625 Implementing Burn Padlet to Improve Interprofessional Collaboration Within the BTSD Interdisciplinary Team

This quality improvement project implemented and evaluated an evidence-based practice (EBP) program at two Army outpatient health care facilities. The EBP program consisted of five implementation strategies that aimed to inculcate EBP into organizational culture as well as nursing practice and culture. A conceptual model of the "Diffusion of Innovations" theory was adapted to explain the application of the program. The Institutional Review Boards at Walter Reed National Military Medical Center and Duke University School of Medicine reviewed and exempted this quality improvement project. A pretest-posttest design was used with four instruments at each facility. The EBP program was successful in enhancing organizational culture and readiness for EBP (p < 0.01) and nursing staff's belief about the value of EBP and their ability to implement it (p < 0.05). Another indicator that the EBP program achieved its goals was the significant difference (p = 0.002) in the movement of the outpatient health care facilities toward an EBP culture. These results suggest that this EBP program may be an effective method for empowering outpatient nursing staff with the knowledge and tools necessary to use evidence-based nursing practice.

Pragmatic Trials and Improving Long-Term Care: Recommendations From a National Institutes of Health Conference.

Objectives:The use of evidence-based practice (EBP) guidelines by psychologists working within the State Insurance Regulatory Authority (SIRA) compensation schemes for treating musculoskeletal injuries has been found to vary. The aim of this study was to qualitatively explore psychologists’ perceived barriers to adhering with EBP guidelines implemented by the New South Wales (NSW) SIRA.Methods:Registered psychologists (n= 20) working within the NSW SIRA compensation schemes participated in four focus groups conducted face-to-face (F2F) and online. Participants’ responses were audiotaped, transcribed verbatim and entered into NVivo 11 software. Text data were analysed to identify recurrent themes within and across groups (metropolitan, regional and rural).Results:Thematic analysis revealed three key issues: (a) a lack of trust in the validity of the recommended EBP guidelines; (b) lack of knowledge of the psychologist’s role in this context and insufficient skills to fully apply the guidelines, protocols and procedures; and (c) a poor fit between EBP guidelines, client presentations and circumstances, and the SIRA compensation schemes.ConclusionThe findings showed that both individual practitioner variables and contextual barriers influenced adherence to EBP. Practical implications for future research include generating recommendations to overcome the identified barriers using a collaborative approach between policymakers, researchers and practitioners.

Many clinical exercise physiologists recognize the term evidence-based practice (EBP) but may not understand its specifics or the rationale for using this framework in clinical care. The EBP process combines evidence from the literature, including findings from randomized controlled trials when available, with clinician expertise and patient preferences in order to guide clinical decision making (12,15,16). The intended outcomes of EBP are reducing the variability in healthcare delivery while increasing its quality and ultimately reducing healthcare costs (13,15). A solid understanding of the EBP process can assist exercise physiologists in improving their treatment decisions and patient outcomes. The purpose of this article is to describe EBP, its use in developing scientific statements, and the use of two types of scientific statements—Clinical Guidelines and Expert Opinion Statements—in clinical practice. Specific examples related to cardiac rehabilitation are provided.The EBP process includes six steps (15,20,22,23; Table 1). The first step is to ASK a clinical question specific to the population and condition of interest in a format that will yield the most useful and relevant research information. These questions are usually asked in a PICOT format: Patient population, Intervention or Issue of interest, Comparison, Outcome, and Time frame.The following is an example of a PICOT question: Among patients in outpatient cardiac rehabilitation programs (P), does the addition of cognitive behavioral exercise counseling (I), as compared to no cognitive behavioral exercise counseling (C), improve rates of adherence to the cardiac rehabilitation program (O) during the first six months (T)?The second step of the EBP process is to systematically SEARCH a variety of online library databases (such as Medline®, CINAHL®, and Embase®) for the most relevant evidence to answer the PICOT question. In this step, the goal is to conduct a thorough and systematic search, gathering all available evidence, including international studies written in English. Systematic reviews, meta-analyses, and well-designed randomized controlled trials are considered the strongest evidence (4,9,19). If one is fortunate and finds either of these two types of comprehensive reviews (systematic or meta-analysis) about the PICOT question, the searching process is easier because they often provide the reader a ready-made reference list of randomized controlled trials. This search step of EBP relies greatly on randomized controlled trials that contain the strongest and most valid research results. However, at times, less controlled studies are gathered. For example, if randomized controlled trials are not available, which is sometimes the case, additional credible types of information may be collected (controlled trials without randomization or case control and cohort studies). Sometimes, no research studies are found about a given PICOT question. In these cases, the person conducting the search collects whatever evidence is available.The third step is to critically APPRAISE the research evidence that has been found through a literature search. In this step, each identified study is evaluated to determine if the findings are valid, reliable, important, and applicable (13). In the cases where there are no well-controlled studies, other types of evidence that have been collected are appraised. Then, the overall body of evidence is synthesized to determine if findings from the various studies are in agreement or disagreement and the overall strength of the body of evidence regarding the PICOT question is determined (15).Step four is to INTEGRATE the evidence with clinical expertise and patient preferences to make a decision or a practice change. The fifth step is to EVALUATE the outcomes of the treatment decision or practice change. The final step is to DISSEMINATE findings and share outcomes with other clinicians and researchers. While the EBP process is time and labor intensive, it can dramatically improve patient care.Scientific statements are formal, highly organized summaries of evidence in an area of practice, published by experts, to provide recommendations for practice (7). When developing scientific statements, experts use the first three steps of the EBP process (ask, search, appraise) to compile and organize the evidence.The clinician generally uses institution policies in combination with his or her own knowledge base, information from the physical exam and history, laboratory reports, and the patient's own concerns about various treatment or exercise options to determine the best course of action. In order to stay current, clinicians typically keep up with the literature and healthcare trends through their professional societies, conferences, and publications. However, most clinicians do not have easy access to the vast amounts of existing data or the time to undertake extensive literature searches. Fortunately, experts have done much work on synthesizing research findings for clinicians and they have organized the results into scientific statements. Therefore, scientific statements developed via an evidence-based process can be tremendously helpful and save the clinician valuable time by summarizing the existing literature and organizing findings into practical recommendations and tools for use with patients (7). Alternatives to using an EBP might be using outdated knowledge or basing practice on experience alone—both of which might be detrimental to patients (15).The topics for scientific statements are often ones of current interest (a hot topic) that are selected by a special task force or suggested by members of a professional organization. The writing team consists of content experts and clinicians—from academic and nonacademic settings—representing different perspectives (research, clinical practice, education, administration, and policy) (7,14). Team members must be free from conflicts of interest or outside influences and must follow written policies should such a conflict arise.Many scientific organizations, such as the American College of Sports Medicine (ACSM), the American Heart Association (AHA), and the Academy of Nutrition and Dietetics (AND), publish scientific statements each year. In addition, a National Guideline Clearinghouse is maintained (8). It contains current, English-language, evidence-based practice guidelines to assist the clinician (www.guideline.gov).Variability exists in the degree to which scientific statements are evidence based. Those that are most complete are written by a group of well-known experts in the field, are usually from professional organizations, and include references from high-quality journals. In addition, they incorporate evidence from other experts in the field, including expert or consensus panels or clinically based and evidence-based practice committees. Moreover, well-written scientific statements follow the six steps of the EBP process (15,20,22). Scientific statements are less helpful if they use a broad PICOT question and therefore conduct a nonspecific review of the literature, do not summarize this broad literature well, present only statements of conventional wisdom, and/or have a short reference list (15).Scientific statements are of two different types: (1) Clinical Guidelines and (2) Expert Opinion Statements. A good understanding of both types of scientific statements, including their strengths and weaknesses, might encourage clinical exercise physiologists to apply these published recommendations more often in practice. Applications to practice as well as specific examples of scientific statements in the cardiac rehabilitation setting are provided.Clinical Guidelines (also known as Position Stands, Guideline Statements, or Practice Guidelines): These guidelines are systematically developed, evidence-based recommendations that result from a synthesis of the best available information (7). Clinical Guidelines identify which specific clinical questions they address and in which specific clinical populations. They address relevant PICOT questions and serve as a tool in clinical decision making (21). A Clinical Guidelines approach is used most typically when there is an intervention or a program with multiple interventions (such as cardiac rehabilitation) that needs to be systematically examined and evaluated. This approach can be used to determine the effectiveness of an intervention or a program in specific populations. This type of scientific statement also serves to identify specific gaps in the literature.Although various organizations develop Clinical Guidelines somewhat differently, there is generally much overlap in their approach. The writing group develops a list of target users of the guidelines, such as the clinical exercise physiologist. The team conducts a systematic review and critical appraisal of the literature, restricting their inclusion of lower-level evidence, such as scientific abstracts and conference presentations (6). The writing group then determines summary statements and overall conclusions/recommendations from the overall body of evidence.The writing team uses a rating system to assign a grade and sometimes also a class to summary statements and overall conclusions/recommendations. The rating system provides the reader with a sense of the strength of the overall body of evidence presented in the guideline. The clinical exercise physiologist is likely to see rating systems used by the ACSM (18) (see Table 2) and the AHA (6,7,24) (see Tables 3 and 4). As an example, an AHA recommendation with a grade of A and a class of I indicates that the recommendation is supported by the strongest evidence that a treatment is useful and effective.The development of Clinical Guidelines is a thorough process. Before releasing the guidelines, the writers must state that the committee has considered the benefits, the side effects, and the risks or harms involved in the recommendations. As a final step, Clinical Guidelines generally undergo multiple external reviews from other scientists and clinicians and concerns are addressed prior to publication. In addition, some organizations also seek comment from the public and the scientific community at large prior to publishing Clinical Guidelines.The strengths associated with Clinical Guidelines are that the methods used are rigorous, transparent, reproducible, and generally available for public view on an organization's website. They rely on best available evidence and particularly on results from randomized controlled trials. Clinicians can find the best evidence summarized in one document. Executive summaries accompanying the guidelines allow an exercise physiologist to focus on key points. Guidelines are a succinct way of discerning what is known and what it not yet known about a specific topic area. This helps to clarify future directions for research. Clinical Guidelines can enhance clinicians' understanding of the research within a specific topic area and inform the clinician as to best treatment approaches for optimal patient care. Clinical Guidelines undergo a much stricter process for development and external review than a general review article and thus carry more weight. They provide recommendations that can serve as standards of care and can have policy implications.Regarding weaknesses, the development of Clinical Guidelines is a time- and labor-intensive process, generally taking 12 to 18 months to develop. The process is a financially costly undertaking. Finally, Clinical Guidelines need to be regularly updated to reflect new research findings and developments in clinical knowledge. Overall, the strengths far outweigh the weaknesses.The application of Clinical Guidelines to practice: Through the use of Clinical Guidelines, clinical exercise physiologists can promote a spirit of inquiry in the clinical setting—a climate where clinicians are encouraged to identify big or pressing clinical questions specific to their settings and to use evidence-based documents to answer compelling PICOT questions (11). They can also be used to engage staff and stakeholders in assessing and eliminating barriers in practice and to share information with patients. As a result, the guidelines can increase clinical knowledge, spark in-depth discussions, promote critical thinking about important clinical questions, and may enable exercise physiologists to facilitate steps toward change.Guideline documents also generally provide instruction on how recommendations can be applied in a clinician's practice setting. By choosing guidelines with a stated objective in the exact topic area, a clinician can use the guidelines to find the evidence base and recommendations related to specific clinical questions about specific clinical populations. The guidelines can dispel misperceptions and eliminate the use of rote clinical policies that rarely undergo review. The widespread use of guideline statements can facilitate current, easily accessible, written policies for clinic staff and assist clinicians in determining whether their standard practices are current and their clinical decisions are evidence based. Guideline documents also generally contain a section on tools for application, which provides guidance on working with patients and implementing guideline recommendations in the clinical setting. The guidelines might also suggest the types of structural modifications and resources needed to implement a change in practice (8,11). Furthermore, the guidelines will identify specific variables or outcomes that should be measured before, after, and at a distal follow-up time point in order to ascertain the effectiveness and the sustainability of the implemented change or intervention. Finally, the guidelines can show whether there is sufficient evidence for the continuation of current practices, whether there is sufficient evidence to propose any new practices, and whether there is sufficient evidence to discontinue certain practices.Clinical Guidelines can also be practical tools for sharing information with patients. Often, patients will seek their own information on the Internet and will begin self-guided programs based on false or popularized information. Clinical Guidelines provide clinicians with straightforward, evidence-based information to share with patients. Clinical Guidelines are purposely presented in clear and specific language and the recommendations themselves are set apart and easily identifiable.Sometimes, patient preferences will be taken into consideration in the development of the Clinical Guidelines and can be shared with patients. These guidelines are also available to patients on the Internet, and when patients ask about the standards of care used in the setting, exercise physiologists can discuss the Clinical Guidelines used. An added benefit is that the professional organization that writes the Clinical Guidelines often develops or provides a link to trusted patient education materials that the clinician can also share with the patient.A specific example in Cardiac Rehabilitation: An example of Clinical Guidelines in cardiac rehabilitation is the AHA's 2007 Scientific Statement "Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update" (3). This publication updates the statement published in 2000 and identifies the core components that all cardiac rehabilitation/secondary prevention programs should contain to reduce cardiovascular disease (CVD) risk, teach and promote healthy behaviors, and reduce disability in patients with CVD. For each core component identified, the publication provides information on evaluation, interventions, and expected outcomes. These evidence-based recommendations are intended to assist cardiac rehabilitation staff as they develop and implement programs and to make a larger audience (such as healthcare providers, insurers, policymakers, and consumers) aware of the comprehensive nature of cardiac rehabilitation programs.Expert Opinion Statements (also known as Opinion Statements, Expert Consensus Statements, or Scientific Advisories): These statements generally result from experts reviewing a growing research base or clinical observations and may or may not include a comprehensive review of the literature. Specifically, an Expert Opinion Statement is developed when (a) an initial search of the literature shows there are not sufficient systematic reviews, meta-analyses, and high-quality randomized controlled trials to develop Clinical Guidelines, (b) it is already known that the topic has an insufficient research base, or (c) a professional organization simply wishes to comment on a topic in a very timely manner. Expert Opinion Statements provide a tool for a timely communication of recommendations and/or considerations for healthcare professionals and policymakers (1).Expert Opinion Statements—developed by unbiased reviewers from several disciplines working together—rely heavily on recent high-level publications (when available) and primarily represent the consensus of the leading experts in the field of interest following much discussion and debate (1,17). Thus, while Expert Opinion Statements are often informed by some available evidence, they are often considered evidence informed rather than evidence based and are far less scientifically rigorous than Clinical Guidelines.Strengths associated with Expert Opinion Statements are that they provide rapid, clear, consistent information on an emerging topic of importance/concern to the public and healthcare professionals (1). Given that not all areas of cardiac rehabilitation have studies at the level of randomized controlled trials as evidence, Expert Opinion Statements allow an opinion or advice to be delivered prior to the accumulation of a large body of research evidence.Weaknesses are that they rely heavily on expert opinions, observations, and smaller, less well-controlled studies. Furthermore, as research is conducted, information may develop rapidly and recommendations/advice may change, necessitating another rapid publication.The application of Expert Opinion Statements to practice: Expert Opinion Statements are an important resource for clinical exercise physiologists. Through the use of Expert Opinion Statements, clinical exercise physiologists can become experts in current healthcare and exercise trends. Clinicians can use the statements to provide their institutions with new ideas that might translate into innovative clinical changes. Expert Opinion Statements can clarify an issue and explain the need for action on an issue. Expert Opinion Statements can inform decision making and policy and, therefore, should be included when gathering evidence (15).When there is little to no research, Expert Opinion Statements serve as a consensus by experts to guide the profession and to present evidence that supports an intervention or a change or to motivate others around a politically charged topic. Thus, evidence in Expert Opinion Statements may be built and presented based on observations and experience (such as from related fields) or from established theory (such as from epidemiological theory or science underlying CVD or CVD risk factor reduction). As such, these statements give clinical exercise physiologists "a leg to stand on" when there is little or no research in an area of interest.Expert Opinion Statements are also a valuable resource for patients. Patients can gain information about what the experts in the field support, even without hard evidence. Expert Opinion Statements represent information from actual experts rather than popular celebrities or health websites created without expert input. Because Expert Opinion Statements are available to patients on the Internet, it is important for clinical exercise physiologists to be familiar with their content so they can direct their clients to the best options for care.A specific example in cardiac rehabilitation: An example of an Expert Opinion Statement relevant to cardiac rehabilitation is the AHA's 2012 Scientific Advisory "Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health Settings" (2). This publication highlights the fact that although there are numerous benefits to outpatient cardiac rehabilitation, referral rates remain very low. This publication is a call to healthcare professionals in inpatient and home health settings to facilitate the referral process to cardiac rehabilitation. The authors call for increased efforts by clinical exercise physiologists working in inpatient settings to communicate the clinical benefits of participating in outpatient cardiac rehabilitation programs. There are numerous randomized controlled trials, systematic reviews, and meta-analyses indicating its benefits on health outcomes (5,10). There are also a variety of studies that examine predictors of cardiac rehabilitation use and of referral to these programs. However, few or no randomized controlled trials have specifically examined the effect of inpatient and home healthcare referrals on overall cardiac rehabilitation participation rates. As shown in this example, Expert Opinion Statements rely less heavily on scientifically objective sources and more heavily on expert opinion.EBP is an approach to clinical care that relies on the best available evidence, clinician expertise, and patient preferences. EBP methodology requires a systematic and critical appraisal of the literature and is used to guide clinical decision making, resulting in reduced variability in how patients are treated and improved patient care and outcomes. Ongoing review of scientific statements within the clinical setting can (a) promote a spirit of inquiry, increase the clinical exercise physiologist's knowledge about specific topics, and help develop EBP expertise among staff; (b) clarify how recommendations can be applied in the clinical setting; (c) promote dialogue and policy change; and (d) provide a very practical resource for sharing information with patients. Clinical exercise physiologists are strongly encouraged to use scientific statements in their practice settings.Finally, we recommend the use of scientific statements to promote the development of EBP expertise in the clinical setting. A unit practice committee or administrator may take responsibility for keeping staff abreast of new evidence-based recommendations or clinicians may develop an EBP team that updates the staff on new scientific statements. A clinical exercise physiologist may be asked to take the lead in creating an EBP team. This team would review scientific statements for relevance to their specific clinical setting and population. The team may wish to seek assistance from an EBP expert with proficiency in article critiquing and evidence-based scientific statements. The EBP team can provide much needed mentorship to further develop the EBP knowledge base and a cadre of EBP mentors in their own clinical setting (11,15). A clinic environment that is supportive of the use of the EBP process in practice is optimal, and within that setting, a clinical exercise physiologist can use scientific statements to enhance decision making to improve patient care outcomes.

Dysarthria: Tools for Clinical Decision-Making

President's message-Maintaining a program of research: Deep work.

Division of Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine Chicago, IL Division of General Internal Medicine and Geriatrics Northwestern University Feinberg School of Medicine Chicago, IL Dr. Weiss received grant support from the National Heart, Lung, and Blood Institute (K23118139-01) and Parker B. Francis Fellowship Program and received support for article research from the National Institutes of Health. Dr. Baker has disclosed that he does not have any potential conflicts of interest.

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Aim To support trainees in completing specific and achievable quality improvement projects (QIP) that are beneficial to patient care and aligned with clinical priority areas in emergency general surgery. Method A fishbone analysis of factors contributing to poor outcomes in patients undergoing emergency laparotomy was created. From this, key priorities for improvement were identified by a multidisciplinary team, enabling multiple QIP with clear aims to be developed. QIP included National Emergency Laparotomy Audit (NELA) data capture, risk scoring and documentation of mortality, identification and management of sepsis, pre-operative antibiotics, infection prevention and early radiological imaging. QIP were allocated to groups of trainees comprising of at least one foundation doctor, one core trainee and one specialty registrar. Mortality and length of stay data was collected over 6 months using the run charts for the hospital site available at data.nela.org. Results In 6 months, 9 QIP were started, with the first cycle of data collected in all projects and 3 projects completed by trainees. Initial QIP results have been presented locally for 5 projects and 2 QIP have been presented nationally, thus supporting completion of ARCP requirements and specialty job applications, as well as the sharing of outcomes. Although not statistically significant a downwards trend in length of stay and mortality has also been observed. Conclusion Having a focused and co-ordinated approach to quality improvement with clear aims and objectives can support training and improve patient outcomes. Further study is required to assess the sustainability and longevity of these results.

Introduced in China in the late 1990s, Peripherally Inserted Central Catheters (PICCs) have undergone rapid development and are widely used to deliver chemotherapy for cancer treatment and to establish adult postoperative parenteral nutrition pathways (Zhong, 2007). The technologies and methods related to PICC insertion have also developed rapidly. The United States Infusion Nurses Society and Oncology Nurses Society have published a number of clinical nursing practice guidelines for vascular access devices (Alexander, 2011; Camp-Sorrell, 2011), which present the best practice evidence for multiple steps of the PICC insertion process, such as the selection and preparation of the puncture site and catheter insertion. Such guidelines aim to standardize the procedures, effectively utilize limited health resources, and protect the patients’ interests. The current PICC insertion procedure in our hospital was developed from experience-based standards and processes are mechanically executed. To address this practice problem, we conducted a project to explore how to effectively implement the best practice of PICC insertion in our hospital. Our hospital is a tertiary cancer care center, affiliated with Fudan University with approximately 400 PICC insertion cases per month. The vascular access care outpatient clinic is led by PICCs specialty nurses and currently staffed with 1 chief nurse, 5 full-time PICC insertion nurses, and 11 full-time point-of-care nurses. This clinic is also equipped with three vascular ultrasound systems. The PICO (Population, Intervention, Comparison, Outcome) question that guided the project was as follows: In patients receiving a PICC line insertion (P) how does use of best practice affect insertion procedures, (I) how does it compare to experience-based insertion procedures, (C) how does it affect patient outcomes and nursing outcomes (O)? Between October and December 2012, the following databases were systematically reviewed: The Joanna Briggs Institute Library (1998–2012), EMbase, Elsevier (1990 to present), Web of Knowledge, Ovid, China National Knowledge Infrastructure (CNKI, 1990–2011) and the Chinese Wanfang database. A Web-based review of relevant guideline websites and professional websites, including the National Guideline Clearinghouse (NGC) and the Registered Nurses' Association of Ontario (RNAO), were also conducted. Five PICCs insertion-related guidelines that were currently in use in the United States, the United Kingdom, and Canada (Alexander, 2011; Camp-Sorrell, 2011; O'Grady et al., 2011; Pratt et al., 2007; Registered Nurses' Association of Ontario, 2008) were obtained. The key terms used in this project included peripherally inserted central catheters or PICCs and best practice or ultraso* or modified Seldinger technique or insertion or chlorhexidine or maximum sterile barrier or catheter tip location and position or complications. Fudan University Evidence-based Nursing Center is one of the cooperation centers of Joanna Briggs Institute (JBI) so the JBI evidence grading system version 2010 in Chinese was used for appraisal (Yan Hu, 2012). When determining appropriate catheter length, a PICC insertion nurse should use a measuring tape to measure from the point of venipuncture, over the course of the selected venous pathway, across the shoulder to the right side of the sternal notch, and down to the third intercostal space (Level III; Camp-Sorrell, 2011; Claasz & Chorley, 2007). Two percent of chlorhexidine gluconate ethanol solution is recommended to disinfect the skin at the catheterization site (Level I; Camp-Sorrell, 2011; Registered Nurses’ Association of Ontario, 2008). During the PICC insertion process, a maximum sterile barrier should be established. The operators should wear masks, hats, sterile powder-free gloves, a sterile gown and spread large, sterile sheets; the patients should wear masks and hats, and their entire body should be covered with sterile sheets (Level I; Alexander, 2011; O'Grady et al., 2011; Pratt et al., 2007). Vascular ultrasound guidance combined with the modified Seldinger technique should be used to insert the PICC catheter into the upper arm, especially the right upper arm, which lead to improved puncture and catheterization success rates and reduced complications related to mechanical damages (Level I; Li, Yan, & Zhang, 2013; Zhang et al., 2011). The optimal position for the catheter tip is from the lower third of the superior vena cava to cavoatrial junction; however, the catheter tip should not enter the right atrium (Level I; Infusion Nurses Society, 2006; National Association for Vascular Access Networks, 1998). Markers for determining the optimal position of the PICC tip on chest X-ray films include the carina of the trachea, the right main bronchus angle, and the upper right edge of the heart shadow, and position 4 cm or two thoracic vertebrae below the carina of trachea are considered appropriate (Level III; Baskin, Jimenez, Cahill, Jawad, & Towbin, 2008; Liu, Zhao, & Wang, 2011; Mahlon & Yoon, 2007). When the PICC have been inserted to the predicted length, an ultrasound probe can be used to detect the jugular vein on the catheterization side to exclude the possibility that the catheter tip entered the jugular vein and to facilitate timely adjustment (Level II; Bullock-Corkhill, 2010; Schweickert et al., 2009). Vascular ultrasound system is recommended to distinguish arteries, veins and nerves or nerve bundles to prevent the accidental perforation of arteries or nerves (Level II; Jin, 2005). The steps of the PICC insertion procedure in our hospital were formed based on the nurses’ experiences. This situation was not conducive to establishing and implementing a best practice. In order to ensure the safety of patients and improve the quality of care, we needed to use the current, best scientific evidence that was available to guide our PICC insertion practices. Before applying the body of evidence to our practice, we formed the project team. The team was led by the nurse researcher, directed by the head nurse of the clinic and supported by the director of hospital nursing service department. The seven-member team ultimately included PICCs insertion nurses, the head nurse, the director of the nursing department, a diagnostic radiologist and an interventional radiologist. The process utilized for integrating the evidence into practice included five steps. A situational assessment and analysis was conducted prior to the clinical implementation of the evidence: (a) an assessment of hospital resources and facilities, current rules or processes, the staff workload, the use of related materials; (b) interviews were conducted with the head nurses and PICC insertion nurses related to attitudes toward the existing PICC insertion process, the practical difficulties expected for evidence implementation, and director's support for and attention to the process; (c) an assessment of the feasibility and complexity of the planned implementation of best evidence for PICC insertion in hospitals, with or without an increase in the workload of the PICC insertion nurses and the nurses’ acceptance of the practices. Based on the assessment of evidence from the literature and our existing procedure, supports or barriers were identified and analyzed, and strategies of maximum resources utilization and evidence-based implementation were developed. For example, the mark, which used to detect the PICC tip position in our hospital, was the count of the rib on X-ray images. It was quite different from the best evidence synthesized at the beginning of the project. Therefore, the recommended detection of the PICC tip position was one of the revised items in PICCs insertion procedure. Additional evidence-based changes were: The implementation of 2% chlorhexidine for disinfectants and a maximum sterile barrier for patients; the use of vascular ultrasound technology; the identification of artery, vein, nerve and the catheter migration into the jugular vein using vascular ultrasound. The vascular access management software was improved by adding information about the catheter tip location, the one-puncture success rate, the tube insertion success rate, and the incidence of complications during catheterization, such as primary catheter malposition. The preliminary investigation conducted before the evidence-based changes were implemented revealed that although the nurses had received the Shanghai Institute of Nursing PICC insertion competency certificate, their training had mainly focused on technical operations; the nurses lacked theoretical training, and their basic knowledge of evidence-based nursing was relatively weak. Before the evidence was implemented, PICC insertion nurses and managers who participated in this project were educated on the updated evidence related to PICCs, new PICC insertion process and relevant documentation requirements. A video demonstrating the new PICC insertion process was produced for training PICC insertion nurses. As a result, full preparation for the transition to the new, evidence-based PICC insertion practice was provided. After receiving permission from the hospital's institutional ethics review board, the PICC insertion checklist and newly revised PICC insertion process was implemented in clinical practice. Core team members were available to answer questions, address issues that arose during the implementation, and provide timely feedback and solutions. It was vital to build in structures and processes to ensure continued and appropriate use of the interventions. A PICC insertion checklist was developed to monitor the quality of PICC insertions conducted by the nurses. This documentation form included the patient ID number and patient identity verification and recorded all the steps according to the PICC insertion process and each item could be marked as “conform” or “did not conform.” The checklist was spot-checked and completed by the chief nurse on the unit. Meanwhile, case study meetings were organized to discuss prevention and treatment measures for common complications that arose during the catheterization processes. After the completion of the clinical implementation, the managers and all PICC insertion nurses met for a discussion and summary to determine areas for further improvement. The data for 867 patients who underwent PICC insertion in the vascular access care outpatient clinic was collected in July and August 2013 before the evidence-based practices were implemented. The period from October 2013 to February 2014 was the implementation phase for evidence-based PICC procedures. The data with 742 patients were recorded and then compared with those before the implementation of the evidence-based protocol. With the provision of additional education, the average knowledge score of nursing staff increased from 110.7 to 118.3 out of a possible total score of 120 on a PICC line insertion knowledge test designed by the team. As part of the education program, all five PICC insertion nurses were trained about PICC insertion updated knowledge about upper arm catheterization under ultrasound guidance combined with the modified-Seldinger technique. The implementation of this evidence-based intervention improved the quality of care in the vascular access outpatient care clinic, as reflected in the following patient outcome indicators: The percentage of patients who chose the upper arm instead of traditional forearm catheterization increased from 98.96% (858/867) before the implementation of evidence-based practices to 99.87% (741/742) after the implementation. The result of Fisher exact probability method showed the difference to be significant (p < .05). The PICC insertion nurses’ updated knowledge related to selection of the catheterization arm also improved patient outcomes. The results of the chi-square test indicated that the percentage of patients (81.4%, 604/742) whose PICC catheter tip reached the optimum position was significantly higher than that (75.78%, 657/867) before the changes (p < .05). Finally, implementing improvements in the methods for measuring the PICC catheter insertion in vitro improved the patient outcome of accurate targeting of the PICC catheter tip in the lower 1/3 of the superior vena cava or cavoatrial junction, and not into the right atrium. Before the changes were implemented, the nurses adjusted the catheter in 19.39% (32/165) cases with the PICC catheter tip positioned too deep. The percentage increased to 47.37% (45/95) cases after the evidence-based practice change. This finding was statistically significant (p < .001). The results showed that the ability of nurses to detect the PICC tip position on X-ray image significantly improved when the catheter tip was positioned too deep. One difficulty in the implementation of evidence-based practices is the normalization of such practices. In addition to training, an effective way to continuously strengthen practices is to integrate them into the daily work of nursing. In this study, we revised the PICC insertion procedures and conducted training to integrate evidence-based practices into the operational procedures. The operational procedures could change the behaviors of the nurses and ultimately enable them to achieve mastery of evidence in their daily work while normalizing the new practices. Continuous strengthening of the evidence and monitoring of implementation measures are key factors in normalizing best practices (Aitken et al., 2011). The primary role of monitoring is to ensure the effective implementation of the evidence-based measures, and the normalization of the changes. In addition, continuous monitoring could reveal whether the current measures required modification or whether new measures needed to be added. The implementation of evidence-based innovations in this project was monitored by the chief nurse using the PICC insertion checklist. During the group discussion on evidence implementation that was part of this project, the nurse researcher and PICC insertion nurses found that some barriers influenced the adherence to evidence-based PICC procedure, such as the inconsistencies between what “they knew” and what “they do.” The key to overcoming this barrier and reduce these inconsistencies was to allow the learned knowledge to be effectively applied in clinical practice. The evidence informs the practitioners about what to do, but the specific procedures still need to be further refined and developed by researchers and practitioners according to specific clinical scenarios, including details pertaining to time, frequency, objects, methods, approaches, recording, and feedback. It is important to progress from experience-based practice to evidence-based practice, and use scientific evidence to guide our practices, to ensure the safety of our patients and improve quality of our care. During the best practices implementation process, it was essential to take full advantage of the functional roles played by researchers, care managers and PICC insertion nurses; apply effective strategies consistent with the clinical context; and make efforts to apply the evidence to daily work to ensure effective implementation. The outcomes of the implementation project were reported to the nurses in the clinic, the IV-team members, and the nursing quality supervisors in our hospital. The implementation protocol was introduced across the hospitals affiliated with Fudan University. Project results were disseminated through oral presentations at four regional and international doctoral student forums and oncology nursing conference. The best evidence on PICCs insertion developed in this project will be published on the website of Fudan University Evidence-based Nursing Center.

Incorporating Quality Improvement Projects Into Stroke Care and Research.

Aims This QIP aims to improve communication and information sharing between the community LD team, administration team, service providers and wider stakeholders, to ensure patient safety. The primary objective is to evaluate local initiatives to improve communication between MDT professionals and wider stakeholders. The secondary objective is to improve patient safety and staff satisfaction. Methods The COVID-19 pandemic created unprecedented communication challenges within the workforce and highlighted areas requiring review; this included information sharing among internal and external teams, collaborative teamworking, support in absence of senior clinical leadership and transition pathways from Child and Adolescent Mental Health Services to adult LD services. The QIP was initiated in March 2021. The discovery process included an initial consultation exploring practitioners’ experiences, areas for development and to share ideas for good practice. We used QI methodology, following ‘plan-do-study-action’ cycles, to analyse change. Change ideas included a single point of contact for internal and external queries, regular complex case management meetings, development of a referral process and clinical review for complex cases along with teaching sessions. Qualitative feedback from the team pre- and post-intervention, at baseline and regular follow-up intervals, in the form of monthly team meetings, emails, focus-groups and semi-structured interviews. Results A full thematic map was created after initial consultation; themes included communication improvement between teams and external agencies, timely support for complex case management, improving transition processes and development of robust clinical review processes. Qualitative feedback has been collated, analysed and final recommendations to be shared with the MDT professionals Conclusion Preliminary results have shown improvements in communication among the MDT, stakeholders, and external agencies. The consultation process highlighted that there is a substantial need for standardisation and consistency within communicative practices to promote enhanced care delivery and improved patient outcomes.

The TREAD Evidence-Based Practice Model is a framework for faculty to use in graduate research courses so students can become excellent consumers of the best available evidence to use in their clinical decision making in the practice setting. This model is based on competency in information literacy as the basis for developing evidence-based search strategies to find, appraise, and synthesize Level I evidence, including systematic reviews, meta-analyses, and evidence-based practice guidelines. This model emphasizes the use of standardized critical appraisal tools, such as the Critical Appraisal Skills Programme (CASP) or Appraisal of Guidelines for Research and Evaluation (AGREE), to facilitate user-friendly rapid appraisal of Level I evidence. Faculty are challenged to embrace this paradigm shift, to unlearn how they learned, and to teach their graduate research course focusing on the importance of Level I evidence to enable their graduates to make informed advanced practice decisions and improve patient outcomes.

IntroductionMethicillin-resistant Staphylococcus aureus (MRSA) is a common pathogen in burn injured patients. Many studies have evaluated the overall utility of MRSA nares swabs for antimicrobial stewardship; however, there is a paucity of data in burn patients. The purpose of this project was to evaluate the diagnostic performance characteristics of MRSA nares in burn patients at an academic medical center.MethodsThis retrospective, single-center chart review included admitted adult burn patients from July 2020 to December 2023. It excluded patients without a MRSA nares swab and a bacterial culture in the same admission, only a urine culture, or a length of stay less than 48 hours. The primary objective was to determine the overall negative predictive value (NPV) of MRSA nares in the burn patient population. Secondary objectives included determining the sensitivity, specificity, positive predictive value (PPV), and the diagnostic accuracy MRSA nares for each specific culture type.ResultsThere were 965 patients screened and 72 included. Median (IQR) age was 58 (37, 66) years and most were Caucasian (56.9%) and male (76.4%). The most common burn mechanism was flame (41.7%). Median (IQR) TBSA burn was 18% (5, 31.5) and 23.6% had inhalation injuries. Most patients required surgery (83.3%) and admission to the surgical trauma burn intensive care unit (79.2%). There were 223 cultures evaluated, with blood cultures being most common (58.7%). Fourteen patients had positive MRSA nares and the overall prevalence of MRSA infections was 16.7%. Median (IQR) time from MRSA nares to first culture was 0 days (0,0.6). For the primary outcome, the NPV of MRSA nares was 93.1% [95% CI 82.5-97.8%]. Secondary outcomes are in Table 1.ConclusionsThe high NPV calculated in this study is consistent with previous literature, demonstrating that this test may potentially be used to rule out MRSA infections when negative.Applicability of Research to PracticeWhile this retrospective chart review is limited by size, it provides valuable information regarding the utility of MRSA nares in burn patients. Overall, this study showed that MRSA nares may be utilized along with other clinical markers to decrease use of empiric antimicrobials targeting MRSA.Funding for the StudyThere is no external funding for this project.

The Burn Unit of the Department of Traumatology in Zagreb, established in 1970, is the only specialized burn unit in Croatia and serves patients with severe burn injuries from across the country and neighboring regions. It was the first center in Croatia to integrate surgeons, nurses, and other healthcare professionals into a dedicated multidisciplinary burn care unit. The unit includes an operating theatre, an intensive care unit for critically burned patients, and a surgical ward. In 2007, the Clinical Unit of the Tissue Bank was established within the Department of Traumatology and later integrated into the Sestre milosrdnice University Hospital Center. The introduction of tissue banking and keratinocyte culture significantly improved survival outcomes in patients with extensive burns, while simultaneously increasing the clinical and organizational demands placed on burn nurses, who are actively involved in tissue sampling, application procedures, and post-application care. Burn nurses play a central role in the comprehensive management of burn patients, applying specialized protocols, ensuring continuity of care, and supporting patients throughout acute treatment and recovery. However, the increasing complexity of burn care, combined with workforce reduction and high physical and emotional demands, has made burn nursing progressively more challenging. This commentary highlights the critical importance of a comprehensive burn nursing team approach in sustaining high-quality burn care and supporting both patient outcomes and nursing practice within the Zagreb Burn Unit.