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Ten Things We Might Not Want to Do Anymore: How Research Changes Nursing Practice
RESEARCH IN EMERGENCY NURSING PRACTICE
TEN THINGS WE MIGHT NOT WANT TO DO ANYMORE: HOW RESEARCH CHANGES NURSING PRACTICE Authors: Lisa A. Wolf, PhD, RN, CEN, FAEN, Margaret J. Carman, DNP, ACNP-BC, CEN, Deborah Henderson, PhD, RN, Mary Kamienski, PhD, APRN, CEN, FAEN, Jane Koziol-McLain, PhD, RN, Anne Manton, PhD, RN, APRN, FAEN, FAAN, and Michael D. Moon, MSN, RN, CNS-CC, FAEN, Des Plaines, IL, Amherst and Hyannis, MA, Durham, NC, Los Angeles, CA, Newark, NJ, San Antonio, TX, Auckland, New Zealand Section Editor: Lisa A. Wolf, PhD, RN, CEN, FAEN
CE Earn Up to 10.5 CE Hours. See page 596. Research in Emergency Nursing Practice is a new series of articles addressing the development of research skills in emergency nursing. Section Editor Lisa A. Wolf, PhD, RN, CEN, FAEN, is also Director of the Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL, and Clinical Assistant Professor, University of Massachusetts, Amherst, Amherst, MA.
E
mergency nurses use a wide repertoire of skills and knowledge to meet the needs of their patients. Many of us learn to be emergency
Lisa A. Wolf, PhD, RN, CEN, FAEN, Member, Pioneer Valley Chapter, is Director, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL, and Clinical Assistant Professor, University of Massachusetts, Amherst, Amherst, MA. Margaret J. Carman, DNP, ACNP-BC, CEN, Member, Cardinal Chapter, is Assistant Professor, Duke University School of Nursing, Durham, NC. Deborah Henderson, PhD, RN, Member, Greater Los Angeles County Chapter, is Associate Professor, Los Angeles Biomedical Research Institute at HarborUCLA Medical Center, Los Angeles, CA. Mary Kamienski, PhD, APRN, CEN, FAEN, Member, Northern New Jersey Chapter, is Chair, Primary Care Department Associate Professor, Graduate Programs MSN, The University of Medicine & Dentistry of New Jersey, Newark, NJ. Jane Koziol-McLain, PhD, RN, International Member, is Professor of Nursing, Co-Director, Interdisciplinary Trauma Research Unit, Auckland University of Technology, Auckland, New Zealand. AnneManton,PhD,RN,APRN,FAEN,FAAN,Member,MayflowerChapter,isaMental Health Nurse Practitioner, Cape Cod Hospital-Cape Psychiatric Center, Hyannis, MA. Michael D. Moon, MSN, RN, CNS-CC, FAEN, Member, San Antonio Chapter, is an Instructor, University of the Incarnate Word, San Antonio, TX, and 2012 Director, ENA Board. For correspondence, write: Lisa Wolf, PhD, RN, CEN, FAEN, Director, Institute of Emergency Nursing, Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016; E-mail: [email protected]. J Emerg Nurs 2012;38:589-91. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.09.003
November 2012
VOLUME 38 • ISSUE 6
nurses by watching and listening to preceptors, mentors, and colleagues. For many of us, however, the clinical “pearls” and skills we learned may be based only on tradition rather than evidence. For example, lavaging an endotracheal tube with 2 to 5 mL of normal saline prior to suctioning was once a standard of care; research findings suggest that this is an inappropriate treatment and may actually harm the patient. 1 In order to promote best practice, emergency nurses must become proficient in keeping up to date with clinical practice and interpreting the available evidence to ensure safe practice and safe care for our patients. Which of the following procedures are current practice in your emergency department? 1. Auscultating over the epigastrium to check for correct nasogastric tube (NGT) placement 2. Using military anti-shock trousers (MAST) to maintain circulation (and control hemorrhage) in the trauma patient 3. Using an ice-water lavage to control bleeding in the patient with an upper gastrointestinal (GI) bleed 4. Applying a tourniquet to a snake-bitten extremity 5. Putting your patients in Trendelenburg position to improve mean arterial pressure (MAP) and cardiac output 6. Weighing pediatric patients in pounds 7. Using sodium bicarbonate during cardiac resuscitation to reverse acidosis 8. Checking Homan's sign to rule out a deep vein thrombosis (DVT) 9. Using a tympanic thermometer to determine if patients are hypothermic/hyperthermic 10. Using an arterial blood gas (ABG) to determine metabolic acidosis Here's the thing: none of these interventions have solid evidence to support them. These are examples of traditional usage rather than basing practice on evidence. 1. Checking placement of an NGT solely by auscultation: The standard of care requires verification of the
WWW.JENONLINE.ORG
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RESEARCH IN EMERGENCY NURSING PRACTICE/Wolf et al
placement of the gastric tube prior to its use in order to minimize complications, such as infusing medications, fluids, or tube feedings into the lungs. Results from a 2006 online survey of 1,600 nurses indicated that 65% used the auscultation verification method most of the time. The Emergency Nurses Association Emergency Nursing Resource on gastric tube placement verification does not recommend using auscultation for verification of tube placement due to unreliability of the practice. 2 2. MAST trousers: In 1988, Moylan et al published a study that suggested that the increased use of endotracheal intubation, blood transfusion, larger volume of electrolyte resuscitation, and increased use of MAST trousers improved morbidity and mortality in air-transported patients. 3 However, in 1999, a Cochrane review concluded that there is no evidence to suggest that MAST/pneumatic antishock garment (PASG) application reduces mortality, length of hospitalization, or length of intensive care unit stay in trauma patients, and it is even possible that it may cause increases in these. There is no support for the continued use of MAST/ PASG in trauma patients. These study findings need to be cautiously interpreted due to the level of evidence reviewed. 4 3. Iced saline/ice-water lavage to slow GI bleeding: In a 1964 article, 5 it was reported that gastric “cooling” was a palliative method of controlling upper GI bleeding and stabilizing clinical condition. Gilbert and Saunders reported in 1981 that there were no data to support the clinical practice of lavaging with iced saline or norepinephrine-containing solutions in human gastric hemorrhage. 6 4. Tourniquet application in the patient with snakebite injury: Tourniquet application for snakebite is often the first treatment method attempted by many first aid providers, with the goal of containing the venom within the extremity. However, severe local ischemic damage to the extremity resulting from tourniquet use for N1 to 2 hours has been reported. 7 Alternatively, venous tourniquets, with a goal pressure of 20 to 30 mm Hg, decrease blood and lymphatic flow from the extremity and can slow the systemic spread of venom. 7 Venous tourniquets should be loose enough to admit one to two fingers. Studies using porcine models have illustrated a decrease in systemic spread of venom with the use of a venous tourniquet; however, these results have not been replicated in human studies. Tourniquet use is not recommended unless lifethreatening neurotoxic effects are observed. 7 5. Trendelenburg position: In the Trendelenburg position, initially used to expose the pelvis for surgical interven-
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TABLE 1
Evidence grading Grading the Quality of the Evidence
I. Acceptable quality: no concerns II. Limitations in quality: minor flaws or inconsistencies in the evidence III. Major limitations in quality: many flaws and inconsistencies in the evidence IV. Not acceptable: major flaws in the evidence Grading the Levels of the Evidence (Melnyk & FineoutOverholt, 2005) I. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials or evidence-based clinical practice guidelines based on systematic reviews of randomized controlled trials II. Evidence obtained from at least one properly designed randomized controlled trial III. Evidence obtained from well-designed controlled trials without randomization IV. Evidence obtained from well-designed case control and cohort studies V. Evidence from systematic reviews of descriptive and qualitative studies VI. Evidence from a single descriptive or qualitative study VII. Evidence from opinion of authorities and/or reports of expert committees Melnyk BM, Fineout-Overholt E. Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia: Lippincott Williams & Wilkins; 2005.
tion, the patient is supine and the head is tilted down, allowing the patient's feet and legs to remain above the level of the heart. Practice assumes that this position diverts blood from the lower extremities into the central circulation. 8 However, a review of literature was conducted in 2005 9; the eight peer-reviewed publications found were grade C (supported by level III to level V evidence). No grade A or grade B clinical evidence was found (Table 1). A 2011 study 10 also found no statistically significant changes to MAP or cardiac output in patients placed in the Trendelenburg position. 6. Pediatric weights: Medication dosages for pediatric patients are generally calculated in mg/kg. Errors in these calculations can be fatal, so precise calculation is critical. Both older and current literature on safety in medication administration 11,12 assumes that all pediatric patients are weighed in kilograms, with medication calculations based on a weight that is not more than four days old. 7. Using sodium bicarbonate during cardiac resuscitation to reverse acidosis: As early as 1986, Guerci et al could find
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no evidence in either the literature or in their own work to support the usefulness of sodium bicarbonate in reversing cardiac arrest due to ventricular fibrillation. 13 The 2010 American Heart Association Advanced Cardiac Life Support Guidelines do not recommend routine use of sodium bicarbonate in cardiac arrest. 14 8. Homan's sign: Homan's sign, which is defined as pain in the calf on forced dorsiflexion of the foot, is not a sensitive or specific test for DVT. 15 Although it has been historically considered an indication of DVT, it is an unreliable diagnostic sign. Fifty percent of persons with clinically significant DVTs do not elicit a positive Homan's sign, and calf pain from muscular injury will also elicit a positive response. 16 9. Using a tympanic thermometer to determine if patients are hypothermic/hyperthermic: Accurate temperature measurement is important not only for initial acuity assignation but also to evaluate the effectiveness of treatment. Tympanic thermometers are commonly used because they are quick and easier to use than an oral thermometer, which requires patient cooperation. However, there is no evidence to support their use in any emergency department population. 17 10. Use of ABGs to determine metabolic acidosis: Venous blood gas measurements are highly sensitive and specific reflections of metabolic acidosis and reduce the associated pain and risks of arterial sticks. 18,19 So, how much of what you do and how you do it is based on what you learned? How much is based on good research evidence? It is the obligation of the emergency nurse to be aware of the current practice recommendations, and to promote their use in their practice. Research findings change practice every day. This article serves as the introduction of a yearlong series in the Journal of Emergency Nursing written by members of the Institute of Emergency Nursing Research Advisory Council to encourage and promote the generation of knowledge specific to the practice of emergency nursing. The goal of the project is to allow bedside nurses practicing in the emergency department to generate clinical questions and to critically examine those aspects of care that we sometimes continue simply because “we've always done it this way.” Our hope is that members will learn that engaging in research is enjoyable, non threatening, and even rewarding. As the most direct person providing care to persons in their most dire hour of need, it is imperative that we ask the questions, find the evidence, and translate it into the best of care. The next article will review how to read research articles.
November 2012
VOLUME 38 • ISSUE 6
REFERENCES 1. American Association of Respiratory Care. AARC Clinical Practice Guidelines: Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55:758-64. 2. Moylan JA, Fitzpatrick KT, Beyer AS 3rd, Georgiade GS. Factors improving survival in multisystem trauma patients. Ann Surg. 1988;207:679-85. 3. Proehl J, Heaton K, Naccarato MK, et al. Emergency nursing resource: gastric tube placement verification. J Emerg Nurs. 2011;37:357-62. 4. Dickinson K, Roberts I. Medical anti-shock trousers (pneumatic antishock garments) for circulatory support in patients with trauma. Cochrane Database Syst Rev. 2000;2CD001856. 5. McHardy G, Atik M, Balart L. An evaluation of gastric hypothermia. Dig Dis Sci. 1964;9:717-25. 6. Gilbert DA, Saunders DR. Iced saline lavage does not slow bleeding from experimental canine gastric ulcers. Dig Dis Sci. 1981;26:1065-8. 7. Anz A, Bushnell B, Halvorsen J, Koman AL, Schweppe M, Sternberg M. Management of venomous snakebite injury to the extremities. J Am Acad Orthop Surg. 2010;18:749-59. 8. Jimenez EJ. Modulating the response to injury (initial management for hypotension). In: Civetta JM, Taylor RW, Kirby RR, eds. Critical Care. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1997:374-5. 9. Bridges N, Jarquin-Valdivia AA. Use of the Trendelenburg position as the resuscitation position: to T or not to T? Am J Crit Care. 2005;14:364-8. 10. Zorko N, Mekis D, Kamenik M. Influence of the Trendelenberg position of haemodynamics: comparison of anesthestitized patients with ischemic heart disease and healthy volunteers. J Int Med Res. 2011;39:1084-9. 11. Dickinson CJ, Wagner DS, Shaw BE, Owens TA, Pasko D, Neidner M. A systematic approach to improving medication safety in a pediatric intensive care unit. Crit Care Nurs. 2012;Q35:15-26. 12. Kelly LY, Joel LA. . Dimensions of Professional Nursing. 8th ed. New York: McGraw-Hill; 1999. 13. Guerci AD, Chandra N, Johnson E, et al. (1986). Failure of sodium bicarbonate to improve resuscitation from ventricular fibrillation in dogs. Circulation. 1986;74(Suppl IV):IV-75-IV-79. 14. American Heart Association guidelines for advanced cardiac life support. Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/ documents/downloadable/ucm_318152.pdf. Accessed August 13, 2012. 15. Hirsh J, Hull RD. Venous Thromboembolism: Natural History, Diagnosis and Management. Boca Raton, FL: CRC Press; 1987. 16. Cranley JJ, Canos AJ, Sull WJ. The diagnosis of deep vein thrombosis: fallibility of clinical symptoms and signs. Arch Surg. 1976;111:34-6. 17. Barnason S, Williams J, Proehl J. Emergency nursing resource: noninvasive temperature measurement in the emergency department. J Emerg Nurs. 2012;38:523-30. 18. Menchine M, Probst MA, Agy C, Bach D, Arora S. Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the emergency department. Acad Emerg Med. 2011;18:1105-8. 19. Hucker TR, Mitchell GP, Blake LD. Identifying the sick: can biochemical measurements be used to aid decision making on presentation to the accident and emergency department. Br J Anaesth. 2005;94:735-41.
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TEN THINGS WE MIGHT NOT WANT TO DO ANYMORE: HOW RESEARCH CHANGES NURSING PRACTICE Authors: Lisa A. Wolf, PhD, RN, CEN, FAEN, Margaret J. Carman, DNP, ACNP-BC, CEN, Deborah Henderson, PhD, RN, Mary Kamienski, PhD, APRN, CEN, FAEN, Jane Koziol-McLain, PhD, RN, Anne Manton, PhD, RN, APRN, FAEN, FAAN, and Michael D. Moon, MSN, RN, CNS-CC, FAEN, Des Plaines, IL, Amherst and Hyannis, MA, Durham, NC, Los Angeles, CA, Newark, NJ, San Antonio, TX, Auckland, New Zealand Section Editor: Lisa A. Wolf, PhD, RN, CEN, FAEN
CE Earn Up to 10.5 CE Hours. See page 596. Research in Emergency Nursing Practice is a new series of articles addressing the development of research skills in emergency nursing. Section Editor Lisa A. Wolf, PhD, RN, CEN, FAEN, is also Director of the Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL, and Clinical Assistant Professor, University of Massachusetts, Amherst, Amherst, MA.
E
mergency nurses use a wide repertoire of skills and knowledge to meet the needs of their patients. Many of us learn to be emergency
Lisa A. Wolf, PhD, RN, CEN, FAEN, Member, Pioneer Valley Chapter, is Director, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL, and Clinical Assistant Professor, University of Massachusetts, Amherst, Amherst, MA. Margaret J. Carman, DNP, ACNP-BC, CEN, Member, Cardinal Chapter, is Assistant Professor, Duke University School of Nursing, Durham, NC. Deborah Henderson, PhD, RN, Member, Greater Los Angeles County Chapter, is Associate Professor, Los Angeles Biomedical Research Institute at HarborUCLA Medical Center, Los Angeles, CA. Mary Kamienski, PhD, APRN, CEN, FAEN, Member, Northern New Jersey Chapter, is Chair, Primary Care Department Associate Professor, Graduate Programs MSN, The University of Medicine & Dentistry of New Jersey, Newark, NJ. Jane Koziol-McLain, PhD, RN, International Member, is Professor of Nursing, Co-Director, Interdisciplinary Trauma Research Unit, Auckland University of Technology, Auckland, New Zealand. AnneManton,PhD,RN,APRN,FAEN,FAAN,Member,MayflowerChapter,isaMental Health Nurse Practitioner, Cape Cod Hospital-Cape Psychiatric Center, Hyannis, MA. Michael D. Moon, MSN, RN, CNS-CC, FAEN, Member, San Antonio Chapter, is an Instructor, University of the Incarnate Word, San Antonio, TX, and 2012 Director, ENA Board. For correspondence, write: Lisa Wolf, PhD, RN, CEN, FAEN, Director, Institute of Emergency Nursing, Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016; E-mail: [email protected]. J Emerg Nurs 2012;38:589-91. 0099-1767/$36.00 Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2012.09.003
November 2012
VOLUME 38 • ISSUE 6
nurses by watching and listening to preceptors, mentors, and colleagues. For many of us, however, the clinical “pearls” and skills we learned may be based only on tradition rather than evidence. For example, lavaging an endotracheal tube with 2 to 5 mL of normal saline prior to suctioning was once a standard of care; research findings suggest that this is an inappropriate treatment and may actually harm the patient. 1 In order to promote best practice, emergency nurses must become proficient in keeping up to date with clinical practice and interpreting the available evidence to ensure safe practice and safe care for our patients. Which of the following procedures are current practice in your emergency department? 1. Auscultating over the epigastrium to check for correct nasogastric tube (NGT) placement 2. Using military anti-shock trousers (MAST) to maintain circulation (and control hemorrhage) in the trauma patient 3. Using an ice-water lavage to control bleeding in the patient with an upper gastrointestinal (GI) bleed 4. Applying a tourniquet to a snake-bitten extremity 5. Putting your patients in Trendelenburg position to improve mean arterial pressure (MAP) and cardiac output 6. Weighing pediatric patients in pounds 7. Using sodium bicarbonate during cardiac resuscitation to reverse acidosis 8. Checking Homan's sign to rule out a deep vein thrombosis (DVT) 9. Using a tympanic thermometer to determine if patients are hypothermic/hyperthermic 10. Using an arterial blood gas (ABG) to determine metabolic acidosis Here's the thing: none of these interventions have solid evidence to support them. These are examples of traditional usage rather than basing practice on evidence. 1. Checking placement of an NGT solely by auscultation: The standard of care requires verification of the
WWW.JENONLINE.ORG
589
RESEARCH IN EMERGENCY NURSING PRACTICE/Wolf et al
placement of the gastric tube prior to its use in order to minimize complications, such as infusing medications, fluids, or tube feedings into the lungs. Results from a 2006 online survey of 1,600 nurses indicated that 65% used the auscultation verification method most of the time. The Emergency Nurses Association Emergency Nursing Resource on gastric tube placement verification does not recommend using auscultation for verification of tube placement due to unreliability of the practice. 2 2. MAST trousers: In 1988, Moylan et al published a study that suggested that the increased use of endotracheal intubation, blood transfusion, larger volume of electrolyte resuscitation, and increased use of MAST trousers improved morbidity and mortality in air-transported patients. 3 However, in 1999, a Cochrane review concluded that there is no evidence to suggest that MAST/pneumatic antishock garment (PASG) application reduces mortality, length of hospitalization, or length of intensive care unit stay in trauma patients, and it is even possible that it may cause increases in these. There is no support for the continued use of MAST/ PASG in trauma patients. These study findings need to be cautiously interpreted due to the level of evidence reviewed. 4 3. Iced saline/ice-water lavage to slow GI bleeding: In a 1964 article, 5 it was reported that gastric “cooling” was a palliative method of controlling upper GI bleeding and stabilizing clinical condition. Gilbert and Saunders reported in 1981 that there were no data to support the clinical practice of lavaging with iced saline or norepinephrine-containing solutions in human gastric hemorrhage. 6 4. Tourniquet application in the patient with snakebite injury: Tourniquet application for snakebite is often the first treatment method attempted by many first aid providers, with the goal of containing the venom within the extremity. However, severe local ischemic damage to the extremity resulting from tourniquet use for N1 to 2 hours has been reported. 7 Alternatively, venous tourniquets, with a goal pressure of 20 to 30 mm Hg, decrease blood and lymphatic flow from the extremity and can slow the systemic spread of venom. 7 Venous tourniquets should be loose enough to admit one to two fingers. Studies using porcine models have illustrated a decrease in systemic spread of venom with the use of a venous tourniquet; however, these results have not been replicated in human studies. Tourniquet use is not recommended unless lifethreatening neurotoxic effects are observed. 7 5. Trendelenburg position: In the Trendelenburg position, initially used to expose the pelvis for surgical interven-
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JOURNAL OF EMERGENCY NURSING
TABLE 1
Evidence grading Grading the Quality of the Evidence
I. Acceptable quality: no concerns II. Limitations in quality: minor flaws or inconsistencies in the evidence III. Major limitations in quality: many flaws and inconsistencies in the evidence IV. Not acceptable: major flaws in the evidence Grading the Levels of the Evidence (Melnyk & FineoutOverholt, 2005) I. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials or evidence-based clinical practice guidelines based on systematic reviews of randomized controlled trials II. Evidence obtained from at least one properly designed randomized controlled trial III. Evidence obtained from well-designed controlled trials without randomization IV. Evidence obtained from well-designed case control and cohort studies V. Evidence from systematic reviews of descriptive and qualitative studies VI. Evidence from a single descriptive or qualitative study VII. Evidence from opinion of authorities and/or reports of expert committees Melnyk BM, Fineout-Overholt E. Evidence-based Practice in Nursing & Healthcare: A Guide to Best Practice. Philadelphia: Lippincott Williams & Wilkins; 2005.
tion, the patient is supine and the head is tilted down, allowing the patient's feet and legs to remain above the level of the heart. Practice assumes that this position diverts blood from the lower extremities into the central circulation. 8 However, a review of literature was conducted in 2005 9; the eight peer-reviewed publications found were grade C (supported by level III to level V evidence). No grade A or grade B clinical evidence was found (Table 1). A 2011 study 10 also found no statistically significant changes to MAP or cardiac output in patients placed in the Trendelenburg position. 6. Pediatric weights: Medication dosages for pediatric patients are generally calculated in mg/kg. Errors in these calculations can be fatal, so precise calculation is critical. Both older and current literature on safety in medication administration 11,12 assumes that all pediatric patients are weighed in kilograms, with medication calculations based on a weight that is not more than four days old. 7. Using sodium bicarbonate during cardiac resuscitation to reverse acidosis: As early as 1986, Guerci et al could find
VOLUME 38 • ISSUE 6
November 2012
Wolf et al/RESEARCH IN EMERGENCY NURSING PRACTICE
no evidence in either the literature or in their own work to support the usefulness of sodium bicarbonate in reversing cardiac arrest due to ventricular fibrillation. 13 The 2010 American Heart Association Advanced Cardiac Life Support Guidelines do not recommend routine use of sodium bicarbonate in cardiac arrest. 14 8. Homan's sign: Homan's sign, which is defined as pain in the calf on forced dorsiflexion of the foot, is not a sensitive or specific test for DVT. 15 Although it has been historically considered an indication of DVT, it is an unreliable diagnostic sign. Fifty percent of persons with clinically significant DVTs do not elicit a positive Homan's sign, and calf pain from muscular injury will also elicit a positive response. 16 9. Using a tympanic thermometer to determine if patients are hypothermic/hyperthermic: Accurate temperature measurement is important not only for initial acuity assignation but also to evaluate the effectiveness of treatment. Tympanic thermometers are commonly used because they are quick and easier to use than an oral thermometer, which requires patient cooperation. However, there is no evidence to support their use in any emergency department population. 17 10. Use of ABGs to determine metabolic acidosis: Venous blood gas measurements are highly sensitive and specific reflections of metabolic acidosis and reduce the associated pain and risks of arterial sticks. 18,19 So, how much of what you do and how you do it is based on what you learned? How much is based on good research evidence? It is the obligation of the emergency nurse to be aware of the current practice recommendations, and to promote their use in their practice. Research findings change practice every day. This article serves as the introduction of a yearlong series in the Journal of Emergency Nursing written by members of the Institute of Emergency Nursing Research Advisory Council to encourage and promote the generation of knowledge specific to the practice of emergency nursing. The goal of the project is to allow bedside nurses practicing in the emergency department to generate clinical questions and to critically examine those aspects of care that we sometimes continue simply because “we've always done it this way.” Our hope is that members will learn that engaging in research is enjoyable, non threatening, and even rewarding. As the most direct person providing care to persons in their most dire hour of need, it is imperative that we ask the questions, find the evidence, and translate it into the best of care. The next article will review how to read research articles.
November 2012
VOLUME 38 • ISSUE 6
REFERENCES 1. American Association of Respiratory Care. AARC Clinical Practice Guidelines: Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care. 2010;55:758-64. 2. Moylan JA, Fitzpatrick KT, Beyer AS 3rd, Georgiade GS. Factors improving survival in multisystem trauma patients. Ann Surg. 1988;207:679-85. 3. Proehl J, Heaton K, Naccarato MK, et al. Emergency nursing resource: gastric tube placement verification. J Emerg Nurs. 2011;37:357-62. 4. Dickinson K, Roberts I. Medical anti-shock trousers (pneumatic antishock garments) for circulatory support in patients with trauma. Cochrane Database Syst Rev. 2000;2CD001856. 5. McHardy G, Atik M, Balart L. An evaluation of gastric hypothermia. Dig Dis Sci. 1964;9:717-25. 6. Gilbert DA, Saunders DR. Iced saline lavage does not slow bleeding from experimental canine gastric ulcers. Dig Dis Sci. 1981;26:1065-8. 7. Anz A, Bushnell B, Halvorsen J, Koman AL, Schweppe M, Sternberg M. Management of venomous snakebite injury to the extremities. J Am Acad Orthop Surg. 2010;18:749-59. 8. Jimenez EJ. Modulating the response to injury (initial management for hypotension). In: Civetta JM, Taylor RW, Kirby RR, eds. Critical Care. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1997:374-5. 9. Bridges N, Jarquin-Valdivia AA. Use of the Trendelenburg position as the resuscitation position: to T or not to T? Am J Crit Care. 2005;14:364-8. 10. Zorko N, Mekis D, Kamenik M. Influence of the Trendelenberg position of haemodynamics: comparison of anesthestitized patients with ischemic heart disease and healthy volunteers. J Int Med Res. 2011;39:1084-9. 11. Dickinson CJ, Wagner DS, Shaw BE, Owens TA, Pasko D, Neidner M. A systematic approach to improving medication safety in a pediatric intensive care unit. Crit Care Nurs. 2012;Q35:15-26. 12. Kelly LY, Joel LA. . Dimensions of Professional Nursing. 8th ed. New York: McGraw-Hill; 1999. 13. Guerci AD, Chandra N, Johnson E, et al. (1986). Failure of sodium bicarbonate to improve resuscitation from ventricular fibrillation in dogs. Circulation. 1986;74(Suppl IV):IV-75-IV-79. 14. American Heart Association guidelines for advanced cardiac life support. Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/ documents/downloadable/ucm_318152.pdf. Accessed August 13, 2012. 15. Hirsh J, Hull RD. Venous Thromboembolism: Natural History, Diagnosis and Management. Boca Raton, FL: CRC Press; 1987. 16. Cranley JJ, Canos AJ, Sull WJ. The diagnosis of deep vein thrombosis: fallibility of clinical symptoms and signs. Arch Surg. 1976;111:34-6. 17. Barnason S, Williams J, Proehl J. Emergency nursing resource: noninvasive temperature measurement in the emergency department. J Emerg Nurs. 2012;38:523-30. 18. Menchine M, Probst MA, Agy C, Bach D, Arora S. Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the emergency department. Acad Emerg Med. 2011;18:1105-8. 19. Hucker TR, Mitchell GP, Blake LD. Identifying the sick: can biochemical measurements be used to aid decision making on presentation to the accident and emergency department. Br J Anaesth. 2005;94:735-41.
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