Opportunities & Challenges with Patient Safety Goals

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Implementing EBP Column

Outcomes of Implementing an Evidence-Based Hypertension Clinical Guideline in an Academic Nurse Managed Health Center Brenda Dyal, DNP, RN, FNP-BC • Maria Whyte, DHSc, RN, FNP-BC • S. Michele Blankenship, MSN, RN, RN-BC • Lynn Gallagher Ford, PhD, DPFNAP, RN, NE-BC

This column shares the best evidence-based strategies and innovative ideas on how to fa- cilitate the learning and implementation of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787

Use of an evidence-based practice (EBP) model can be an important aid to ensuring consistent patient care among providers, aid in the delivery of quality health care, and cost effectively improve patient outcomes (Harris et al., 2014). Providers who practice using an evidence-based model uti- lize critical thinking skills to translate and implement research into clinical practice in the care of patients either directly or indirectly. In the direct care of patients, providers must make decisions incorporating current literature, patient preference, cost, resources, and cultural norms. This requires the provider to seek out knowledge, ask questions, and understand their own level of expertise. Evidence-based clinical guidelines are typically developed by a medical specialty association or pro- fessional society, public or private organization, government agency, or healthcare organization or plan based on a system- atic review of evidence and provide recommendations for op- timal patient care for specific clinical circumstances (National Guideline Clearinghouse, 2014).

EBP incorporates current best evidence, individual clin- ical expertise and patient preferences in decision making. Evidence-based clinical guidelines exist that are useful for health screening, health promotion, and the management and treatment of chronic conditions. Evidence-based clinical guide- lines can be used as a means to improve and maintain the qual- ity of patient care and potentially improve patient outcomes (Keogh & Courtney, 2001; Varaei, Salsali, Cheraghi, Tehrani, & Heshmat, 2013).

Nurse managed health clinics provide high-quality care and achieve high patient satisfaction rates and often exceed national benchmarks for treatment of chronic diseases to include hy- pertension, diabetes, and asthma (Barkauskas & Pohl, 2009; Esperat, Hansen-Turton, Richardson, Debisette, & Rupinta,

2012). Nurse managed clinics increase accessibility of health care, especially among the underserved population, promote interprofessional collaboration, and promote the use of tech- nology in the practice setting (Laurant et al., 2005; Winter, Lavendar, & Blesing, 2012). Valdosta State University’s School of Nursing developed a nurse managed clinic within the Lown- des County Partnership Health Center, an established health center which served the working uninsured adults and their adult dependents. This nurse managed clinic served as a model for faculty practice, a site for educational experiences for grad- uate and undergraduate nursing students, and a site to model standards of EBP.

BACKGROUND The Valdosta State University School of Nursing was estab- lished in 1968 and graduated the first baccalaureate prepared nursing students in 1972. The adult nurse practitioner pro- gram was established in 2007 and transitioned to the adult gerontology nurse practitioner program in 2011. In 2009, the School of Nursing developed a nurse managed clinic within the Lowndes County Partnership Health Center. Col- laboration with the Valdosta State University School of Nurs- ing and the Lowndes County Partnership Health Center was funded through a Health Resources and Services Administra- tion Nurse Education, Practice and Retention Health Link grant No. D11HP14615. Services provided included health screen- ings, smoking cessation, diabetes education, management of chronic disease, and follow-up care for patients recently dis- charged from inpatient care. Included in the objectives of the Health Link project was the integration of current evidence- based clinical literature including the development of protocols and guidelines to promote best practices (Temple, 2008).

Implementing an Evidence-Based Hypertension Clinical

An evidence based-clinical guideline was developed with the intention to provide patients of the nurse managed clinic with quality patient care and improved outcomes. Nursing faculty, nursing students, health center nurses, the medical director, and volunteer providers worked together in the development of a hypertension guideline for use in the health center. The framework for the project was the Iowa Model of Research- Based Practice to Promote Quality Care (Titler et al., 2001). The steps of the algorithm established in the Iowa Model in- clude: (a) select a topic and determine that the topic is a priority for the organization; (b) form a team; (c) assemble relevant lit- erature, critique and synthesize research for use in practice, determine existence of a sufficient research base, pilot the change in practice; (d) if, appropriate, adopt in practice; and (e) disseminate the results (Titler et al., 2001).

THE PROJECT Internal Evidence A review of health center data revealed the top five diagnoses among the client population ranked hypertension as the num- ber one diagnosis, followed in order by thyroid disease, di- abetes, asthma, and then depression. Based on the order of the top five diagnoses, it was determined that priority for the first guideline would be the development of a clinical prac- tice guideline for the management of hypertension. Follow- ing the Iowa Model algorithm, an interdisciplinary advisory committee was formed to work on the process. Members of the interdisciplinary advisory committee included two faculty nurse practitioners, adult-gerontology nurse practitioner stu- dents who were assigned to the health center as part of their clinical rotation, the health center medical director and col- laborating physician, the principle investigator of the grant who was also a registered nurse, and the clinic administrative director.

As the committee began its work, one of the barriers iden- tified was the individual providers’ willingness to “buy in” and use the guidelines. Other barriers to the use of evidence-based clinical guidelines were identified, not the least of which is the terminology to use when referring to EBP. An area of disagree- ment among the committee working on this project was the use of the term “protocol.” Some members of the committee felt the use of the term “protocol” could be interpreted as being mandated and would not be inclusive of providers’ ability to utilize clinical expertise if it became necessary to deviate from a recommended treatment plan. The physician committee members stated that they would not work under protocols but would not mind if the protocols were in place for the nurse prac- titioner providers. Nurse practitioner providers took exception to the idea that they would be expected to gain permission if it became necessary to deviate from the recommended treatment plan. After much discussion among members of the advisory committee, it was determined that use of the term “guideline” or “evidence-based clinical guideline” was preferred.

INTEGRATION OF CURRENT EVIDENCE-BASED CLINICAL LITERATURE An exhaustive search of the literature using the databases of PubMed, CINAHL, Academic Search Complete, and Pro- Quest was conducted using key words EBP, clinical protocol, clinical guideline, health promotion, health education, nurs- ing practice, patient outcomes, advanced practice, nurse man- aged clinic, and free health clinic. Literature was reviewed in English from 2002 to present. Literature was narrowed to the following subsets: EBP, clinical guidelines, and clinical protocols.

Following the literature search, the advisory committee es- tablished that evidence-based clinical guidelines for hyperten- sion existed in the literature and it was important to implement a process with the greatest potential of being effective with our at-risk client population. Assessment of the patient population preferences and values revealed that important components of the guideline for consideration needed to include parameters that addressed the socioeconomic status of our patient popu- lation including options for inexpensive medications, the cost and availability of certain tests and diagnostics, and the need to make patient education available to all patients.

Based on these considerations, the Georgia Public Health Nurse protocol for hypertension (Georgia Department of Pub- lic Health, 2011) was selected and adapted for use in the health center. Areas of concern in the primary document included the limited formulary and dated treatment algorithms. All providers in the health center were invited to provide com- ments and feedback during the development of the hyperten- sion practice guideline. Adaptations to the protocol included: (a) the addition of wording for nurse practitioner to diagnose and prescribe medications, (b) the addition of generic med- ications to the list of preferred medications, (c) addition of DASH dietary recommendations, (d) the inclusion of available laboratory tests, and (e) the addition of cost list for specific diag- nostic tests which patients would need to self-pay. The adapted guideline was shared with members of the medical advisory committee for review. The guideline was considered complete and ready for implementation when the stakeholders were sat- isfied that the guideline was based on current best practices, could be used by all providers, and could be implemented with the health center patient population.

Development of evidence-based clinical guidelines contin- ues to be an ongoing, interprofessional team process. To ensure that the guidelines are consistent with current best practices, a very specific policy and process was developed to guide updates to the evidence-based clinical guideline; this includes the pro- cess for biannual updates to the guideline. The hypertension guideline was uploaded as an electronic file onto the computer in each exam room to facilitate clinician utilization. In addition, evidence-based guidelines have been incorporated into the new electronic health record and a link to the National Guidelines Clearinghouse website was added to all computers in the exam rooms for point-of-care access.

Implementing EBP Column

Table 1. JNC 7 Algorithm

Systolic And/ Diastolic

Stage bloodpressure or bloodpressure

Normal <120 And <80

Prehypertension 120–139 Or 80–89

Hypertension, stage 1 140–159 Or 90–99

Hypertension, stage2 �160 Or �100

Student Impact Adult-gerontology nurse practitioner students’ treatment decisions are influenced by preceptors in the educational and clinical settings (Carr & Schott, 2001). In our setting, the nurse practitioner faculty modeled use of evidence-based clinical guidelines in precepted experiences. At the end of each semester, all students were asked to complete an anony- mous survey questionnaire. Students reported a noticeable difference in the use of evidence-based clinical guidelines among nurse practitioner faculty preceptors in the health center setting and preceptors in other settings. The students also found their participation with teambuilding efforts with the establishment of the medical advisory committee to be a valuable learning experience (Carr & Schott, 2001).

Patient Impact To measure the impact of the integration of the evidence-based hypertension guideline, we analyzed blood pressure values of patients who presented to the clinic between October 2012 and December 2013 with a blood pressure categorized as either Hypertension, Stage 1, or Hypertension, Stage 2 (Table 1), ac- cording to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure algorithm (United States Department of Health and Human Services, 2004). The change from the first visit where the blood pressure was considered hypertensive to their latest blood pressure reading was compared and analyzed.

Sample The sample consisted of a convenience sample of records of 304 patients who presented between October 2012 and December 2013 with a blood pressure category of Hypertension, Stage 1 or Stage 2, to the health center. The mean age was 50.37 years with an age range of 25 years and 65 years and 85.5 % of the sample was between the ages of 50 and 59 years; females represented 71.1% of the sample with only 28.9% males. African Americans represented the largest segment of the sample (65.8%) while 98.4% of the sample was non-Hispanic.

Table 2. Category of Most Recent Blood Pressure

Valid Cumulative

Frequency Percent percent percent

2 .7 .7 .7

Normal 37 12.1 12.1 12.7

Prehypertension 131 42.8 42.8 55.6

Valid hypertension, stage 1

99 32.4 32.4 87.9

Hypertension, stage2

37 12.1 12.1 100.0

Total 306 100.0 100.0

RESULTS The range of the initial systolic blood pressure values was 120–231 mmHg with a mean systolic blood pressure of 149.2 mmHg. The range of the initial diastolic blood pressure values was 48–148 mmHg with a mean of 91.1 mmHg. The range of the most recent systolic blood pressure was 90–225 mmHg with a mean of 134.21. The range of the most recent dias- tolic blood pressure was 58–112 mmHg with a mean of 83.20 mmHg. When examining the category of initial blood pres- sure, 68% of the sample was categorized as Hypertension, Stage 1, and 31.4% was Hypertension, Stage 2. In comparison, the most recent blood pressure was found to be categorized as normal (12.1%), prehypertensive (42.8%), Hypertension, Stage 1 (32.4%), and Hypertension, Stage 2 (12.1%; Table 2).

A paired t test was used to determine the mean difference between the most recent systolic blood pressure and the ini- tial systolic blood pressure. The difference in the most recent systolic blood pressure (M = 134.21, SD = 17.522) from the initial systolic blood pressure (M = 149.20, SD = 15.80) was a statistically significant change of 14.990 (95% CI 12.677– 17.303) mmHg, t (303) = 12.751, p < .001, d = .731. A paired t test was used to determine the mean difference between the initial diastolic blood pressure and the most recent diastolic blood pressure. The difference between the most recent dias- tolic blood pressure (M = 83.2, SD = 10.129) and the initial diastolic blood pressure (M = 91.10, SD = 11.515) was a statisti- cally significant change of 7.895 (95% CI 6.504–9.286), t (303) = 11.167, p < .001, d = .640; Table 3).

Additionally, a Wilcoxon signed ranks test was performed to determine the change from the initial blood pressure cate- gory to the most recent blood pressure category. The Wilcoxon signed ranks test indicated that the category of the most

Implementing an Evidence-Based Hypertension Clinical

Figure 1. Wilcoxon signed ranks test.

Table 3. Paired Samples Correlations

N Correlation Sig.

Pair 1 Initial systolic bloodpressure& most recent systolic blood pressure

304 .247 .000

Pair 2 Initial diastolic bloodpressure& most recent diastolic blood pressure

304 .357 .000

recent blood pressure was statistically significantly lower than the initial blood pressure (Z = −11.776, p < .001; Figure 1).

DISCUSSION The implementation of an evidence-based guideline for hy- pertension had a positive impact for the nurse practitioner students and patient outcomes. Adult-gerontology nurse prac- titioner students gained invaluable experience in team build- ing; they practiced active learning and gained understanding of key concepts of EBP. Students experienced the translation

of evidence-based clinical guidelines and decision making into clinical practice, as well as the use of evidence-based health pro- motion. It is anticipated that providing nursing students with practice in the utilization of evidence-based clinical guidelines and modeled behavior will result in nurses in practice settings who understand the value and importance of EBP.

Graduate students in the adult-gerontology nurse practi- tioner track participated as advisory committee members and assisted in the development and implementation of the hy- pertension clinical guideline. Other opportunities for student involvement with the development of EBP guidelines included: the implementation of an Asthma Action Plan, assessing the needs of the diabetic population, the assessment of the use of the MedBank program, and an update of the hypertension guideline. WVN

LINKING EVIDENCE TO ACTION

� Current evidence can be integrated into clinical practice to drive best practice and significantly im- pact patient outcomes.

� Creating and implementing evidence-based clin- ical guidelines is a cost-effective way to improve care and outcomes.

Implementing EBP Column

� Clinical preceptors who teach and model EBP in- fluence students’ utilization of evidence in prac- tice.

� Development and integration of evidence-based clinical guidelines can be an opportunity to build teams and interdisciplinary collaboration.

Author information

Brenda Dyal, Associate Professor, School of Nursing, Valdosta State University College of Nursing and Health Sciences, Val- dosta, GA, USA; Maria Whyte, Simulation Lab Coordinator, Florida State University College of Nursing, Tallahassee, FL, USA; S. Michele Blankenship, Instructor School of Nursing, Valdosta State University College of Nursing and Health Sci- ence, Valdosta, GA, USA; Lynn Gallagher Ford, Director, Cen- ter for Transdisciplinary Evidence-based Practice, Clinical As- sociate Professor, The Ohio State University College of Nurs- ing, Columbus, OH, USA The project described was supported by Grant Number _D11HP14615 (Health Link) from Health Resources and Ser- vices Administration, Nurse Education, Practice and Retention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Valdosta State University School of Nursing or Health Resources and Services Administration. Address correspondence to Dr. Brenda Dyal, Valdosta State University College of Nursing and Health Sciences, 1500 N. Patterson Street, Valdosta, GA 31698; [email protected]

References Barkauskas, V. H., & Pohl, J. M. (2009). Measurement of evidence-

based clinical outcomes of nurse managed health center care. Paper presented at the 10th Annual National/International Evidence- Based Practice Conference, Glendale, AZ.

Carr, C., & Schott, A. (2001). Using student-collected practice data as a teaching tool. Journal of Nursing Education, 40(4), 183–190.

Esperat, M. C. R., Hansen-Turton, T., Richardson, M., Debisette, A. T., & Rupinta, C. (2012). Nurse-managed health centers: Safety- net care through advanced nursing practice. Journal of the Amer- ican Academy of Nurse Practitioners 24(1), 24–31.

Georgia Department of Public Health. (2011). Public health nurse protocols hypertension. Retrieved from https://dph.georgia. gov/sites/dph.georgia.gov/files/NurseProtocolsFullVersion2012. pdf

Harris, M. F., Lloyd, J., Krastev, Y., Fanaian, M., Gawaine, D., Zwar, N., & Siaw-Teng, L. (2014). Routine use of clinical management guidelines in Australian general practice. Australian Journal of Primary Health, 20(1), 41–46.

Keogh, S. J., & Courtney, M. D. (2001). Developing and imple- menting clinical practice tools: the legal and ethical implications. Australian Journal of Advanced Nursing, 19(2), 14–19.

Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & Sibbald, B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database Systematic Review, 2(2), CD001271. doi: 10.1002/14651858.CD001271.pub2

National Guideline Clearinghouse. (2014). Inclusion criteria: [criteria for inclusion of clinical practice guidelines in NGC]. Retrieved from http://www.guideline.gov/about/inclusion- criteria.aspx#ref]

Temple, J. S. (2008). Health resources and services administration nurse education, practice and retention: Health link: Health care for uninsured employed adults. NEPR program narrative (Report), Valdosta, GA: Valdosta State University.

Titler, M. G., Kleiber, C., Steelman, V., Rakel, B. A., Budreau, G., Everett, L. Q., . . . Goode, T. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13, 497–509.

United States Department of Health and Human Services. (2004). The seventh report of the Joint National Commit- tee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Retrieved from http://www.nhlbi.nih.gov/ files/docs/guidelines/jnc7full.pdf

Varaei, S., Salsali, M., Cheraghi, M., Tehrani, M., & Heshmat, R. (2013). Education and implementing evidence-based nurs- ing practice for diabetic patients. Iranian Journal of Nursing & Midwifery Research, 18(3), 251–257.

Winter, H., Lavendar, V., & Blesing, C. (2012). Assessing satisfac- tion with a nurse-led clinical trials clinic. Cancer Nursing Practice, 11(9), 23–27.

doi 10.1111/wvn.12135 WVN 2016;13:89–93

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