In 2003, the Honour Society of Nursing, Sigma Theta Tau International and Nursing Spectrum sponsored an “Innovations in Clinical Excellence” contest to recognise exemplars of evidence-based nursing practice. The following 5 papers are winning entries, which are published with permission of the Honour Society of Nursing, Sigma Theta Tau International.

PRACTICE PROBLEM

The most uncomfortable part of hospital admission for patients requiring coronary interventional and/or diagnostic procedures is the time required to lie flat after removal of the indwelling femoral arterial introducer sheath. Conventional practice required a minimum of 6 hours of supine bed rest after sheath removal, often resulting in the problem of back pain.

The Nurse Practitioner/Clinical Nurse Specialist (NP/CNS) for interventional cardiology targeted this problem for further investigation in 1994 and took the lead in determining the process and strategies to be used. A group of interested physicians and nurses was convened, reflecting the multidisciplinary interest in addressing this clinical problem.

TYPE OF EVIDENCE USED

The basis for the practice of prolonged bed rest was a mix of ritual, research, and expert opinion. The expert consensus was that prolonged bed rest was required to ensure adequate haemostasis at the femoral arterial puncture site. Research, much of it conducted by nurse researchers, had been gradually demonstrating the safety of reducing bed rest times from a high of 24 hours to a low of 6 hours after sheath removal.

METHOD USED TO OBTAIN AND REVIEW EVIDENCE

Electronic databases including Medline and CINAHL were reviewed for all entries matching target search terms. Relevant articles were identified, copies obtained, and the findings were reviewed by the NP/CNS and the medical director of interventional cardiology.

The findings of the literature review revealed a split between patients undergoing diagnostic cardiac catheterisation and percutaneous coronary intervention (PCI) procedures. It was agreed that, initially, the diagnostic and the PCI patients would be treated as 2 distinct groups of patients. Several research studies examined bed rest times <6 hours after diagnostic catheterisation, whereas there were no studies published examining bed rest of <6 hrs after PCI at the time of the review.

PLANNED STRATEGY FOR IMPROVEMENT

Diagnostic catheterisation group. At a meeting of the interest group in 1996, the results of the literature review were presented. It was decided that the published research supported making a change in practice from 6 hours to 2 hours of bed rest. A plan was developed for introducing the change using close monitoring and follow up for the first 50 inpatients. This would allow for the gradual introduction of the practice change in a controlled fashion.

PCI Group. At this same meeting in 1996, it was decided to explore the possibility of conducting a research study to examine reducing bed rest to <6 hours after PCI.

HOW THE STRATEGY WAS IMPLEMENTED

Diagnostic catheterisation group. The first 50 inpatients were followed up between March and May 1997.

PCI group. A research study proposal was developed and funding successfully applied for and obtained. Nursing staff from a variety of clinical areas were involved in the process of recruitment, data collection, and patient care during the research process. Educational sessions were held to prepare them for their role and to introduce the concept of evidence-based nursing practice.

A total of 354 patients were recruited into the BAC Trial between March 1997 and October of 1998. The start of data collection was timed to coincide with the implementation of the practice change for inpatients undergoing diagnostic cardiac catheterisation. This streamlined the launch and recruitment efforts.

METHOD OF EVALUATION

Diagnostic catheterisation group. Follow up evaluation of the data from the first 50 patients demonstrated the safety of the practice change and the efficacy in reducing patient discomfort. A decision was made to continue with 2 hours of bed rest for this group.

PCI group. Data analysis verified that 2 hours of bed rest was safe and significantly effective in reducing back pain in patients undergoing PCI. The investigators reviewed the data, and in March 1999, 2 years after data collection began, the findings were presented to the nursing and medical staff. The change in practice was implemented the next day. A process for ongoing evaluation of outcomes was initiated to ensure continued patient safety.

OUTCOMES/RESULTS

Clinical practice changes. In the end, the diagnostic cardiac catheterisation group and the PCI group, initially divided by the research literature, had the same outcome. Reducing bed rest time from 6 hours to 2 hours after arterial sheath removal and promoting early mobilisation is a safe and effective nursing intervention that prevents and/or reduces back pain, while potentially decreasing costs. Follow up has confirmed the safety and efficacy of this evidence-based change in practice.

Peer communication. The process and findings of our experience were presented by means of 6 oral papers at local, national, and international conferences between 1998 and 2000. A total of 3 poster presentations were made between 1997 and 1998. Audience members included both nursing and medical professionals.

A summary of the BAC trial results is available on-line in the Registry of Nursing Research, Sigma Theta Tau website (www.nursingsociety.org). Two publications in peer reviewed journals, including one which is available online via Medscape, round out the communication strategy.

Further study. A meta-analysis of the existing research data on bed rest after cardiac diagnostic and interventional procedures is currently under way. Plans after completion of the analysis include conference presentation and submission to the Cochrane Collaboration for possible inclusion in the evidenced-based practice database.

LESSONS LEARNT

• Identify at least 1 person to champion the project from the beginning. This person must be intimately involved in the process and sustain momentum over time.

• Use all relevant members of the multidisciplinary team. Clinical problems are patient focused, not discipline focused, and therefore usually require the efforts and expertise of different professionals to find appropriate solutions. Excluding other professionals from the process may result in opposition and blocking behaviours when it comes time to implement change.

• Have patience. The process of change takes a long time. It is now 9 years since the bed rest project was initiated and, although change in clinical practice has occurred in our institution, many other centres are still imposing prolonged bed rest on their patients. The meta-analysis currently underway will hopefully continue to add to the body of evidence that other institutions can utilise.