Running Head: EVIDENCE BASED PRACTICE PROJECT
Emily Cornell
Evidence Based Practice Project
Ferris State University
1
EVIDENCE BASED PRACTICE PROJECT
Table 1
2
1-3 sentences describing your thoughts on the
issue related to that element
I wonder if utilizing clean technique to change
tracheostomy tubes and suctioning contributes to
respiratory infections in pediatric patients.
2. Questions at issue or central problem (all
Do respiratory infections decrease in patients who
reasoning is an attempt to figure something use sterile technique to change tracheostomy tubes
out, to settle some question, solve some
and suctioning? By how much?
problem)
1. Purpose (all reasoning has a purpose)
3. Point of view (all reasoning is done from
some point of view; think about the
stakeholders)
4.
Information (all information is based on
data, information, evidence, experience,
research)
5. Concepts and ideas (all reasoning is
expressed through, and shaped by,
concepts and ideas)
6. Assumptions (all reasoning is based on
assumptions-beliefs we take for granted)
7.
Implications and consequences (all
reasoning leads somewhere. It has
implications and when acted upon, has
consequences)
Clean technique is easier and less time consuming.
The patients will benefit from a less restrictive
procedure. Tracheostomy tubes are not always
sterilized but are always sanitized and stored in
clean containers to reduce the risk of
contamination.
My agency’s current protocol using clean
technique is based on current EBP. I want to find
evidence that clean technique is not adequate to
prevent respiratory infection.
Some of my clients and clients of the agency are
fragile and infection may mean a hospital
admission with extensive interventions. All clients
have other chronic health conditions, but infection
occurs almost exclusively in the respiratory tract.
My clients and their families have the right to
remain in the best health their disease process
allows.
The assumption with using clean technique is the
germs in the home are colonized or present in the
client and are generally not harmful to the client.
All outside staff use universal precautions to avoid
cross contamination. Another assumption is that
the tracheostomy tubes are sanitized, when parents
or nursing staff may not have properly cleaned
them.
Worst-case scenario is a child dies from
complications to respiratory infection. More
realistically, hospital admissions will continue for
the clients, respiratory status can deteriorate
impacting quality of life. Risk of antibiotic
resistant bacteria colonizing and/or infecting the
client r/t semi-regular ATB use.
Utilizing sterile technique is more labor intensive
and less cost effective.
EVIDENCE BASED PRACTICE PROJECT
8.
Inference and interpretation (all reasoning
contains inferences from which we draw
conclusions and give meaning to data and
situations)
3
Utilizing sterile technique for tracheostomy tube
changes will decrease hospital admissions,
antibiotic use, respiratory infections, and
respiratory deterioration in pediatric clients.
EVIDENCE BASED PRACTICE PROJECT
4
Annotated Bibliographies
Al-Samri, M., Mitchell, I., Drummond, D. S. (2010). Tracheostomy in children: A population
based experiences over 17 years. Pediatric Pulmonology. 45, 487–493. doi:
10.1002/ppul.21206.
Mohammed Al-Samri is an assistant professor at United Arab Emirates University, Ian Mitchell,
Derek Drummond and Candice Bjornson are physicians at Alberta Children’s hospital and
faculty at University of Calgary in Alberta. The article begins with an overview of what a
tracheostomy is and what its indications are. The study focused on children with acute and
chronic illness who required tracheostomies, and followed their care from admission through
outpatient monitoring. The goal of this article is to provide an explanation of indications, risks,
and benefits of a tracheostomy in children. The authors show that 90% of children in the study
were subject to tracheostomy related infections of various organisms at different treatment
intervals, and suggest infection is an unavoidable side effect. The authors also admit that there is
a lack of evidence-based information related to tracheostomy care and that more studies are
needed.
Iwanaga, K., Carter, E. (2012). Myobacterium abscessus complex lung infection in a toddler
with a tracheostomy. Pediatric Pulmonology. Case report. doi: 10.1002/ppul.22789.
Kensho Iwanaga and Edward Carter are physicians at Seattle Children’s hospital and faculty at
University of Washington School of Medicine in Seattle. This article focuses on one pediatric
patient with a tracheostomy and a complex infection. There is no indication or assumption on
whether tracheostomy care was the result of the infection. The authors write with the assumption
that the reader is familiar with a variety of pulmonary related infections. The history of the
patient includes a series of ambiguous symptoms and various treatment for unrelated infections
that never seemed to resolve. The persistent infection was not detected on routine sputum
cultures hindering effective treatment. The authors suggest that the cause of the infection was the
patient’s tracheostomy, combined with various other bacteria that colonized the tracheostomy
stoma and the airways, it went undetected for months. The authors admit there is limited research
in this particular infection in pediatric patients.
Graf, J. M., Montagnino, B. A., Huekel, R., McPherson, M. L. (2008). Pediatric tracheostomies:
A recent experience from one academic center. Pediatric Critical Care Medicine. 9(1).
96-100. Retrieved from PubMed Database June 13, 2013.
Jeanine Graf and Mona McPherson are physicians in the department of Pediatrics at Baylor
College of Medicine, Barbara Montagnino is a CNS who works for Texas Children’s Hospital,
and Remi Huekel is a FNP at Duke University. This article discusses the impact on health care
costs and that acutely ill pediatric patients with tracheostomies have, and the likelihood that this
patient population will be technology dependent. The patients studied were evaluated for length
of stay and total cost of their care in the PICU. The article discussed the high readmission rate of
pediatric patients with tracheostomies and the implications of their continued care. This article
seemed to be a bit narrow, the study only included patients from one hospital. It did not give
reasoning to why the readmissions happened, just that they did. The authors communicate the
need for further study of this particular patient population.
EVIDENCE BASED PRACTICE PROJECT
5
McClean, E. B. (February, 2012). Tracheal suctioning in children with chronic tracheostomies: A
pilot study applying suction both while inserting and removing the catheter. Journal of
Pediatric Nursing. 27(1). 50-54. Doi:
http://0dx.doi.org.libcat.ferris.edu/10.1016/j.pedn.2010.11.007.
Elise McClean is a CNS at Children’s Hospital in Orange, CA. The article focuses on tracheal
suctioning in eighteen children with chronic tracheostomies. The author provides a quick
overview of the indications for tracheostomy in children and the risks and goals of suctioning. A
comparison was done between the traditional practice of suctioning and the practice
recommended by the American Thoracic Society (ATS) in a small sample population of 18
pediatric patients. The goal of the paper is to discover if there is a difference in heart rate, SpO2,
and amount of secretions captured between the two. The author reports that parents and
guardians are using the ATS suctioning practice and that it warrants further study. This article
did not discuss the implications of infection prevention or management, however did report that
the majority of the study participants were admitted because of infection.
EVIDENCE BASED PRACTICE PROJECT
1.
2.
3.
4.
5.
6
Questions
The planning process helped prepare me for the EBPP by helping me focus on what
problems in my workplace deserve to be looked at more closely. It helped my prioritize
and categorize the problems in my workplace into problems that need solving, problems
that need more research and problems that myself and other nurses are inventing or
otherwise allowing to interfere with our work. After planning for the EBPP I am better
able to understand what a “real” workplace problem looks like.
The peer evaluation process had good and bad points to it. I read over several of my
classmates’ EOR sheets and I found myself wanting to learn about possible solutions to
their problems. I feel in the EORs I critiqued I was able to ask provoking questions to
help the writers to better ask their questions and get adequate answers. Unfortunately, I
felt the person who critiqued my EOR was ambiguous and did not help me to understand
what they were wanting me to change.
Finding relevant up-to-date research for my topic proved to be quite difficult. The
practice standard is using clean technique for home tracheostomy changes and suctioning,
and no new research has been performed that I was able to find in our databases. The
researchers have predicated their work with the assumption that all tracheostomy patients
will have infections related to the tracheostomy, seemingly without any evidence to back
them up. With the information I was able to find, I am not prepared to elicit change in my
practice. However, I am curious and would like to perform a study to answer the
questions I set out to answer with this project. I feel we owe this particular population the
benefit of relevant up-to-date research concerning tracheostomies and the care they
require.
If I had to do this project over again I would have started sooner on the research. That
would have allowed me to formulate a better question than the one I began with in order
to have a more positive experience with this project. On the other hand, the struggle I had
with this project showed me that there is a serious lack of research concerning my topic
and that there is a need to be fulfilled.
I use the EOR to varying degrees. I am able to clearly define a purpose or problem and
ask questions about it to get a satisfactory answer. However, I have found that I need to
better understand concepts and ideas a little more. Sometimes I have to do some research
to understand the problem I see in better terms, key words and concepts. This usually
happens when I am learning a new procedure or about a new disease process. By better
understanding concepts and ideas, I am able to make better, more relevant assumptions
about the problem I am seeing. After doing this project, I have seen how the EOR
template can be useful in identifying, an researching problems and implementing change
in my nursing practice.