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Learning While Going Through the Process of an Evidence-Based Practice Project

Nancy M. Beck MSN, RN, NDP-BC

Jackie Bradstock BSN, RN, PCCN

The Johns Hopkins Hospital, Baltimore, MD, USA

Practice Question

At The Johns Hopkins Hospital (JHH), policies and protocols require renewal every three years, necessitating review of the most recent evidence. A team of clinical nurses, clinical nurse specialists, and educators who sit on JHH's Department of Surgery standards of care committee reviewed the chest tube policy. Through conversation, the team discovered that practices as well as level of comfort when caring for a patient with chest tubes varied between units and departments.

After identifying these discrepancies, the committee decided they would use this opportunity to complete their first EBP project using the JHEBP model.

The team developed the background EBP question:

What are the best practices for nursing management and care of chest tubes (I) in the in-patient setting (P)?

Evidence

The EBP team completed a review of the literature using numerous search terms (e.g., chest tubes, dressings) in PubMed and CINAHL. The medical librarian at JHH was essential in completing this literature search. Keywords searched included chest tube, placement, insertion, removal, pain, pain management, dressing, occlusive dressing, securement, stripping, milking, suction, drainage, assessment, education, best practice, guidelines, and policies. Inclusion criteria included English language journal, adult patients, and publication within the last 10 years. The articles underwent a title, abstract, and full text screening for relevance to the practice question by two individual reviewers. The group organized the results using specific categories. Initially the research yielded 173 articles. Of these articles, 31 met inclusion criteria. The team appraised those 31 articles for level and quality using the JHEBP model; see Figure 10.1.

Figure 10.1

Articles appraised, listed by level and quality.

The evidence entailed six random control trials (RCT), 11 clinical practice guidelines, and three quality improvement (QI) projects, with the remainder being quasi-experimental, systematic reviews, prospective descriptive, and quantitative designs. Overall, synthesis of the evidence revealed a lack of compelling evidence to make drastic changes to the protocol. Our current practice for accidental tube removal was consistent with the literature. The evidence did not indicate a superior method for tube-to-tube securement or chest tube dressing. Several articles supported digital over analog drainage systems. Evidence also indicated that delivering education to nurses by self-learning modules was effective, and the use of a bedside checklist might prevent adverse events. Regarding pain, cold therapy was determined to be effective. Other evidence supported our current practice of intermittent clamping and discouraged milking and stripping.

Translation

Due to the lack of compelling evidence, the team recommended only minor ...

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