PRACTICE STRATEGIES

Evidence Based Practice Strategies

Evidence Based Practice Strategies

Madigan Army Medical Center (MAMC) is a 204-bed, level two trauma center responsible for care of soldiers and their beneficiaries. Located near Tacoma, WA, on Fort Lewis, this medical center serves more than 120,000 beneficiaries for primary and tertiary care in the region, and is the largest Army Medical Center on the West Coast of the continental United States. Although military hospitals are not required to have Joint Commission reviews, the facility gladly welcomes surveyors and scores very highly with each periodic review. The ability to compare military services to civilian health care networks by Joint Commission reviews allows the military health care system to demonstrate high standards of patient care and delivery methods. Additionally, such reviews demonstrate that Army hospitals meet the same standards by which civilian facilities are judged. Within MAMC, this is demonstrated by an intense focus on graduate medical education and registered nurse advanced skills training courses as noted by 19 residency programs, 8 fellowship programs, one of four 16-week Army critical care nursing programs, a clinical site for nurse anesthetist training, and a 16-week operating room nursing course. (Halm 2009, 581-584)

In continued efforts to maintain high standards of patient care at MAMC, the Joint Commission's 2008 National Patient Safety Goals were reviewed formally. This review was part of the systematic approach to improving health care in the critical care arena and the continued pursuit of an evidence-based health care methodology. Reducing the risk of harm resulting from falls (Goal #9) became the focus of the Critical Care Section for the step-down telemetry unit. This unit was identified to have greater than 75% patient movement and a high turnover rate of nursing staff. The number of patient falls in the last year was the impetus for selecting this goal. Also, potential implementation of measures to decrease the fall rate were examined.

Prevention Strategies

Detection. Enteral feedings provide numerous benefits to patients; however, the aspiration of enteral feedings is a very serious complication. Coughing or signs of distress do not always accompany aspiration events. Consequently, aspiration episodes may not always be evident even to skilled personnel (Arrowsmith, 2003; Elpern, 2007).

Bedside assessment and radiography are the two methods available for aspiration detection. Current bedside aspiration detection methods include direct observation, glucose testing, and blue dye instillation (Elpern, 2007; Metheny & Clouse, 2007). However, the efficacy of these methods are questionable. Technology has made it possible for techniques such as scintigraphy, video fluoroscopy, and video endoscopy to determine swallowing function and aspiration. However, these techniques require more specialized staff, time, transport, and expense than is feasible in daily practice (Elpern, 2007).

The blue-dye technique, while simple and readily available, has questionable accuracy and probable side effects. A positive test does not clearly indicate the potential causes of aspiration nor does it recognize the difference between aspirated oropharyngeal material and aspirated feedings (Elpern, 2007; Metheny & Clouse, 2007). There is a false sense of security with this technique because it is not reliable (Elpern, 2007; Metheny ...