EBT_Task_3
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EBT_Task_3

Course Number: NURSING EBT_Task_3, Winter 2013

College/University: Western Governors

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1 EBT1 TASK 3 724.8.3-06, 8.4-01-05 Evidence-Based Practice and Applied Nursing Research Melissa Noterman Western Governors University 2 A. Perioperative procedure: Prevention of Deep Vein Thrombosis (DVT) before and after surgery A1. Procedure change The procedure I have chosen is prevention of DVT before and after surgical operations. Venous thrombosis is a condition in which a blood clot (thrombus) forms in...

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TASK 1 EBT1 3 724.8.3-06, 8.4-01-05 Evidence-Based Practice and Applied Nursing Research Melissa Noterman Western Governors University 2 A. Perioperative procedure: Prevention of Deep Vein Thrombosis (DVT) before and after surgery A1. Procedure change The procedure I have chosen is prevention of DVT before and after surgical operations. Venous thrombosis is a condition in which a blood clot (thrombus) forms in a vein. This clot can limit blood flow through the vein, causing swelling and pain. Most commonly, venous thrombosis occurs in the "deep veins" in the legs, thighs, or pelvis (figure 1); this is called a deep vein thrombosis, or DVT ( Pai & Douketis, 2013). The current practice in many facilities is pharmacological medications i.e. Warfarin, Aspirin, and Heparin to prevent DVT and Pulmonary Embolism (PE) from occurring. This procedure needs to be changed because drug therapy increases the patients risk for hemorrhage as well as surgical complications like post-operative bleeding, bruising, GI bleeding, and compartment syndrome. If the clot is located in the femoropoliteal vein of the thigh, treatment consists of bed rest and five days of heparin therapy followed by three months of Warfarin. Outpatient Warfarin treatment for six to 12 weeks is sufficient. These treatment regimens are designed to prevent the occurrence of a fatal pulmonary embolism and reduce the morbidity associated with DVT ( Saliman, 2009). The alternative that is proposed in this paper will discuss mechanical prophylaxis. Sequential Compression Devices (SCDs) will provide an alternative method to pharmacological agent prophylaxis, especially for those patients that are at high risk for bleeding out. This will also ensure safety for critically ill if there are no contraindications like broken 3 EBT1 TASK 3 bones, fractures or previously known blood clots. figure 1 (Saliman, 2009) A2 a. Who determined the former practice? The former practice was determined by evidence-based practice at that time conducted by a counsel of Cedars-Sinai Orthopaedic surgeons. They held many meetings in discussing the best acceptable practice in preventing surgical complications like DVT by research trial and error. They used and published their findings in the he American Association of Hip and Knee Surgeons for research. A2 b. Rationale behind the decision of using pharmacological prophylaxis The rationale behind using pharmacological prophylaxis is still considered the 4 number one recommended therapy for the treatment and prevention of venous thrombosis. According to evidence-based practice, clinicians still consider using 5000 units of heparin, two to three times daily to prevent DVT in hospitalized surgical patients because the benefits outweigh the risk. A2 c. Reasons behind practice The practice is done this way because it is proven to drastically reduce the rate of deaths related to DVT. "A review of the general surgical literature shows that the incidence of DVT can be diminished by as much as 20% to 40% with min-dose prophylactic heparin" (Toker, Hak, & Morgan, 2011, p.3). Again, the benefits outweigh the risks. It is now standard precaution to administer any sort of blood thinners to help lower the risk. Pregnancy is also a well-established risk factor to the development of DVT or PE. Most women do not like taking any sort of medication while pregnant and opt for other forms of treatment. One such treatment is Compression stockings. This is considered the old mechanical prophylaxis way in the treatment and prevention of DVT. Cedars-Sinai Medical Center did use the elastic stockings as a mechanical prophylaxis based on the evidence they had at the time. This worked out rather nice until new and efficient prototypes were developed. A3. Review of the literature Pai, M. & Douketis, J. (2013) Patient information: Deep vein thrombosis (DVT) (Beyond the Basics). Wolters Kluwers Health UpToDate. Retrieved on February 5, 2013, from http://www.uptodate.com/contents/deep-vein-thrombosis-dvt-beyond-thebasics The authors of this report are both Medical Doctors and based their 5 EBT1 TASK 3 findings as a secondary source of literature to keep doctors and other health professionals up-to-date on the latest medical findings. This article is very informative of the preventative treatment of DVT through inflatable compression devices that periodically fill with air and are worn around the legs during and immediately after surgery. These devices apply gentle pressure to improve circulation and help prevent clots. This article contains multiple references to the research on which they are based. (Pai & Douketis, 2013) Saliman, J. (2009) Deep Vein Thrombosis. American Academy of Orthopaedic Surgeons. Retrieved on February 5, 2013, from http://orthodoc.aaos.org/JustinSalimanMD The author of this report is a Medical Doctor and bases his information as a primary source of literature to inform and serve medical advice. This article is short and easy to understand about cause, contributing factors, consequences, symptoms, diagnosis, prevention and treatment of DVT. The findings to the prevention of DVT are intended to concentrate on the issue of coagulation and stasis. A combination therapy of heparin and external compression device is used upon admission or pre-op and anticoagulation therapy afterwards until discharge. Range of motion or light exercise is always encouraged. (Saliman, 2009) Sud, S., Mittmann, N., Cook, D., Geerts, W., Chan, B., Dodek, P., & ... Fowler, R. (2011). Screening and prevention of venous thromboembolism in critically ill patients: a decision analysis and economic evaluation. American Journal Of 6 Respiratory And Critical Care Medicine, 184(11), 1289-1298. doi:10.1164/rccm.201106-1059OC The authors of this report all have exquisite credentials and base their long and complex piece of literature as a secondary source. In this report, patients received thromboprophylaxis with low-molecular-weight heparin (LMWH), 5,000 U subcutaneously once daily, and underwent ipsilateral compression ultrasound only if symptoms or signs of lower-extremity DVT were present, plus a repeat examination in 3 days if the initial examination was negative. The authors conclude prophylaxis provides better value in terms of costs and health gains than routine screening for DVT. Resources should be targeted at optimizing thromboprophylaxis. This article also contains multiple references to the research in which they are based. (Sud et al., 2011) Toker, S., Hak, D., & Morgan, S. (2011) Deep Vein Thrombosis Prophylaxis in Trauma Patients. Thrombosis. doi:10.1155/2011/505373 In the base case, the article does not disclose the authors credentials. The purpose of this article is to investigate various approaches for DVT prophylaxis in trauma patients and report what appears to be the best practice for optimal DVT prophylaxis. There were still contraindications for high-risk patients on taking pharmacological prophylaxis. A detailed literature search was completed with multiple references to extrapolate articles that described DVT and DVT prophylaxis. (Toker, Hac, & Morgan, 2011) Walker, L., & Lamont, S. (2008). Graduated compression stockings to prevent deep vein thrombosis. Nursing Standard, 22(40), 35-38 7 EBT1 TASK 3 Walker is head of nursing at a hospital and Lamont is a clinical procurement and risk-management coordinator. This article provides very knowledgeable information in the nursing of patients at risk in developing DVT. The authors describe the correct use and length of graduated elastic compression stockings and establish whether treatment is effective in the prevention of DVT in surgical patients. This article provides a plethora of detailed references used to base their information. (Walker & Lamont, 2008) A4. Clinical implications Based on my review of literature, the clinical implications of this practice mean cost allocation to new equipment versus certain favored medications. This might affect hospital revenue due to the fact less pharmaceuticals may be used due to the specialized equipment. Education implications include teaching staff about the new standardize practice. All personnel are expected to know how to properly use SCDs and teach patients why they are used and why hospital change policy is important to incorporate the new practice. Its all for the safety of our patients. Patient outcome will be improved from the positive effects this equipment will bring instead of side effects from medication. The latest technology is proven to the effectiveness SCDs bring to patient care. A5. Procedural discussion The prevention and treatment of DVT can be done better by instituting mechanical prophylaxis along with pharmaceutical prophylaxis. Certain high risk patients undergoing surgery may be given anticoagulants to decrease the risk of blood 8 clots.. some surgical patients are fitted with inflatable compression devices that are worn around the lower limbs before, during, and immediately after surgery. Gentle pressure is periodically applied by air to improve circulation and help prevent clots ( Pai & Douketis, 2013). This will implement old evidence-based practice along with new studies to allow current, efficient practice. The procedure could be more cost effective by lessened cost of pharmaceuticals due to the mechanical combination. Home use may or may not be an additional cost rather than using traditional drug protocols depending on the patients insurance. The benefit, however, are those persons that dont particularly like taking drugs to compliment their condition have a choice bringing high patient compliance. The expected improved outcomes are increased patient satisfaction and better control of DVT formation. A6 a. Involvement of key stakeholders I would involve the stakeholders in the decision to change the old procedure to the new procedure by giving a presentation for how mechanical prophylaxis would improved patient outcome would benefit patients based on evidence. I would also ask for their compliance by testing the proposed procedure in prepping for OR so the evidence can speak for itself. I would also want to remind stakeholders that in order to be the leading competitor hospital we must change with the leading technology and this is one technology that can differentiate us from other hospitals. The patients will care about this change because it will be more beneficial to the prevention of DVT. Staff will care about this change because they are expected to tell patients how to use the equipment and why they are using it. Hospital business personnel will care about this change because it could affect or fluctuate cost. This change will also affect 9 EBT1 TASK 3 pharmaceutical distributers because hospitals will drastically reduce medication supply and demand costs. Promoting positive change involves stakeholders to provide what we need and what they need. Different hospital investors and directors all share responsibility for patient outcome and measurable strategies. This will in turn identify those whom are important and involve them for constructive change. B1. Difficulties in translating the identified research into practice There are numerous difficulties in transforming identified research into practice. The first would be someone that takes the findings seriously. Its easy to dismiss new information in fear of change and/or complexity of the issue. As a nurse leader, I would expect my team to have knowledgeable research skills to discern between credible sources and non-credible sources. I would emphasize the importance of choosing studies that are within five years to better execute current results. I expect the research to have limited trial studies and information due to the fact it is a new study. This would directly correlate with difficulty finding relevant issues regarding the new practice. The team is expected to formulate the results on a report to be critiqued and peer-reviewed. At this point, interpreting what research says and synthesizing it into practice identify more difficulties. Patents protect manufactured goods, but this research is meant for all patients to get the best care. After the report was polished and published, the research is then put into action on a practical level. The new product should be purchased on a trial bases and then report the finding in the review of literature. This will ensure skeptics that the research is based on evidence that will allow this product to be conducted as the new medical treatment. 10 B2. Possible barriers Change involves streamlining an idea, optimizing, integrating, and adapting to increase efficiency. Change is meant to make patients safer while making our practice easier. Potential barrier that I could come across in attempting to institute a change in procedure is hospital personnel resisting the adjustment. Other barriers I expect to see is lack of coordination lack of knowledge, lack of communication, and limited resources. Removing barriers can execute my vision and implement a change faster. Hospitals may not be on board with new change unless there is financial or legal incentive. This process normally takes about 5 years. B3. Strategies used to overcome barriers Specific strategies that my team and I would use to overcome these barriers is facilitating staff education on evidence-based practice and facilitating training. Education is important because it breaks the barrier of lack of knowledge and helps other comprehend understanding of why these new practices are being implemented. In addition, facilitating training will allow the staff to effectively teach patients why we are innovating the new change and how it will help improve preventative treatment for their safety. This will hopefully encourage patient satisfaction to accept new procedural change. Communication is very important to address change and implement collaboration of new strategies. B4. Implementation of findings I can apply my findings to guide implementation of improving the risk of DVT by establishing evidence-based research study and accepting a product that makes this possible. There are many competitive product out there and will always be in need of 11 EBT1 TASK 3 supply and demand. My proposition is implementing the top product for our patients to be the leading hospital with new innovations at work. The change I want to employ is incorporating new perfected mechanical Sequential Compression Devices along the standard evidence-based practice of pharmacological prophylaxis. Walker and Lamont similarly conclude "Prophylaxis against DVT is an important aspect of nursing care and can be achieved using mechanical methods such as intermittent pneumatic compression or GECS and/or pharmacological methods, for example subcutaneous injection of heparin and low molecular weight heparin" (Walker & Lamont, 2008, p. 35). This treatment together proves best prevention and treatment of DVT and PE. Often times chemical prophylaxis is contraindicated and elastic stocking are not sufficient enough. SCD offer gentle pressure that fluctuates to ensure circulation in lower limbs that is similar to walking normally. My proposed findings indicated that Low Molecular Weight Heparin (LWMH) could lower the general rate of DVT incidence when used in combination with SCD's. This, in turn, should reduce costs and reduce burden upon the patient and family. Additional studies will always be welcomed to new and upcoming procedures to test safety and efficiency. 12 References Pai, M. & Douketis, J. (2013) Patient information: Deep vein thrombosis (DVT) (Beyond the Basics). Wolters Kluwers Health UpToDate. Retrieved on February 5, 2013, from http://www.uptodate.com/contents/deep-vein-thrombosis-dvt-beyond-thebasics Saliman, J. (2009) Deep Vein Thrombosis. American Academy of Orthopaedic Surgeons. Retrieved on February 5, 2013, from http://orthoinfo.aaos.org/topic.cfm?topic=A00219&webid=22DCE155 Sud, S., Mittmann, N., Cook, D., Geerts, W., Chan, B., Dodek, P., & ... Fowler, R. (2011). Screening and prevention of venous thromboembolism in critically ill patients: a decision analysis and economic evaluation. American Journal Of Respiratory And Critical Care Medicine, 184(11), 1289-1298. doi:10.1164/rccm.201106-1059OC Toker, S., Hak, D., & Morgan, S. (2011) Deep Vein Thrombosis Prophylaxis in Trauma Patients. Thrombosis. doi:10.1155/2011/505373 Walker, L., & Lamont, S. (2008). Graduated compression stockings to prevent deep 13 EBT1 TASK 3 vein thrombosis. Nursing Standard, 22(40), 35-38

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