Running head: EBP PROJECT PAPER
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Evidence Based Practice Project Paper
Katherine Jackson
University of South Florida
EBP PROJECT PAPER
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EBP Project Paper
There is an opportunity at All Children’s Hospital (ACH) to lessen the amount of time
patients undergoing cardiac catheterizations spend in states of hypoxia. The use of near infrared
spectroscopy (NIRS) for prompt detection of impaired tissue perfusion may be used. Prompt
identification of impaired oxygenation can help shorten the time patients spend in a hypoxic
state, essentially reducing complications of impaired perfusion. The clinical question
investigated is as follows: In pediatric patients undergoing cardiac catheterization, is NIRS
compared with pulse oximetry more prompt in diagnosing impaired tissue perfusion during the
intraoperative and postoperative period? Management of all units involved support this change in
practice.
Literature Review
In conducting research on near infrared spectroscopy, four articles are referenced. The
search engines most utilized include CardioSource and PubMed accessed through the Shimberg
Health Sciences Library. Keywords used during research were near infrared spectroscopy, pulse
oximetry, pediatrics, cardiac catheterization, and tissue perfusion.
Research done by Hansen et al. (2013) illustrates the effectiveness of near infrared
spectroscopy during the postoperative period in detecting impaired tissue perfusion in contrast to
measurements taken by Bhutta et al. (2007) during the catheterization period. Both studies
illustrate success of NIRS in detecting impaired oxygenation. Hansen et al. (2013) illustrates
continuous noninvasive monitoring of the NIRS probes detected impaired oxygenation early on
in the postoperative period; values gathered from cerebral and somatic probes provided a good
estimate of overall oxygenation. Hansen et al. (2013) concludes the lower cSO2 values in the
early postoperative period may be predictive of postoperative complications; cerebral probes
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detected impaired oxygenation much quicker compared to somatic probes. Data collected by
Zulueta, Vida, Perisinotto, Pittarello, and Stellin (2013) may be compared to data gathered by
both Bhutta et al. (2007) and Hansen et al. (2013) because subjects were monitored
intraoperatively and postoperatively; in essence Zulueta et al. (2013) used a combination of
methods practiced in the other studies. Supported by Hansen et al. (2013) near infrared
spectroscopy serves as a good tool in monitoring for impaired tissue perfusion during the
postoperative period, and detecting impairments early on particularly values obtained from
cerebral tissue.
Similar to Hansen et al. (2013), Bhutta et al. (2007) provides evidence to show NIRS has
the capability of accurately detecting cerebral tissue oxygenation in pediatric patients with a
history of cardiac problems. Subject populations in both studies have congenital heart defects
rendering impaired tissue oxygenation a serious threat. The studies were composed of rather
small study groups; Bhutta et al. (2007) utilized 29 pediatric patients while Hansen et al. (2013)
utilized 32 pediatric patients. The highly specific nature of this technology leads to the belief that
perhaps NIRS is more prompt and accurate when monitoring tissue perfusion, not only
postoperatively but intraoperatively as illustrated by Zulueta et al. (2013), compared to the
transcutaneous monitoring of pulse oximetry.
Investigation of pulse oximetry and the accuracy of the technology in the study
conducted by Carter et al. (1998) conclude pulse oximetry varies in accuracy with hypoxemic
pediatric patients. In contrast to Bhutta et al. (2007) and Hansen et al. (2013) this study focuses
on comparing different brands of pulse oximetry, excluding NIRS. Conversely, the research done
by Carter et al. (1998) is similar to the other studies because pediatric patients with already
compromised tissue oxygenation were used. The variability of pulse oximetry is illustrated from
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this study by the difference in measurements collected from the probes of two different
manufacturers.
Little question remains after reviewing the research of Zulueta et al. (2013) about the
reliability of NIRS in detecting cerebral and somatic tissue oxygenation with accuracy, and in a
timely manner. Similar to Bhutta et al. (2007) and Hansen et al. (2013) the study conducted by
Zulueta et al. (2013) utilized a small study group, comprised of 22 pediatric patients with
congenital heart disease predisposing them to low oxygen saturation. In contrast to the studies
conducted by Bhutta et al. (2007) and Hansen et al. (2013) this study not only demonstrated the
effectiveness of NIRS detecting impaired tissue perfusion, but also the promptness of the
technology.
Proposed Change
A recommendation for intensive care units, operating rooms, and catheterization labs at
ACH, is the use of near infrared spectroscopy in determining tissue oxygenation instead of the
current practice using pulse oximetry. The use of this technology allows for prompt and accurate
recognition of tissue oxygen saturation, aiding in quicker interventions, less time spent in
hypoxic states, and ultimately less complications seen in this patient population.
Change Strategy
Evidence based practice (EBP) mentors will be utilized to cultivate a vision of change in
settings implementing NIRS. Involving clinical experts such as nurse practitioners, nurse
educators, and critical care nurses, who have experience with NIRS will be utilized in sharing
knowledge and success stories with staff members. Establishing a leadership team composed of
various staff members who are enthusiastic about EBP is crucial to beginning the process of
change; these team members may choose to hold monthly meetings to track progress, regression,
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and plan accordingly. It is vital to obtain support from clinical practice administrators; presenting
the technology of NIRS and current research supporting its success is essential in gaining support
for change (Melnyk & Fineout-Overholt, 2011).
All stakeholders involved in the implementation of NIRS must be engaged, this includes
critical care nurses, operating room and catheterization lab nurses, nurse anesthetists, leadership
team members, nurse practitioners, physicians, EBP mentors, and research nurses. The
stakeholders need to have access to public search engines and databases to continue research on
NIRS and support the change. It is essential to identify and eliminate barriers to change.
Identifying those individuals who are influential in promoting change, and have authority to
make decisions must be utilized in the process (Melnyk & Fineout-Overholt, 2011).
Research must be combined with practice to bring about a permanent change in the
outlook of pediatric intensive care units, operating rooms and catheterization labs. The
technology NIRS will be successful when evidence is resilient, staff and environment are
sympathetic to the change, and the process is properly expedited. Physicians, nurse anesthetists,
and intensive care nurses who currently use NIRS technology can provide encouragement and
build team enthusiasm about adopting this new practice. Staff needs to be educated and trained
on the proper use of NIRS; knowledge deficits should be identified so gaps can be bridged
between how to use NIRS and why NIRS should be utilized, supported with evidence (Melnyk &
Fineout-Overholt, 2011).
A pilot study done in catheterization labs only will be useful in determining issues in
using NIRS and allows for the opportunity to iron out any problems before the practice is
implemented on a larger scale. Staff feedback can be applied to improve the change and allow
for a smoother transition and wider acceptance of NIRS (Melnyk & Fineout-Overholt, 2011).
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Acknowledging staff members critical in helping NIRS become integrated into practice
should be recognized; these team members will be more likely to help engage new practices in
the future if their effort and hard work is esteemed (Melnyk & Fineout-Overholt, 2011).
Rollout Plan
The rollout plan is developed to span one year, with steps taking place sequentially; the
first 11 months will be utilized to get NIRS in action, reserving the last month for creating a
method to present findings at facilities outside of ACH. The following is the sequence of events
for the rollout plan:
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January: develop a vision for changing current gold standard from pulse oximetry
to near infrared spectroscopy
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February: engage stakeholders with focus groups and presenting research
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March: evaluate physical environment, resources, and establish a practice change
team on each unit
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April: assess and eliminate barriers utilizing staff surveys and unit meetings
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May: train staff and stakeholders involved on proper use of NIRS technology with
education meetings
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June through August: deliver NIRS as pilot study in catheterization labs
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September: gain approval for change

October: circulate evidence from pilot study and educate staff with education
meetings on each unit

November: implement NIRS practice in all units, work out issues specific to each
unit, continue collecting data to support publications and presentations in the
future
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
December: analyze data, synthesize method to present data to other facilities

Ongoing: celebrate units’ success and acknowledge key team members with
cafeteria and uniform gift cards
(Melnyk & Fineout-Overholt, 2011)
Project Evaluation
Data will be collected from NIRS simultaneously with data collected from pulse oximetry
utilizing forms staff will fill out by hand; the patient will have a pulse oximeter probe attached to
the finger and NIRS probes attached to the head. Data collected from each method will be
compared to observe at what point in time impaired tissue perfusion is detected, in other words,
which method detects impaired perfusion sooner. Post-procedural care will be performed in the
usual manner. The data collected will be the amount of time the patients spend within the normal
range of tissue oxygenation (SctO2 70%-80% with the NIRS and SaO2 94%-100% with pulse
oximeter), and the actual O2 readings for each method will be recorded. A difference in time
between the initial NIRS alert versus the initial pulse oximeter alert of impaired tissue
oxygenation will show which method is more time efficient in detecting impaired tissue
perfusion in pediatric patients. Mean time values for pulse oximetry and NIRS will be compared;
the method which detects impaired tissue perfusion the quickest resulting in shorter periods of
hypoxia will be deemed more effective. Cerebral Hypoxia (2013) explains it only takes up to five
minutes of hypoxia to cause serious brain damage, and some brain cells die within three minutes.
Given this information, the method able to identify hypoxia to initiate treatment in three minutes
or less will be evaluated as more prompt and effective in reducing the amount of time pediatric
patients spend in life threatening hypoxic states.
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Dissemination of EBP
Caregivers at All Children’s Hospital implementing NIRS should share success stories
and experiences using NIRS with outlying pediatric facilities. This can encourage other staff
members to get involved and perhaps build their own teams to champion the use of NIRS in their
particular clinical settings. Staff from ACH, other hospitals and surgery centers- all of which
treat critically ill pediatric patients-should partake in educational in-services and training to
prepare for practice change. Eliminating knowledge and skill deficits will help to strengthen the
connection between how to implement NIRS and why NIRS should be implemented. Supporting
the change with evidence from units currently using NIRS, and also research exploring the
effectiveness of NIRS, will help to gain support on a larger scale. To aide in dissemination,
literature illustrating NIRS as quick and effective in monitoring tissue perfusion may be
published by project leaders, and unit presentations created during the final month of the rollout
plan can be offered at conferences nationwide. Continuing this EBP and sharing the outcomes,
has the potential to designate NIRS as the new gold standard for monitoring tissue oxygenation
in vulnerable pediatric patients locally, regionally, and possibly nationally.
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References
Bhutta, A., Ford, J., Parker, J., Prodhan, P., Fontenot, E., Seib, P., …Morrow, W. (2007).
Noninvasive cerebral oximeter as a surrogate for mixed venous saturation in children.
Pediatric Cardiology, 28(1), 34-41. doi: 10.1007/s00246-006-1379-z
Carter, B., Carlin, J., Tibbalis, J., Mead, H., Hochmann, M., & Osborne, A. (1998). Accuracy of
two pulse oximeters at low arterial hemoglobin-oxygen saturation. Critical Care
Medicine, 26(6), 1128-1183.
Cerebral Hypoxia. (2013). MedlinePlus. Retrieved
from www.nlm.nih.gov/medlineplus/ency/article/001435.htm
Hansen, J.H., Schlangen, J., Armbrust, S., Jung, O., Scheewe, J., & Kramer, H.H. (2013).
Monitoring of regional tissue oxygenation with near-infrared spectroscopy during the
early postoperative course after superior cavopulmonary anastomosis. European Journal
of Cardio-Thoracic Surgery, 43(2), 37-43. doi: 10.1093/ejcts/ezs581
Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare.
Philadelphia, PA: Lippincott Williams & Wilkins.
Zulueta, J.L., Vida, V.L., Perisinotto, E., Pittarello, D., & Stellin, G. (2013). The role of
intraoperative regional oxygen saturation using near infrared spectroscopy in the
prediction of low output syndrome after pediatric heart surgery. Journal of
Cardiothoracic Surgery. doi: 10.1111/jocs.12122.