Engaging in Evidence Based Practice and Clinical Effectiveness - Essay Example

? Engaging in Evidence Based Practice and Clinical Effectiveness HEAB 394 Academic Year 07/15 TABLE OF CONTENTS Engaging in Evidence Based Practice and Clinical Effectiveness 0 HEAB 394 0 1 INTRODUCTION 2 CRITICAL REVIEW OF LITERATURE 3 ANALYSIS 9 DISCUSSION 10 CONCLUSION 11 REFERENCES 12 INTRODUCTION Evidence Based Practice (EBP) in nursing is founded on the principle that the quality of healthcare in institutions, patient service in hospitals, and emergency preparedness of nursing staff are all increased when the individuals providing the healthcare services are well informed with the latest medical research. (Parahoo, 1997) EBP is also a key factor in the NMC (2008) Code of Professional Conduct, which states that nursing professionals are personally accountable for their quality of care giving, and must provide the highest quality of service to patients that is consistent with evidence-based research. In 2005, NICE was combined with the Health Development Agency as an independent organization to deliver quality healthcare based on professional standards of medical practice in a standardized manner across public healthcare institutions and in order to assist with government programs intended to improve the quality of service in the industry. Nurses are increasingly expected to base their practice on empirical medical research data represented in scientific literature or established medical treatment practices that are generated through research publications (Burns & Grove 1999). The purpose of this report is to apply the principles of Evidence Based Practice (EBP) to the use of supplemental oxygen (O2) in hospitals as a treatment response for myocardial infarction (MI). The rationale for this search is that supplemental oxygen is used in hospitals and clinics traditionally in ways that is inconsistent with latest medical research and this has led to a recent change in practice in healthcare institutions as well as in public policy that still may not be represented in everyday nursing practice. By applying EBP principles, a nurse can review the medical literature and research regarding the use of oxygen in MIs by focusing on the most recent clinical trials. By understanding the use and contra-indications of supplemental O2 in MIs as accepted in published literature, nurses on coronary care units (CCU) can be more prepared for work in the workplace. In order to effectively search the topic of oxygen use in clinical applications related to heart treatment, it was important to clearly define the research by using the PICO framework (Patients, Interventions, Comparisons and Outcomes) to develop the areas of inquiry. The search criteria focused on were based initially the keywords: “Myocardial, Infarction, Hyperoxic, Coronary, and Oxygen”. Published papers were identified through a search of online databases via the University of Plymouth intranet site including; CINAHL, MEDLINE, SwetsWise, Taylor & Francis, Oxford Journals & ScienceDirect. In the search, very few original research studies published between 2001 to 2011 were found, it was required to revise the search to include a more specialized use of keywords, all relating to “oxygen and myocardial function”. Five research papers were then selected as representative of consensus in medical research through peer review and implementation in cardiac treatment programs. CRITICAL REVIEW OF LITERATURE Previously oxygen was given as a standard aspect of MI treatment, regardless of the patient’s level of oxygen saturation level, as part of the standard response of health practitioners to a critical care emergency such as a heart attack. Although NICE (2010) have amended their guidelines to recommend that patients only be given oxygen if their blood saturation level is below 94% , many nurses on general wards are still giving oxygen to critical heart attack patients as a regular aspect of treatment, as they are unaware of its detrimental effects in counter-indications or the latest research on the topic. Since many hospitals are still in the process of reviewing their protocols with regard to these treatment guidelines, it is a critical responsibility of new nurses to be aware of the problem and lead a change in local policy. The most recent research about the use of supplemental oxygen (O2) in treatment for MI is represented in the Ranchord, et al. (2011) study ‘A randomised controlled trial of the effect of high concentration oxygen on myocardial ischaemia during exercise,’ which found that some international guidelines currently recommend the use of supplemental O2 in MI response where the latest clinical data may indicate that this could be detrimental and unnecessary in non-complicated MI patients. (Ranchord, et al., 2011) This study reported that high-concentration O2 treatment has increased the physical recovery time of patients from MIs, which they verified through muscle and exercise tests on the patients in a sample group. The importance of the Ranchord (2011) study is that it is a controlled trial that looked at exercise rates in MI recovery patients in order to analyze the ability of the patients to walk or run on a treadmill following a heart attack. Reinforcing this research is a study by Mariero et al. (2011), ‘Hyperoxia during early reperfusion does not increase ischemia/ reperfusion injury,’ published in the European Journal of Cardio-thoracic Surgery that suggested supplemental O2 is a standard and accepted part of traditional health practice but that those standards are changing because of EBP and policy reviews. The Mariero (2011) study was intended to test whether increased O2 concentrations could be harmful to patients under the circumstances of recovery from anesthesia, and can be classified as a controlled clinical trial on animals where the control group received O2 at room concentration and the variable group concentrated supplemental O2. (Mariero et al., 2011) In the Ranchord study (2011), the two groups were divided into those who received supplemental O2 treatment as part of the coordinated MI response, and those who did not. The researchers found that those who did not receive supplementary O2 treatment as part of their healthcare were able to recover from MI to exercise at a higher level than those who did receive supplementary concentrated O2 treatment. The patients in this study were adult males and MI patients. There were a total of 19 participants in the study and the P values were calculated for Oxygen minus air at 0.007 for MI and 0.12 Angina. (Ranchord, et al., 2011) In contrast, the Mariero et al. (2011) study tested two groups of rats and their recovery rates from anesthesia using 40% O2 and 95% O2 concentrations. The trial consisted of rats in control groups with test group= 11 rats, and the control group= 14 rats. The P values for this study were 0.06. The bias is related to the validity of animal vs. human testing on the subject. The researchers found that ventilation with normobaric hyperoxia at onset of reperfusion tended to reduce lethal arrhythmias in rats but this did not influence further impact the infarct size of the group. (Mariero et al., 2011) Another historically significant study representative of the change in medical consensus on the clinical use of O2 in MIs is represented in the Frobert (2004) report which states that oxygen has a correlative effect on coronary dilation and for this reason higher oxygen concentrations should be tested for the effect on ventricular performance. (Frobert, 2004) This Frobert (2004) study was not a controlled clinical trial, but rather a report of the results of medical analysis from a single group of participants. The researchers found that hypoxia improves systolic myocardial performance and hyperoxia worsens systolic myocardial performance in healthy male volunteers. The report of Cabello, Emparaza, Ruiz, and Burl (2009) can also be taken as supportive of these findings through a web-based review of current practices. This report is titled, “Oxygen therapy for acute myocardial infarction: a web-based survey of physicians' practices and beliefs,” and represents the latest research into the use of supplemental oxygen in Acute Myocardial Infarction (AMI) treatment. In Frobert (2004), the results were gathered from the measurement of diastolic function in muscle tissue. The study consisted of male volunteers, average age 38, with a total of 7 participants. The P values were listed as P < 0.001 // P < 0.05. Researchers reported a bias in that no adjustments for heart rate were made in participants. The study concluded that a reduction in cardiac ability of blood pressure results from hypoxia, as the increase in O2 levels requires less natural activity to fuel the tissues. (Frobert, 2004) In contrast, the Cabello (2009) report was based upon randomized control groups in clinical studies selected according to a criteria of inclusion based upon AMI reports in institutional data. (Cabello et al, 2009) This study analyzed the use of face-mask administered O2 in the treatment of AMI across a number of published studies, looking at the summarized cause of death in the procedures. The data from the Cabello et al. (2009) study is further reinforced by a follow up study conducted by the group of Cabello, Emparaza, Ruiz, and Burl (2009), which reviewed the varieties of medical intervention for AMIs and sought to build conclusions from composite data in previously published in peer-reviewed journals. The initial study used three trials meeting exclusion criteria were combined for the research for a total of 387 patients. The P values were stated as time to revascularization at 41 minutes shorter in the air group (P = 0.052). (Cabello et al, 2009) The bias of the study can be found in the inclusion criteria, which may have been limited to exclude contradicting data. The follow-up Cabello (2009) study found more deaths overall related to treatment which included the administration of O2 directly vs. where room air only was received by the patient. These results are validated further by the report ‘Routine use of oxygen in the treatment of myocardial infarction: systematic review’ by M Wijesinghe et al. (2009) where the scientists found that there was insufficient evidence provided by latest accepted research into the use of supplemental O2 to continue to recommend this as standard treatment response to uncomplicated MIs. Included in the Wijesinghe (2009) study was a recognized increase in the risk of mortality in patients. When researchers sought to identify the cause of increased mortality, they concluded that haemodynamic effects in patients can lead to a reduction in coronary blood flow. (Wijesinghe et al., 2009) These researchers further recommended a change in standards in institutions internationally to reflect this research. In summary, the findings of these combined studies were that it is not statistically significant to conclude more from current clinical research than that O2 is not demonstrated to be directly beneficial in AMI treatment generally, with more research required to determine the risk of detrimental outcomes. The effect of O2 use on pain management in AMIs was not considered. While the follow up study conducted by Cabello et al. (2010) on this topic titled “Oxygen therapy for acute myocardial infarction: a web-based survey of physicians' practices and beliefs” sought to further investigate evidence from controlled clinical trials in order to determine the effects of inhaled oxygen in acute myocardial infarction (AMI) and the effects on mortality and pain experience in patients, its results cannot be considered conclusive due to possible bias in the data set of email respondents. (Cabello et al., 2010) The follow-up study used an email survey to inquire with healthcare professionals about their use of O2 as assisted treatment in AMIs and sought to review this against EBP critically to determine if institutional policy was in line with medical consensus and clinical research. The researchers found that over 85% of participants reported the regular use of supplemental O2 in AMI response, and that over 44% believed that this was beneficial in pain reduction in patients. This research was conducted by a web survey using email with 169, 158, 157 and 155 participants in each part of the survey. P values are listed at < 0.001, with the bias represented in the emails sent to respondents, as only those with an interest in the subject may have participated. (Cabello et al., 2010) Further reinforcing data for these findings are found in a systematic review of literature on the clinical use of supplemental O2 in MIs is offered in Thomson et al. (2006), ‘Effects of short-term isocapnic hyperoxia and hypoxia on cardiovascular function,’ which discussed the way that hypoxia and hyperoxia effect on ventricular performance through the changes in heart rate, cardiac output, and vascular resistance. (Thomson et al., 2006) Thomson et al. (2006) measured the combined factors of blood pressure (BP), heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI) and arterial stiffness (AI) during one hour of exposure of by patients to either hyperoxia or hypoxia in order to examine the interrelated effects of the two conditions on an array of values in the patients’ recovery process. The participants in the study were healthy men, with a total of 8 participants tracked. The P values are: Hyperoxia vs. SVRI (P< 0.001); reduced HR (P Read More