RT
, bu
t n ot
re lia
bl e
en ou
gh
to re
co m
m en
d as
s ta
n- da
rd o
f c ar
e
C I =
c on
fid en
ce in
te rv
al ; C
R =
ca rd
io pu
lm on
ar y
ar re
st o
r co
de r at
es ; D
N R
= do
n ot
r es
us ci
ta te
; D V =
d ep
en de
nt v
ar ia
bl e;
H M
R =
ho sp
ita l-w
id e
m or
ta lit
y ra
te s;
IC U
= in
te ns
iv e
ca re
un
it; IV
= in
de pe
nd en
t v ar
ia bl
e; M
D =
m ed
ic al
d oc
to r; N
R =
no t r
ep or
te d;
O R
= od
ds r at
io ; P
ed s
= pe
di at
ric s;
R C
T =
ra nd
om iz
ed c
on tro
lle d
tri al
; R R
= re
la tiv
e ris
k; R
RT =
r ap
id
re sp
on se
te am
; S R
= sy
st em
at ic
r ev
ie w
; U K
= U
ni te
d Ki
ng do
m
46 AJN ▼ November 2010 ▼ Vol. 110, No. 11 ajnonline.com
as well as a good num ber of jour- nals have encouraged their use. When they review the actual guidelines, the team notices that they seem to be fo cused on re- search; for example, they require a research question and refer to
the study of an intervention, whereas EBP projects have PICOT questions and apply evidence to practice. The team discusses that these guidelines can be confusing to the clinicians au thoring the re- ports on their proj ects. In addition, they note that there’s no mention of the syn thesis of the body of evidence that should drive an evidence-based project. While the SQUIRE Guidelines are a step in the right direction for the future, Carlos, Rebecca, and Chen con- clude that, for now, they’ll need to learn to read these studies as they find them—looking care- fully for the details that inform their clinical question.
Once the data have been en- tered into the table, Carlos sug- gests that they take each column, one by one, and note the similari- ties and differences across the studies and projects. After they’ve briefly looked over the columns, he asks the team which ones they think they should focus on to an- swer their question. Re becca and Chen choose “Design/ Method,” “Sample/Setting,” “Findings,” and “Appraisal: Worth to Practice” (see Table 1) as the ini tial ones to consider. Carlos agrees that these are the columns in which they’re most likely to find the most pertinent information for their syn thesis.
Chen in their efforts to appraise the MERIT study and comments on how well they’re putting the pieces of the evidence puzzle to- gether. The nurses are excited that they’re able to use their new knowledge to shed light on the
study. They discuss with Carlos how the interpretation of the MERIT study has perhaps con- tributed to a misunderstanding of the impact of RRTs.
Comparing the evidence. As the team enters the lower-level evi- dence into the evaluation table, they note that it’s challenging to compare the project reports with studies that have clearly described methodology, measurement, anal - ysis, and findings. Chen remarks that she wishes researchers and clinicians would write study and project reports similarly. Although each of the studies has a process or method determining how it was conducted, as well as how out- comes were measured, data were analyzed, and results interpreted, comparing the studies as they’re currently written adds an other layer of complexity to the eval- uation. Carlos says that while it would be great to have studies and projects written in a similar for- mat so they’re easier to compare, that’s unlikely to happen. But he tells the team not to lose all hope, as a format has been de veloped for re porting quality improve- ment initiatives called the SQUIRE Guidelines; however, they aren’t ideal. The team looks up the guide- lines online (www.squire-statement. org) and finds that the In stitute for Healthcare Improve ment (IHI)
reviews, which are higher-level evidence, seem to have an inher- ent bias in that they included only studies with control groups. In general, these studies weren’t in favor of initiating an RRT. Carlos asks Rebecca and Chen whether,
now that they’ve appraised all the evidence about RRTs, they’re con - fident in their decision to include all the studies and projects (in - cluding the lower-level evidence) among the “keepers.” The nurses reply with an emphatic affirma- tive! They tell Carlos that the pro j - ects and descriptive studies were what brought the issue to life for them. They realize that the higher- level evidence is somewhat in conflict with the lower-level evi- dence, but they’re most interested in the conclusions that can be drawn from considering the entire body of evidence.
Rebecca and Chen admit they have issues with the systematic reviews, all of which include the MERIT study.1-4 In particular, they discuss how the authors of the systematic reviews made sure to report the MERIT study’s finding that the RRT had no effect, but didn’t emphasize the MERIT study authors’ discussion about how their study methods may have influenced the reliability of the findings (for more, see “Critical Appraisal of the Evi dence: Part II,” Septem ber). Carlos says that this is an excellent observation. He also reminds the team that clinicians may read a systematic review for the conclusion and never consider the original stud- ies. He encourages Rebecca and
It’s not the number of studies or projects that determines
the reliability of their findings, but the uniformity and
quality of their methods.
[email protected] AJN ▼ November 2010 ▼ Vol. 110, No. 11 47
SYNTHESIZING: MAKING DECISIONS BASED ON THE EVIDENCE Design/Method. The team starts with the “Design/Method” column because Carlos reminds them that it’s important to note each study’s level of evidence. He suggests that they take this information and create a synthesis table (one in which data is extracted from the evaluation table to better see the similarities and differences bet ween studies) (see Table 21-15). The synthesis table makes it clear that there is less higher-level and more lower-level evidence, which will impact the reliability of the overall findings. As the team noted, the higher-level evidence is not without meth odological issues, which will increase the challenge of coming to a conclusion about
the impact of an RRT on the out - comes.
Sample/Setting. In reviewing the “Sample/Setting” column, the group notes that the number of hospital beds ranged from 218 to 662 across the studies. There were several types of hospitals represented (4 teaching, 4 com- munity, 4 no mention, 2 acute care hospitals, and 1 public hos- pital). The evidence they’ve col- lected seems applicable, since their hospital is a community hos pital.
Findings. To help the team better discuss the evidence, Car- los suggests that they refer to all pro j ects or studies as “the body of evidence.” They don’t want to get confused by calling them all studies, as they aren’t, but at the
same time continually referring to “stud ies and projects” is cum- bersome. He goes on to say that, as part of the synthesis process, it’s impor tant for the group to determine the overall impact of the intervention across the body of evi dence. He helps them create a second synthesis table contain- ing the findings of each study or pro ject (see Table 31-15). As they look over the results, Rebecca and Chen note that RRTs reduce code rates, par ti cularly outside the ICU, whereas unplanned ICU admissions (UICUA) don’t seem to be as affected by them. How ever, 10 of the 15 studies and projects reviewed didn’t ev aluate this outcome, so it may not be fair to write it off just yet.
Table 2: The 15 Studies: Levels and Types of Evidence
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Level I: Systematic review or meta-analysis
X X X
Level II: Randomized con- trolled trial
X
Level III: Controlled trial without randomization
Level IV: Case-control or cohort study
X X
Level V: Systematic review of qualitative or descrip- tive studies
Level VI: Qualitative or descriptive study (includes evidence implementation projects)
X X X X X X X X X
Level VII: Expert opinion or consensus
Adapted with permission from Melnyk BM, Fineout-Overholt E, editors. Evidence-based practice in nursing and healthcare: a guide to best practice. 2nd ed. Philadelphia: Wolters Kluwer Health / Lippincott Williams and Wilkins; 2010.
1 = Chan PS, et al. (2010); 2 = McGaughey J, et al.; 3 = Winters BD, et al.; 4 = Hillman K, et al.; 5 = Sharek PJ, et al.; 6 = Chan PS, et al. (2009); 7 = DeVita MA, et al.; 8 = Mailey J, et al.; 9 = Dacey MJ, et al.; 10 = McFarlan SJ, Hensley S.; 11 = Offner PJ, et al.; 12 = Bertaut Y, et al.; 13 = Benson L, et al.; 14 = Hatler C, et al.; 15 = Bader MK, et al.
hav ing level- VI evidence, a study and a project, had statistically significant (less likely to occur by chance, P < 0.05) reductions in HMR, which in creases the reli- ability of the results.
Chen asks, since four level-VI reports documented that an RRT reduces HMR, should they put more confidence in findings that occur more than once? Carlos re- plies that it’s not the number of studies or projects that determines the re liability of their findings, but the uniformity and quality of their methods. He recites something he heard in his Expert EBP Mentor program that helped to clarify the concept of making decisions based on the evidence: the level of the evidence (the design) plus the quality of the evidence (the validity of the methods) equals the strength of the evidence, which is
what leads clinicians to act in con - fidence and apply the evidence (or not) to their practice and expect similar findings (outcomes). In terms of making a decision about whether or not to initiate an RRT, Carlos says that their evidence stacks up: first, the MERIT study’s results are questionable because of problems with the study meth- ods, and this affects the reliability of the three systematic reviews as well as the MERIT study it self; second, the reasonably conducted lower-level studies/projects, with their statistically significant find- ings, are persuasive. Therefore, the team begins to consider the possibility that initiating an RRT may re duce code rates outside the ICU (CRO) and may impact non- ICU mor tality; both are outcomes they would like to address. The evidence doesn’t provide equally
The EBP team can tell from reading the evidence that research - ers consider the impact of an RRT on hospital-wide mortality rates (HMR) as the more important outcome; however, the group re - mains unconvinced that this out- come is the best for evaluating the purpose of an RRT, which, according to the IHI, is early in - tervention in patients who are unstable or at risk for cardiac or respiratory arrest.16 That said, of the 11 studies and projects that evaluated mortality, more than half found that an RRT reduced it. Carlos reminds the group that four of those six articles are level-VI evidence and that some weren’t research. The findings produced at this level of evidence are typi- cally less reliable than those at higher levels of evidence; how- ever, Carlos notes that two articles
48 AJN ▼ November 2010 ▼ Vol. 110, No. 11 ajnonline.com
Table 3: Effect of the Rapid Response Team on Outcomes
1a 2a 3a 4a 5a 6a 7 8 9 10 11 12 13 14 15
HMR adult b
peds
b NE c b NR NE c NE b, d
CRO NE NE NE NE c b NE NE b c b c NE c c
CR b
peds and adult
NE b NE b c NE NE NE NE b NE NE
UICUA NE NE NE NE NE NE NE b c NE NE NE b
1 = Chan PS, et al. (2010); 2 = McGaughey J, et al.; 3 = Winters BD, et al.; 4 = Hillman K, et al.; 5 = Sharek PJ, et al.; 6 = Chan PS, et al. (2009); 7 = DeVita MA, et al.; 8 = Mailey J, et al.; 9 = Dacey MJ, et al.; 10 = McFarlan SJ, Hensley S.; 11 = Offner PJ, et al.; 12 = Bertaut Y, et al.; 13 = Benson L, et al.; 14 = Hatler C, et al.; 15 = Bader MK, et al.
CR = cardiopulmonary arrest or code rates; CRO = code rates outside the ICU; HMR = hospital-wide mortality rates; NE = not evaluated; NR = not reported; UICUA = unplanned ICU admissions a higher-level evidence; b statistically significant findings; c statistical significance not reported; d non-ICU mortality was reduced
[email protected] AJN ▼ November 2010 ▼ Vol. 110, No. 11 49
the important outcomes to mea- sure are: CRO, non-ICU mortality (excluding patients with do not resuscitate [DNR] orders), UICUA, and cost.
Appraisal: Worth to Practice. As the team discusses their syn- thesis and the decision they’ll make based on the evidence,
data in the “Findings” column that shows a financial return on in vestment for an RRT.9 Carlos remarks to the group that this is only one study, and that they’ll need to make sure to collect data on the costs of their RRT as well as the cost implications of the outcomes. They determine that
promising results for UICUA, but the team agrees to include it in the outcomes for their RRT pro j - ect be cause it wasn’t evaluated in most of the articles they ap- praised.
As the EBP team continues to discusses probable outcomes, Re becca points to one study’s
Table 4. Defined Criteria for Initiating an RRT Consult
4 8 9 13 15
Respiratory distress (breaths/min)
Airway threatened Respiratory arrest RR < 5 or > 36
RR < 10 or > 30
RR < 8 or > 30
Unexplained dys- pnea
RR < 8 or > 28
New-onset difficulty breathing
RR < 10 or > 30
Shortness of breath
Change in mental status
Change in LOC Decrease in Glasgow Coma Scale of > 2 points
ND Unexplained change Sudden decrease in LOC with normal blood glucose
Decreased LOC
Tachycardia (beats/ min)
>140 > 130 Unexplained > 130 for 15 min
> 120 > 130
Bradycardia (beats/ min)
< 40 < 60 Unexplained < 50 for 15 min
< 40 < 40
Blood pressure (mmHg)
SBP < 90 SBP < 90 or > 180
Hypotension (unex- plained)
SBP > 200 or < 90 SBP < 90
Chest pain Cardiac arrest ND ND Complaint of nontrau- matic chest pain
Complaint of nontraumatic chest pain
Seizures Sudden or extended ND ND Repeated or pro- longed
ND
Concern/worry about patient
Serious concern about a patient who doesn’t fit the above criteria
NE Nurse concern about overall deterioration in patients’ condi- tion without any of the above criteria (p. 2077)
Nurse concern • Uncontrolled pain • Failure to respond to
treatment • Unable to obtain prompt
assistance for unstable patient
Pulse oximetry (SpO2) NE NE NE < 92% < 92%
Other • Color change of patient
• Unexplained agita- tion for > 10 min
• CIWA > 15 points
• UOP < 50 cc/4 hr • Color change of patient
(pale, dusky, gray, or blue)
• New-onset limb weak- ness or smile droop
• Sepsis: ≥ 2 SIRS criteria
4 = Hillman K, et al.; 8 = Mailey J, et al.; 9 = Dacey MJ, et al.; 13 = Benson L, et al.; 15 = Bader MK, et al.
cc = cubic centimeters; CIWA = Clinical Institute Withdrawal Assessment; hr = hour; LOC = level of consciousness; min = minute; mmHg = millimeters of mercury; ND = not defined; NE = not evaluated; RR = respiratory rate; SBP = systolic blood pressure; SIRS = systemic inflammatory response syndrome; SpO2= arterial oxygen saturation; UOP = urine output
50 AJN ▼ November 2010 ▼ Vol. 110, No. 11 ajnonline.com
that an RRT is a valuable inter- vention to initiate. They decide to take the criteria for activating an RRT from several successful studies/projects and put them into a synthesis table to better see their ma jor similarities (see Table 44, 8, 9, 13, 15). From this com- bined list, they choose the criteria for initiating an RRT consult that they’ll use in their project (see Table 5). The team also be gins discussing the ideal make up for their RRT. Again, they go back to the evaluation table and look
of excitement about their project, that their colleagues across all disciplines have been eager to hear the re sults of their review of the evidence. In addition, Carlos says that many re sources in their hos- pital will be available to help them get started with their project and reminds them of their hospital administrators’ commitment to support the team.
ACTING ON THE EVIDENCE As they consider the synthesis of the evidence, the team agrees
Re becca raises a question that’s been on her mind. She reminds them that in the “Appraisal: Worth to Practice” column, teaching was identified as an important factor in initiating an RRT and expresses concern that their hospital is not an aca demic medical center. Chen re minds her that even though theirs is not a designated teaching hospital with residents on staff 24 hours a day, it has a culture of teaching that should enhance the success of an RRT. She adds that she’s al ready hearing a buzz
Table 5. Defined Criteria for Initiating an RRT Consult at Our Hospital
Pulmonary
Ventilation Color change of patient (pale, dusky, gray, or blue)
Respiratory distress RR < 10 or > 30 breaths/min or unexplained dyspnea or new-onset difficulty breathing or shortness of breath
Cardiovascular
Tachycardia Unexplained > 130 beats/min for 15 min
Bradycardia Unexplained < 50 beats/min for 15 min
Blood pressure Unexplained SBP < 90 or > 200 mmHg
Chest pain Complaint of nontraumatic chest pain
Pulse oximetry < 92% SpO2 Perfusion UOP < 50 cc/4 hr
Neurologic
Seizures Initial, repeated, or prolonged
Change in mental status • Sudden decrease in LOC with normal blood glucose • Unexplained agitation for > 10 min • New-onset limb weakness or smile droop
Concern/worry about patient
Nurse concern about overall deterioration in patients’ condition without any of the above criteria
Sepsis
• Temp, > 38°C • HR, > 90 beats/min • RR, > 20 breaths/min • WBC, > 12,000, < 4,000, or > 10% bands
cc = cubic centimeters; hr = hours; HR = heart rate; LOC = level of consciousness; min = minute; mmHg = millimeters of mercury; RR = respiratory rate; SBP = systolic blood pressure; SpO2 = arterial oxygen saturation; Temp = temperature; UOP = urine output; WBC = white blood count
[email protected] AJN ▼ November 2010 ▼ Vol. 110, No. 11 51
3. Winters BD, et al. Rapid response sys - tems: a systematic review. Crit Care Med 2007;35(5):1238-43.
4. Hillman K, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised con- trolled trial. Lancet 2005;365(9477): 2091-7.
5. Sharek PJ, et al. Effect of a rapid re - sponse team on hospital-wide mortal- ity and code rates outside the ICU in a children’s hospital. JAMA 2007; 298(19):2267-74.
6. Chan PS, et al. Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA 2008;300(21):2506-13.
7. DeVita MA, et al. Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 2004;13(4): 251-4.
8. Mailey J, et al. Reducing hospital standardized mortality rate with early interventions. J Trauma Nurs 2006; 13(4):178-82.
9. Dacey MJ, et al. The effect of a rapid response team on major clinical out- come measures in a community hos- pital. Crit Care Med 2007;35(9): 2076-82.
10. McFarlan SJ, Hensley S. Implementa- tion and outcomes of a rapid response team. J Nurs Care Qual 2007;22(4): 307-13.
11. Offner PJ, et al. Implementation of a rapid response team decreases cardiac arrest outside the intensive care unit. J Trauma 2007;62(5):1223-8.
12. Bertaut Y, et al. Implementing a rapid- response team using a nurse-to-nurse consult approach. J Vasc Nurs 2008; 26(2):37-42.
13. Benson L, et al. Using an advanced practice nursing model for a rapid re - sp onse team. Jt Comm J Qual Pa tient Saf 2008;34(12):743-7.
14. Hatler C, et al. Implementing a rapid response team to decrease emergen- cies. Medsurg Nurs 2009;18(2):84-90, 126.
15. Bader MK, et al. Rescue me: saving the vulnerable non-ICU patient popu- lation. Jt Comm J Qual Patient Saf 2009;35(4):199-205.
16. Institute for Healthcare Improvement. Establish a rapid response team. n.d. http://www.ihi.org/IHI/topics/ criticalcare/intensivecare/changes/ establisharapidresponseteam.htm.
evidence that led to the project, how to call an RRT, and out- come measures that will indicate whether or not the implementation
of the evidence was successful. They’ll also need an evaluation plan. From reviewing the studies and projects, they also re alize that it’s important to focus their plan on evidence implementation, in- cluding carefully evaluating both the process of implementation and project outcomes.
Be sure to join the EBP team in the next installment of this se - ries as they develop their imple- mentation plan for initiating an RRT in their hospital, including the submission of their project proposal to the ethics review board. ▼
Ellen Fineout-Overholt is clinical pro- fessor and director of the Center for the Advancement of Evidence-Based Prac - tice at Arizona State University in Phoe - nix, where Bernadette Mazurek Melnyk is dean and distinguished foundation professor of nursing, Susan B. Stillwell is clinical associate professor and pro- gram coordinator of the Nurse Educator Evidence-Based Practice Men torship Program, and Kathleen M. Williamson is associate director of the Center for the Advancement of Evidence-Based Pra ctice. Contact author: Ellen Fineout- Overholt, ellen.fineout-overholt@asu. edu.
REFERENCES 1. Chan PS, et al. (2010). Rapid re -
sponse teams: a systematic review and meta- analysis. Arch Intern Med 2010;170(1):18-26.
2. McGaughey J, et al. Outreach and early warning systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007;3:CD005529.
over the “Major Variables Studied” column, noting that the composition of the RRT varied among the studies/projects. Some
RRTs had active physician partic- ipation (n = 6), some had desig- nated phy sician consultation on an as-needed basis (n = 2), and some were nurse-led teams (n = 4). Most RRTs also had a respira- tory therapist (RT). All RRT mem- bers had expertise in intensive care and many were certified in ad vanced cardiac life support (ACLS). They agree that their team will be comprised of ACLS- certified mem bers. It will be led by an acute care nurse prac ti- tioner (ACNP) credentialed for advanced procedures, such as cen tral line insertion. Members will include an ICU RN and an RT who can intubate. They also discuss having physicians will- ing to be called when needed. Although no studies or projects had a chaplain on their RRT, Chen says that it would make sense in their hospital. Carlos, who’s been on staff the longest of the three, says that interdisci- plinary collaboration has been a mainstay of their organization. A physician, ACNP, ICU RN, RT, and chaplain are logical choices for their RRT.
As the team ponders the evi- dence, they begin to discuss the next step, which is to develop ideas for writing their project im plementation plan (also called a protocol). Included in this pro- tocol will be an educational plan to let those involved in the proj- ect know information such as the
As they consider the synthesis of the
evidence, the team agrees that an RRT is a
valuable intervention to initiate.
