EBP and Consensus Guidelines for ICU

Authored by Jesse

In my role as Clinical Nurse Consultant in Intensive Care I have to regularly review the things we do in daily practice against the best available evidence. Unfortunately, due to the processes and politics of many organisations, there is significant duplication in clinical practice guidelines. One of the most frequent complaints I have when reviewing expired or forthcoming guidelines, is that the search strategy and evidence appraisal process is not transparent, and that the top references are just those of sister hospitals’ guidelines. The problem that arises from this is that practice guidelines can be easily compared current practice and if no discrepancies exist then the guideline is deemed contemporary. Last year when tweeting for advice regarding tracheostomy care best practice, Kaye Rolls (@Kaye_Rolls) directed me to the work of the NSW Agency for Clinical Innovation. This organisation is built around a knowledge translation and best practice philosophy and the website hosts a huge compendium of evidence based (& consensus) practice guidelines for all healthcare specialties. Below, I have included links to just a handful of high quality guidelines that have help inform practice and review in my unit.

Tracheostomy Care – http://www.aci.health.nsw.gov.au/resources/respiratory/tracheostomy/acute-tracheostomy

Central Venous Access Device Managementhttp://www.aci.health.nsw.gov.au/resources/intensive-care/central_venous_catheters_cvc/cvad

Pleural Drains / Intercostal Catheter Managementhttp://www.aci.health.nsw.gov.au/resources/respiratory/pleural_drains/pleural-drains

Non-Invasive Ventilation For Acute Respiratory Failure http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/239740/ACI14_Man_NIV_1-2.pdf

In addition to evidence based practice guidelines, the NSW Agency for Clinical Innovation (@NSWACI), is the hub for a number of clinician collaboration networks. I have been a member of ICU Connect since mid-2015 and have found it immeasurably helpful forum for benchmarking practice, particularly in areas where guiding literature is sparse. So just like embracing #FOANed, I’d urge every nurse interested in creating communities of practice to join the conversation.

ICU Connecthttp://www.aci.health.nsw.gov.au/networks/intensive-care/clinicians/icu-connect

 

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Editorial check: Wayne Varndell

Domestic Violence and the ED: AENJ Hot Topic #FOANed

Peer reviewEditor’s Note: In a second installment from newly appointed Associate Editor and author, Wayne Varndell presents a snapshot of a current political and social priority and how it relates to those working in Emergency Care. Periodically the Australian Emergency Nursing Journal intend to release a number of “Hot Topic” publications from recent and older journal issues as Free Open Access articles. Due to a dearth of high-quality free accessible literature to support nursing practice, Wayne will bring us a round-up each time a new “Hot Topic” release occurs. Once again by way of disclosure, no member of the editorial team receives any incentives from AENJ and these blogs are intended to promote quality evidence based nursing materials to a wider readership.

 

 


 

Authored by Wayne

Domestic violence is a pervasive, global problem of serious proportion. In Australia, the majority of dangerous, abusive and violent behaviour that occurs in the privacy of people’s homes is committed by men against women, with one woman dying per week.1 Men experience dangerous, abusive and violent behaviour, with one man every ten days dying in Australia.2 A study in Victoria found that deaths from intimate partner violence made up 2.3% and 12.9% (femicide and suicide, respectively) of the disease burden, and at the time of the report, intimate partner violence represented a greater disease burden than many well-known risk factors such as high blood pressure, smoking and obesity (Figure 1).3

 

Domestic violence graphFigure 1: Top eight risk factors contributing to the disease burden in women aged 15-44 years, Victoria, Australia, 2001.

As one of the primary health services, the emergency department is frequently used by those in a violent relationship, and is commonly seen as the first point of refuge. However, victims of intimate partner violence may be reluctant to disclose the violence unless asked directly by clinicians. Despite valid and reliable screening tools being available,4 routine screening for intimate partner violence in the ED setting is low, contrary to evidence suggesting that when asked directly, a significant number of victims disclose the violence.5, 6 While intimate partner violence against women has become more known and studied, more research and action is needed regarding male victims of intimate partner violence.

The emergency department is for many people, the first and often continuing point of medical assistance and safety. Intimate partner violence remains one of the greatest disgraces in Australia. Through increased awareness, screening and early intervention it can be dramatically improved. The Australasian Emergency Nursing Journal is pleased to provide open-access to essential content on ways and means to improve identifying and responding to victims of intimate partner violence within the ED setting:

 

References

  1. White Ribbon. Why is the work of White Ribbon important? 2015 [cited 2015 November]; Available from: http://www.whiteribbon.org.au/white-ribbon-importance.
  2. Dutton, D. and Nicholls, T., The Gender Paradigm in Domestic Violence Research and Theory: Part 1—The Conflict of Theory and Data. Aggression and Violent Behavior, 2005. 10(6): p. 680-714.
  3. Victorian Health, The health costs of violence: Measuring the burden of disease caused by intimate partner violence – a summary of findings., Department of Human Services: Victoria.
  4. Rabin, R., Jennings, J., and Bair-Merritt, M., Intimate partner violence screening tools. American Journal of Preventative Medicine, 2009. 36(5): p. 439-445.
  5. Schimanski, K. and Hedgecock, B., Factors to consider for family violence screening implementation in New Zealand emergency departments. Australasian Emergency Nursing Journal, 2009. 12: p. 50-54.
  6. Ramsden, C. and Bonner, M., An Early Identification and Intervention Model for Domestic Violence. Australasian Emergency Nursing Journal, 2009. 5(1): p. 15-20.

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#FOANed From Australian Emergency Nursing Journal

Editor’s note: Of late I have spent an increasing amount of time searching for quality, accessible, nurse driven open access content. Two things have struck me: 1) there are a huge number of nursing blogs that have had no new content for 2-5 years; and 2) We are not advancing and discussing the evidence base of our profession in an online environment. Enter Wayne Varndell, Clinical Nurse Consultant at Prince of Wales Hospital Emergency Department, NSW Branch President for the College of Emergency Nursing Australasia, and Tweeter for @TheAENJ. For this post Wayne has put together a tasting plate of great open access journal articles from the AENJ over the past two years. If you like what you read be sure to check out the fully free February volumes from 2008-2015 here. I have absolutely zero conflict of interest to declare in relation to AENJ, I just think it is a great journal, with articles that are accessible and translatable for the shop floor critical care nurse. While open access journals are nothing new to the world, nursing has a stronger push culture in education as opposed to pull. Many nurses respond well to education materials placed at their fingertips as opposed to those that must be sought out. So hopefully with a broad range of topics in the included articles, some unknown-unknowns may be uncovered, curiosities piqued and an appetite for evidence ignited. Kudos to Professor Ramon Shaban and the editorial board of AENJ for supporting #FOANed. There is now a ‘FOANed Articles’ tab on the landing page guiding to free open access articles from a range of issues.

#FOANed-4

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature Natalie Hood, Julie Considine 18(3): 118-137

Spinal immobilisation has been a mainstay of trauma care for decades, yet there are no high-level studies assessing its efficacy in preventing further neurological. Routine application is questionable, and should be considered on a patient-by-patient basis.

 

Assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients and implications for emergency nursing practice: A systematic literature review Wayne Varndell, Doug Elliott, Margaret Fry 18(2): 59-67

The assessment and management of sedation for critically ill intubated patients requires highly-complex skills, knowledge and expertise, yet is routinely undertaken by emergency nurses. No state or national models of education or training for this extended practice were identified; no research has addressed the safety and efficacy of continuous sedation of critically ill intubated patients in ED.

 

HIRAID: An evidence-informed emergency nursing assessment framework Belinda Munroe, Kate Curtis, Margaret Murphy, Luke Strachan, Thomas Buckley 18(2): 83-97

Emergency nurses must be highly skilled at performing accurate and comprehensive patient assessments, a structured systematic approach that is evidence-based, can enhance clinical performance, and improve patient care.

 

Turkish parents’ management of childhood fever: A cross-sectional survey using the PFMS-TR Nursan D. Cinar, İnsaf Altun, Sevin Altınkaynak, Anne Walsh 17(1): 3-10

Parent’s practices in managing their child’s fever can be enhanced, and trigger appropriate action

through the use of an 8-item Parents’ Fever Management Scale.

 

Patient characteristics and institutional factors associated with those who “did not wait” at a South East Queensland Emergency Department: Who are those who “did not wait” in ED? Nicola Melton, Marion Mitchell, Julia Crilly, Marie Cooke 17(1): 11-18

Patient’s who elect to leave the ED prior to completing care are a key concern for emergency clinicians. Understanding the characteristics of patients who leave, might enable strategies to be developed to mitigate the potential risk, and keep patients engaged.

 

The quality of life of flood survivors in Thailand, Nakhon Pathom Rajabhat University Wanpen Waelveerakup 17(1): 19-22

The flood crisis of 2011 was a disaster of the highest order in Thailand and Nakhon Pathom Province; understanding its impact on survivors’ health and quality of life after returning to normal life is important in designing and delivery healthcare and aid.

 

Implications of the emergency department triage environment on triage practice for clients with a mental illness at triage in an Australian context Marc Broadbent, Lorna Moxham, Trudy Dwyer 17(1): 23-29

The architectural environment of triage, the first and continuing point of contact for consumers presenting to ED, impacts on mental health consumer’s behaviour, and limits the ability for emergency clinicians to assess and provide optimal care for this vulnerable cohort.

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Learn to Take the Heat at SMACC Dublin

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Next week the second (much smaller) round of SMACC Dublin registrations go live. In all the hype, don’t forget you can go back and add pre-conference workshop registrations at any time until they are sold out. Too many to decide? Curious about Stress Inoculation Training? Want to find out if Swami exists in real life? We have the workshop for you! Jump on http://www.smacc.net.au and be part of the team looking out how to translate training from other high performance professions into medical education.

Here is a preview of just some of what may be in store for you.

 

For a wrap up from SMACC Chicago check out http://lifeinthefastlane.com/learning-to-take-the-heat-at-smaccus/

And for some excellent content on high performance psychology for clinicians, check out my good friend Jason Brooks’ site http://www.phenomenaldocs.com

For more great high performance and stress inoculation FOAM form Mike Lauria go to http://emcrit.org/author/mikelauria/

SMART Goals for Simulation Learning Objectives

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As educators move to use simulation as a teaching modality, there can be a tendency to start with the simulator (mannequin) and work backward, allowing the tools to define the goal. With the rise of modern the healthcare simulation “industry”, many hospitals have invested heavily in simulation technology, with less attention paid to technique.

In attempting to develop and refine goal-directed simulation, we can learn from long-standing practices in other domains. First published by Doran in 1981, the S.M.A.R.T. Goals mnemonic aids in the refinement of an objective into a statement of anticipated results. SMART, grounded in the project management sector, has reasonable applicability to the development of learning objectives for education in it’s generic form. For the Teaching Course New York, I have paired up with Brent Thoma (@Brent_Thoma) for a breakout session focusing on quality improvement through simulation. As a Flipped Classroom teaching exercise we are circulating the below exercise to participants to take home, develop an objective, and return to the course tomorrow to present, discuss and revise. As part of this process, Brent and I have created a modified SMART template aimed specifically at the development of learning objectives for simulation education. We would love your feedback and suggestions (in the blog comments) to keep refining this tool.

References

Doran, G. T. (1981). “There’s a S.M.A.R.T. Way to Write Management’s Goals and Objectives”, Management Review, Vol. 70, Issue 11, pp. 35-36.

Wikipedia (Last modified Nov 2015), “SMART Criteria”, accessed 12th Nov 2015.

Goal Directed Simulation at The Teaching Course New York

NYC

It is with great excitement and a healthy case of imposter syndrome, that I will be coordinating the simulation workshop at the Teaching Course in New York on the morning of November 13th. In what could only be described as a Dream Team faculty, we will be running 2hrs of small group mini-workshops, followed by a super panel Q&A focusing on debriefing. We want to supercharge the workshop and maximise the participants access to some of the best clinician educators in the business, so I have curated this Flipped Classroom curriculum for In Situ Sim. These are a selection of some of the best FOAM resources to broaden knowledge on the topics that will be workshopped at #TTCNYC15

The first two hours will comprise a brief introduction and overview to the concept of Goal-Directed In Situ Simulation followed by four break out mini workshops:

The Fiction Contract – Confederates and Simulated Patients  – Natalie May & Salim Rezaie

Titration of Stress – Chris Hicks & Swami

Pre-brief and Debrief the bread of the Sandwich – George Willis & Simon Carley

QI through Simulation – Jesse & Brent Thoma

#FOAMed

General Overview of In Situ Goal-Directed Sim

Injectable Orange –  Simulation Basics – Back to the Future Podcast

St Emlyn’s – Top Ten Tips for In Situ Sim Blog and Podcast

Injectable Orange – Tips for Team Simulation blog

ICN — Guerilla Sim: Anyone, anytime, Anywhere (Jon Gatward’s talk at SMACC 2013)

LITFL CCC — In situ simulation (overview of pros and cons and safety issues in in situ simulation)

 

Building Fidelity in In Situ Simulation – Fiction Contract

Injectable Orange – Plants in Simulation Vodcast

St Emlyn’s – Actors in Simulation (Nice review of Natalie May’s simulation experiences at SWEETs 15)

KI Docs — Tim Leeuwenburg’s excellent Simulation apps review

 

Titration of Stress in Simulation – Stress Inoculation

SMACCUS Stress Inoculation Training – Intro podcast from the Swami

Life in The Fast Lane – Review of Stress Inoculation Training workshop + resources a plenty

 

Pre-briefing and Debriefing – The Bread of the Sandwich

Jenny Rudolph and Harvard Sim Team – Establishing a safe container for learning in simulation: The role of pre-simulation briefing – Journal article 

iTeachEM  Thorough Vodcast overview of Simulation Debriefing from Sim expert Danielle Hart

St Emlyn’s – A great blog on real world Debriefing from Natalie May – not specific to simulation, but incredibly applicable to In Situ sim.

MobileSim – Excellent blog resource on Debriefing with a great structured approach to In Situ Sim debrief

Injectable Orange – Debriefing: a little carrot, a little stick – blog with quick beginners guide tips for debrief.

 

In Situ Simulation Resources for Quality Improvement

MobileSim –  MobileSim (Jon Gatward’s excellent in situ simulation website including guides, templates and scenarios

INTENSIVE – ICU-IS-SIM (resources for the in situ simulation program at The Alfred ICU, including scenarios)

Injectable Orange Templates – These documents are pro-formas that may assist with planning and evaluating scenarios Scenario Template (doc) & Post Scenario Report (doc)