Evidence-Based Infusion Practice

Mary E. Hagle

Beth Ann Taylor

PRACTICE BASED ON EVIDENCE

Nursing practice based on best evidence is a defined, specific, and dynamic process that draws upon the latest research findings, clinical data, or, if necessary, expert opinion to drive clinical and leadership improvements in health care. Simply put, this process requires nurses to use evidence rather than tradition or personal opinion in their approach to providing care to patients. Florence Nightingale used statistics to influence changes in how British soldiers were cared for during the Crimean War (Stanley & Sherratt, 2010), and thus was born the foundation of nursing practice based on the effective use of data to ensure better health outcomes. Using evidence to inspire changes in practice is neither a new nor novel idea but rather a fundamental tenet of professional nursing.

Infusion nurses, along with other nursing specialties, share the common challenge of staying current with the rapidly growing and changing information base in their area of practice. The American Nurses Association (ANA, 2010) and Infusion Nurses Society (INS, 2011) professional standards call for infusion nurses to use research findings and to practice with the current best evidence, “The registered nurse integrates evidence and research findings into practice” (ANA, 2010, p. 51). “The nurse shall use research findings and current best evidence to expand nursing knowledge in infusion therapy, to validate and improve practice, to advance professional accountability, and to enhance evidence-based
decision making” (INS, 2011, p. S13). These standards are inclusive of all roles in professional nursing, and at all levels; the novice nurse understands that institutional policies and procedures are based on best evidence, while the infusion team manager plans and executes a budget for staffing based on sound administrative principles and analysis of patient needs.

For example, the Centers for Disease Control and Prevention (CDC, 2011) strongly recommended that only trained personnel with demonstrated competence manage peripheral and central venous catheters (CVCs); this was based on the evidence of 14 studies. The authors in three of the more recent studies described the initiation of infusion teams with measurable outcomes or quantified the infusion therapy procedure for average nursing times and costs (Brunelle, 2003; Hawes, 2007; Pierce & Baker, 2004), providing evidence for the manager and administrator on budgeting, staffing, and quality outcomes for patients (Box 11-1). These studies also provide evidence for any nurses, leaders, or managers who wish to compare their outcomes with another agency reporting quality practice. One more strong recommendation was to ensure that intensive care units are staffed at appropriate levels, and with nurses who regularly work for the institution, in order to prevent central line-associated blood stream infection (CLABSI) (CDC, 2011). This evidence is from two separate yet classic studies (Alonso-Echanove et al., 2003; Robert et al., 2000). Besides implementing best evidence, this is an example of the need for additional studies to provide a more robust body of evidence that drives staffing with measurable outcomes.

EVIDENCE-BASED PRACTICE

The INS Standard of Practice for Research and Evidence-based practice (EBP) states, “The nurse shall integrate evidence-based nursing knowledge with clinical expertise and the patient’s preferences and values in the current context when providing infusion therapy” (INS, 2011, p. S13). The infusion nurse exemplifies this standard by basing his or her practice on the best evidence, through lifelong learning to advance one’s clinical expertise, and by centering the focus of care on the patient. EBP occurs at the intersection of the three circles shown on the Venn diagram (Figure 11-1).

EBP is not simply the application of the latest research findings; it goes beyond seeking the best evidence related to a clinical or leadership question. It incorporates the best available evidence with the expertise of the nurse and the patient preferences in the context of care delivery. Therefore, the application of evidence is not done in isolation of the desires and goals of the patient, it is dependent upon the expertise of the individual nurse, and it is accomplished in the context of the care environment. For example, in home care, this context reflects the resources the nurse brings as well as what the patient has in his or her home and who can help. Additionally, context incorporates the professional practice model of the nurse and organization (Hoffart & Woods, 1996). It might be relationship-based care (Koloroutis, 2004), partnership (Jonsdottir, Litchfield, & Pharris, 2004), or caring science (Drenkard, 2008). The American Nurses Credentialing Center (ANCC) defines a professional practice model as a schematic or diagram, sometimes with descriptions, of the theory or system that “depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality care for those served by the organization” (ANCC, 2011). All of these components provide support for the infusion nurse making the best decision at the time.

BOX 11-1 SELECTED STUDIES CITED BY CDC (2011) AS SUPPORT FOR THE RECOMMENDATION THAT ONLY TRAINED PERSONNEL SHOULD MANAGE PERIPHERAL AND CENTRAL VENOUS CATHETERS

Source	Assessment	Intervention	Outcomes
Brunelle (2003)	Identified problems: “(1) below-standard practice for bedside care, (2) multiple use of the same catheter, (3) staff shortage, (4) below-standard education for staff, and (5) growing number of elderly patients who are more susceptible to infection” (p. 362) Prevalence survey to provide systematically gathered data on infection source, insertion and management practices	Develop IV team to Educate staff Serve as a resource Track patients with CVCs for maintenance of devices and clinical outcomes	Process outcome: IV team does all CVC dressing changes; serves as resource to nurses Clinical outcome: Catheter-related bloodstream infections (year/frequency): 1996/45 2001/19
Hawes (2007)	Problem identified of: Inadequate peripheral veins for peripherally inserted central catheter (PICC) placement Unnecessary “urgent” placement requests at end of week	Develop infusion team to: “Increase number of PICCs placed at the bedside. Improve patient outcomes related to infusion therapy. Improve patient satisfaction related to infusion therapy” (p. 35)	Clinical outcomes: Increase from 50% to over 80% PICCs placed at bedside at consistent rate All levels of phlebitis decreased from 24% to less than 5% over 18 mo Less than 10% PIVs infusing irritants Increase of 7% for patient satisfaction with “Courtesy of the person that started your IV”
Pierce and Baker (2004)	Quantify time and effort involved in service provision for infusion therapy procedures of nonchemotherapeutic agents in outpatient infusion centers Data collected through direct observation and staff interviews of 78 patients in 75 different offices	Not applicable	Process outcomes: Average nursing time, average labor costs, and average time for each phase of infusion therapy were calculated and reported

EBP is the “right thing to do” for many reasons (Melnyk & Fineout-Overholt, 2011):

It leads to best patient outcomes.
It reduces health care costs (Hollenbeak, 2011).
It supports clinicians feeling empowered and more satisfied in their roles.

The critical nature of nurses understanding and using evidence to drive practice is underscored by Institute of Medicine’s goal proposing, “By 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence” (Institute of Medicine, 2007, p. ix). To meet this goal, EBP must be an integral part of the organization’s culture. Each organization will have to evaluate their current state and identify needs of the staff. Based on a recent national survey of ANA members, work remains to be done. Less than 54% of 876 RNs strongly agreed/agreed that EBP was consistently implemented in their setting and less than 47% strongly agreed/agreed that findings from research are routinely implemented to improve patient outcomes (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). In the same study, nurses’ beliefs about their own practice demonstrated moderate agreement with the statement, “I consistently implement evidence-based practice with my patients”; that is, nurses rated their agreement with this
statement an average 3.82 (standard deviation 0.883), on a scale of 1 to 5, strongly disagree to strongly agree (ibid p. 412). Interpreting this finding means there are opportunities for leaders at all levels to facilitate nurses consistently implementing EBP with their patients.

FIGURE 11-1 Components of evidence-based practice. (From Veterans Health Administration, Office of Nursing Services, Evidence-Based Practice Resource Center.)

CREATING A CULTURE OF EVIDENCE-BASED PRACTICE

Effective nursing leadership is essential at all levels of the organization to create a culture that values and supports nurses in developing a spirit of inquiry, generating and answering relevant clinical questions, and making recommendations that can be operationalized (Newhouse, 2007). A robust EBP culture shortens the time between the emergence of new research findings and their implementation in clinical settings (Brady & Lewin, 2007). Adopting a model for EBP, identified and selected by all staff, may initiate a culture change. There are several models that outline steps, provide a decision tree, or give broad concepts to the process (Table 11-1). Staff nurses and organizations are varied in how they approach change, thus an open and ongoing dialogue about EBP models may be helpful.

Additionally, there are generational differences, learning differences, and attitudes that affect how a culture changes to being evidence-based. Providing options for learning about EBP will appeal to a wider variety of learners. A variety of online tutorials are available (Box 11-2), numerous texts, and summer courses across the United States, as well as those offered by the international Joanna Briggs Institute. An increasing number of journals focus solely on reports of literature synthesis and research translation projects, in addition to journals focused on infusion therapy but publishing literature syntheses, such as the Journal of Infusion Nursing and Journal of the Association for Vascular Access. Learning more about EBP was the most common response to the question, “What one thing would help to implement EBP in your daily practice?” (Melnyk et al., 2012, p. 414). Having access to information was the second request. Advocating for resources is an accountability of leaders, in partnership with staff for appropriate materials and strategies to make these accessible.

Evidence-based leadership in nursing makes each experience count. EBP gathers the wide array of skill sets that each participant brings to the health care setting and influences decisions related to patient care. Essential components for the creation of an EBP culture include institutional support, strong clinical leadership, availability of resources, and feedback on outcomes (Newell-Stokes, 2004). Enabling nurses to consistently use best evidence at the point of care with their patients means that systems need to be in place for best evidence to be easily available, or, a culture of EBP.

STEPS FOR PRACTICE BASED ON EVIDENCE

Type of Evidence

At the organizational level, there are several elements to promote EBP. Having a model is one element that may be helpful, as it guides the team along the journey of discovery. Another element is understanding what constitutes evidence. Nurses may actively seek evidence, but just as likely, they will be provided with evidence for support of some policy, procedure, or recommendation. Whether part of a team or not, each infusion nurse must be able to recognize what type of evidence is being submitted. As shown in the evidence pyramid in Figure 11-2, there are a wide variety of sources of evidence, and it is important to note that not all evidence is obtained from research. At the lowest level of evidence is nonresearch. Examples of nonresearch sources of evidence are as follows:

TABLE 11-1 MODELS OF EVIDENCE-BASED PRACTICE

Name of Model	Reference	Brief Description
ACE Star Model of Knowledge Transformation	Stevens, K.R. (2004). ACE Star Model of EBP: Knowledge transformation. Academic Center for Evidence-Based Practice. The University of Texas Health Science Center at San Antonio. www.acestar.uthscsa.edu	Five stages of transforming knowledge into the clinical setting for practice use. Circular model.
Iowa Model of Evidence-Based Practice to Promote Quality Care	Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., et al. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509.	Decision tree starting with triggers to action. Facilitates decisions to use the evidence or to conduct research.
Johns Hopkins Evidence-Based Practice Model	Dearholt, S., & Dang, D. (2012). Johns Hopkins nursing evidence based practice model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau.	Focuses on best available evidence; multidisciplinary approach. Provides tools for EBP use.
Model for Change to Evidence-Based Practice	Rosswurm, M.A., & Larrabee, J.H. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31, 317-322.	Linear model of six steps is explained to guide nurses through the EBP process.
PARiHS (Promoting Action on Research Implementation in Health Services)	National Collaborating Centre for Methods and Tools. (2011). PARiHS framework for implementing research into practice. Hamilton, ON: McMaster University. http://www.nccmt.ca/registry/view/eng/85.html. Based on: Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality in Health Care, 7, 149-158.	Provides a method to implement research into practice. Identifies three key elements for knowledge translation: Evidence (E), Context (C), and Facilitation (F). It emphasizes that successful implementation of evidence into practice is related to context or the setting where the new evidence is being introduced as the quality of the evidence.
Steps of the EBP Process Leading to High-Quality Healthcare and Best Patient Outcomes	Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.) (p. 16). New York, NY: Wolters Kluwer/Lippincott Williams & Wilkins.	Decision tree with six key steps for implementing an EBP project.
Stetler Model	Stetler, C.B. (2001). Updating the Stetler model of research utilization to facilitate evidencebased practice. Nursing Outlook, 49, 272-279.	Model helps to “focus on a series of judgmental activities about the appropriateness, desirability, feasibility, and manner of using research findings in an individual’s or group’s practice” (p. 272).