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Evidence-Based Practice Habits: Putting More Sacred Cows Out to Pasture Mary Beth Flynn Makic, Kathryn T. VonRueden, Carol A. Rauen and Jessica Chadwick Crit Care Nurse 2011;31:38-62 doi: 10.4037/ccn2011908 © 2011 American Association of Critical-Care Nurses Published online http://www.cconline.org Personal use only. For copyright permission information: http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT Subscription Information http://ccn.aacnjournals.org/subscriptions/ Information for authors http://ccn.aacnjournals.org/misc/ifora.shtml Submit a manuscript http://www.editorialmanager.com/ccn Email alerts http://ccn.aacnjournals.org/subscriptions/etoc.shtml Critical Care Nurse is the official peer-reviewed clinical journal of the American Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2011 by AACN. All rights reserved. Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 Feature Evidence-Based Practice Habits: Putting More Sacred Cows Out to Pasture Mary Beth Flynn Makic, RN, PhD, CNS, CCNS Kathryn T. VonRueden, RN, MS, ACNS-BC Carol A. Rauen, RN, MS, CCNS, CCRN, PCCN Jessica Chadwick, RN, MSN, CCNS For excellence in practice to be the standard for care, critical care nurses must embrace evidence-based practice as the norm. Nurses cannot knowingly continue a clinical practice despite research showing that the practice is not helpful and may even be harmful to patients. This article is based on 2 presentations on evidence-based practice from the American Association for Critical-Care Nurses’ 2009 and 2010 National Teaching Institute and addresses 7 practice issues that were selected for 2 reasons. First, they are within the realm of nursing, and a change in practice could improve patient care immediately. Second, these are areas in which the tradition and the evidence do not agree and practice continues to follow tradition. The topics to be addressed are (1) Trendelenburg positioning for hypotension, (2) use of rectal tubes to manage fecal incontinence, (3) gastric residual volume and aspiration risk, (4) restricted visiting policies, (5) nursing interventions to reduce urinary catheter–associated infections, (6) use of cell phones in critical care areas, and (7) accuracy of assessment of body temperature. The related beliefs, current evidence, and recommendations for practice related to each topic are outlined. (Critical Care Nurse. 2011;31:38-62) I f we want excellence in practice to be the standard for care, critical care nurses must embrace evidence-based practice as the norm. We CEContinuing Education 1. Understand how embracing evidencebased practice can immediately improve patient care 2. Recognize 7 areas of clinical practice in which tradition and the evidence do not agree 3. Identify recommendations for practice related to 7 older practice issues or “sacred cows” ©2011 American Association of CriticalCare Nurses doi: 10.4037/ccn2011908 cannot knowingly continue a clinical practice despite research that shows that the practice is not helpful and may even be harmful to the patients we serve. This article is devoted to putting some clinical sacred cows out to pasture. It is based on 2 presentations on evidence-based practice from the American Association of CriticalCare Nurses (AACN) National Teaching Institute in 2009 and 2010. The Institute of Medicine defines evidence-based practice as “The integration of best research, clinical expertise, and patient values in making decisions about the care of individualized patients.”1 One would hope that clinicians would strive for this goal in all practice decisions. Unfortunately, philosophical goals and clinical realities are not always congruent. Many practice decisions that were originally based on intuition and tradition have not changed despite compelling evidence that change is warranted. The classic example (addressed in the first article in this series, “Seven EvidenceBased Practice Habits: Putting Some Sacred Cows Out to Pasture”2) is the use of instillation of normal saline into an endotracheal tube before suctioning to “loosen secretions.” Not only does this practice not loosen secretions, it harms patients and may be a major contributing factor to ventilator-associated pneumonia.2 Cutting-edge practice decisions are commonly based on research or the best available evidence.3 It is the older practice habits or “sacred cows” that are more challenging to change because the practices are considered routine and beyond dispute. The implementation of evidencebased practice at the bedside takes commitment and an effective process. Excellent process models to assist in 38 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org Table 1 Evidence-based practice Table 2 Systems for evaluating levels of evidence models Iowa model4 American Association for Critical-Care Nurses (AACN)13 AACN levels of evidence: 6-level tool for grading; level A is the strongest evidence and M is manufacturer’s recommendation only Centers for Disease Control and Prevention14 Modified HICPAC Categorization Scheme for Recommendations: 5-scale system Society of Critical Care Medicine15 Grades of Recommendation, Assessment, Development and Evaluation (GRADE System) was used to evaluate evidence for Surviving Sepsis Guidelines American Heart Association16 Used an 8-level scale with 4 classifications to support recommendations for Basic Life Support and Advanced Cardiac Life Support Stetler’s model5 Rosswurm and Larrabee’s model6 Johns Hopkins Nursing model7 ACE Star Model of Knowledge Transformation8 ARCC (Advancing Research and Clinical Practice Through Close Collaboration) model9 AHRQ (Agency for Healthcare Research and Quality) model10 PARIHS (Promoting Action on Research Implementation in Health Services) framework11 Colorado model12 this goal have been published. Table 14-12 lists 9 evidence-based practice models that offer step by step approaches and frameworks to use. The typical process prescribed by the models is to ask a clinical question, determine whether solid evidence exists to support a particular practice, compare current practice with the research recommendations, and make appropriate clinical changes based on the evidence. Although the process is seemingly simple, articulating the implementation is more challenging, although not impossible. Once the research or evidence is collected, it must be evaluated for strength and quality by using levels of evidence. AACN recently published an updated guide for level of evidence in Critical Care Nurse.13 Table 2 provides examples of other evaluation tools that may be used to assist clinicians in the evaluation of research and evidence in deciding if the evidence is compelling enough to recommend a change in practice. This article addresses 7 practice issues that were selected for 2 reasons. First, they are within the realm of nursing, and a change in practice Authors Mary Beth Flynn Makic is a research nurse scientist in critical care at the University of Colorado Hospital and an adjoint assistant professor at the University of Colorado, Denver, in Aurora, Colorado. Kathryn T. VonRueden is a clinical nurse specialist at the R. Adams Cowley Shock Trauma Center at the University of Maryland Medical Center and an assistant professor at the University of Maryland School of Nursing in Baltimore. Carol A. Rauen is an independent clinical nurse specialist and education consultant and a staff nurse in the emergency department at Outer Banks Hospital in The Outer Banks of North Carolina. Jessica Chadwick is a clinical nurse specialist in the emergency department at Inova Fairfax Hospital in Fairfax, Virginia. Corresponding author: Mary Beth Flynn Makic, RN, PhD, CNS, CCNS, 7830 W. 72nd Place, Arvada, CO 80005 (e-mail: [email protected]). To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. www.ccnonline.org could improve patient care immediately. Second, these are areas in which the tradition and the evidence do not agree and practice continues to follow tradition or “sacred cows.” The topics to be addressed are as follows: 1. Trendelenburg positioning for hypotension 2. Use of rectal tubes to manage fecal incontinence 3. Gastric residual volume (GRV) and aspiration risk 4. Restricted visiting policies 5. Nursing interventions to reduce urinary catheter–associated infections 6. Use of cell phones in critical care areas 7. Accuracy of assessment of body temperature The related beliefs, current evidence, and recommendations for practice related to each topic are described. Trendelenburg Positioning for Hypotension Use of the Trendelenburg position was originally intended to improve surgical exposure for abdominal procedures. In the late 1800s, Friedrich Adolf Trendelenburg and one of his students, W. Meyer, first CriticalCareNurse Vol 31, No. 2, APRIL 2011 39 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 described the position as a supine head-down tilt of at least 45º.17 Use of this position became common practice in the operating room but was associated with complications such as increased central venous pressure, engorgement of head and neck veins, increased cerebral spinal fluid pressure, hypertension, retinal detachment, impaired oxygenation and ventilation, gastric secretions and mucus in the oropharynx causing aspiration.17 From a practical aspect, patients placed in the Trendelenburg position had to be prevented from sliding head-down off the table.17 Despite these adverse outcomes for patients, the practice of placing patients in the Trendelenburg position persists. Related Beliefs and Current Evidence The use of the Trendelenburg position for hypotension and shock has been studied for more than 50 years. The proposed physiological benefit is the shift of intravascular volume from the lower extremities and abdomen to the upper part of the thorax, the heart, and the brain, thus improving perfusion to heart and brain. It is estimated that a headdown position results in a 1.8% displacement of blood volume.18 In the 1960s, however, Weil and Whigham19 reported deleterious effects of using the Trendelenburg position in animals and humans. In a hemorrhagic shock model with rats, mortality and hemodynamic responsiveness were least favorable in the head-down position; in humans with hypotensive shock, blood pressure decreased, lung volumes were compromised, and the risk of retinal detachment and cerebral edema increased.19,20 Cardiovascular response to the Trendelenburg position appears to be influenced by the presence of hypotension and the patient’s ability to maintain homeostasis. For example, in normotensive patients placed in the Trendelenburg position, little deleterious hemodynamic effect is observed.21-23 Even in elderly normotensive patients, who may have some degree of impairment of vasomotor control owing to their age, no deterioration was noted in cardiac hemodynamic parameters with use of the Trendelenburg position.24 Hypotensive patients appear to have different and more varied cardiovascular responses to the headdown position,21,25 and they show no improvement in blood pressure or cardiac index.18-21,24-26 As well, key components of tissue oxygenation are not improved with the Trendelenburg position.27 Most investigators have concluded that use of the Trendelenburg position in hypotensive patients has no cardiovascular benefit.18-21,24-26 Hewer,17 in his 1956 review of complications of the Trendelenburg position, discussed the untoward effects on lung ventilatory mechanics and pulmonary gas exchange. These effects included reduced vital capacity even at 20º head-down tilt, increased work of breathing, and impaired respiration causing hypercarbia and hypoxemia. In the head-down tilt position, the cephalad shift of abdominal contents increases abdominal pressure, impairs diaphragmatic function, and impedes lung expansion. In the Trendelenburg position, mechanical impedance of the lung and chest wall increases and is associated with increased resistance and decreased tidal volume.28,29 Lung compliance can decrease by 20%, PaCO2 increases, and a mild metabolic acidosis may develop.26 Ventilation and perfusion abnormalities, evidenced by an increase in intrapulmonary shunting, are also reported in the Trendelenburg position.21 Not surprisingly, as body weight increases, lung resistance and gas exchange abnormalities also increase significantly,28,29 which has important clinical implications for obese critically ill patients; thus the Trendelenburg position should be avoided in such patients. Little research is available on the effect of Trendelenburg position on intracranial pressure; however, some agree that it is likely to increase intracranial pressure because of the increased central venous pressure,17,24,30-32 but the effects on cerebral blood flow are uncertain. Distension of the internal jugular vein has been measured and is increased in head-down tilt, but internal jugular blood flow is unchanged. Researchers disagree on the effect of the Trendelenburg position on intracranial pressure and cerebral blood flow, with some concluding that those factors do increase,32 while others conclude that cerebral hemodynamics are not affected.22 One clinical protocol that uses Trendelenburg positioning for postural drainage of the lungs in patients with brain injury originally incorporated criteria based on changes in intracranial pressure and cerebral perfusion pressure33 and now also includes reduced brain tissue oxygenation for more precision, as the basis for returning the patient to supine or head-up position. 40 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org In reviewing the literature related to the physiological effects of the Trendelenburg position and its use to treat hypotension and shock, we encountered a number of limitations that made it difficult to draw definitive conclusions. Studies were conducted with a variety of populations (eg, animals, healthy volunteers, or normotensive patients), sample sizes were relatively small, the methods used various degrees of head-down positioning that ranged from 10º to 30º and the length of time in this position also varied, and various end points were measured. Despite these study limitations, most of the findings are consistent in that they show no demonstrated benefit of the Trendelenburg position for hypotension or shock. Thus the evidence does not support the use of head-down tilt for hypotension. Recommendations for Practice Trendelenburg position increases venous return but has little or no beneficial effect on cardiac output or blood pressure; the improvement, if any, is temporary. Pulmonary gas exchange is impaired in the headdown tilt position, thus overall oxygen delivery may not improve at all. As well, the deleterious effects on lung mechanics and oxygenation are more exaggerated in obese patients. Cerebral blood flow and intracranial pressure most likely increase in the Trendelenburg position, and the effect may be deleterious in some patients with brain injuries. The gravitational movement of mucus and gastric secretions to the oropharynx may increase the potential for aspiration. Table 3 provides a summary of the evidence and physiological response to the Tren- www.ccnonline.org delenburg posiTable 3 Physiological effects of Trendelenburg positioning tion.17,21,24,25,27-32 in hypotensive patients Alternatives Cardiovascular to TrendelenSlight increase in mean arterial pressure burg positionNo increased preload Dilated right ventricle ing, such as Decreased right ventricular ejection fraction passive leg lift, Decreased cardiac output may provide Increase in systemic vascular resistance greater benefit Pulmonary Reduced vital capacity for initial manIncreased work of breathing agement of Decreases in PaO2 hypotension or Increases in mechanical impedance of lung and chest wall Decreased tidal volume prediction of Decreased lung compliance fluid responIncreases in PacO2 siveness with Tissue perfusion No change in oxygen delivery minimal or no No change in oxygen extraction untoward No change in oxygen consumption effect.34,35 RaisGastrointestinal ing the patient’s Cephalad shift of abdominal contents Increased abdominal pressure legs while keepImpaired diaphragmatic function ing the head of Impeded lung expansion the bed horiNeurological zontal relative Possible increase in intracranial pressure associated with increase in central venous pressure to the patient’s Distention of internal jugular vein trunk produces an approximate Trendelenburg position for patients volume shift of 150 to 300 mL to 34,35 with hypotension and/or hypothe upper part of the thorax. volemic shock, and such positioning This shift increases aortic volume, is associated with impaired ventilamay not activate baroreceptors, and tion and oxygenation and may have avoids risk of gastric aspiration. In 25 other deleterious effects as just menone study, researchers reported tioned. Despite these findings, a the same adverse cardiovascular survey of critical care nurses about and pulmonary effects for passive practices related to use of Trendelenleg raising as for Trendelenburg burg position conducted in the late positioning in 18 cardiac surgery 1990s showed that 80% of the patients. Others have shown that respondents would consider using this maneuver correlates with the Trendelenburg positioning to improve response to fluid loading and is hypotension.36 Although little new predictive of the need for fluid research has been done since that when a patient’s cardiac output, time, dissemination of information stroke volume variation, or blood related to the deleterious effects and pressure respond positively to the 34,35 lack of benefit of this position has leg lift maneuver. continued.37 A repeat survey would The evidence, despite the aforebe useful to determine if this traditionmentioned limitations, does not based practice persists. show a demonstrated benefit of the 21-27 21,26,28,29 27 26,28,29 17,24,30-32 CriticalCareNurse Vol 31, No. 2, APRIL 2011 41 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 Use of Rectal Tubes to Manage Fecal Incontinence Critically ill patients with incontinence are at high risk for perineal skin damage, which may also increase the patient’s risk for pressure ulceration, secondary dermal injury, and infection.38-40 Urinary and fecal incontinence harm the protective skin barrier through excessive moisture that macerates the skin, compromising its defensive functions for the body. Digestive enzymes and bacteria inherently found in feces alter the pH and irritate the skin, increasing the risk of incontinenceassociated dermatitis and infection.38,40,41 Nursing management of critically ill patients with acute diarrhea is focused on protecting the skin as well as containing the diarrhea. Research to effectively manage acute fecal incontinence is limited; however, evidence is evolving and best practice guidelines are available to guide practice.40,42 Related Beliefs and Current Evidence Use of rectal tubes to divert fecal material away from the skin and into a collection bag, a traditional approach, is the least safe intervention and the procedure is poorly defined.40,42,43 Little research exists to support the use of traditional rectal tubes (eg, mushroom catheter with a soft flared tip, urinary catheter with a balloon); however, these devices have been used in practice without clear evidence of the efficacy and safety of the devices for management of fecal incontinence.44 Best practice for the management of fecal incontinence, to minimize skin breakdown (ie, incontinenceassociated dermatitis and pressure Table 4 Possible risk factors to consider in evaluating the cause of acute fecal incontinence Type Risk factor Disease processes45,47 Gastrointestinal and hepatic diseases Sepsis Spinal cord injury Enterotoxins Medications48 Nonsteroidal anti-inflammatory drugs, antimicrobial agents, angiotensin-converting enzyme inhibitors, β-blocking agents, digoxin, lactulose, diuretics Nutrition49 Enteral tube feeding (consult nutritionist to determine optimal tube feeding formula and rate to minimize diarrhea) ulcers), starts with an evaluation of the cause of the diarrhea.41,45,46 Begin by reviewing the patient’s medical history, current medications, and treatments that may increase gastric motility or diarrhea. Table 445,47-49 provides a list of factors to consider in evaluating the etiology of the patient’s diarrhea. Fecal incontinence may be a secondary consequence of the patient’s disease or treatment (eg, antibiotics), so several interventions can be implemented to protect the skin before placement of a device in the rectum to divert stool. Nursing interventions to minimize skin breakdown from fecal incontinence should be implemented early by anticipating excessive moisture or diarrhea on the basis of the patient’s current plan of care (Table 5). When fecal incontinence is excessive or incontinence-associated dermatitis is progressing, the use of fecal containment devices may be indicated. These devices can be divided into 2 categories: fecal pouches or indwelling retention devices (tubes). When choosing a fecal containment device to move effluent away from the perigenital skin, critical care nurses should assess the patient’s perineal skin and factors believed to be associated with the diarrhea. Fecal collectors, also called anal bags/pouches, when applied correctly are an effective option to control and contain liquid feces.38,40,57 Fecal collectors are external devices that consist of a self-adhering skin barrier and attached pouch that connects to a drainage bag, providing a closed system to move liquid stool away from the skin. This system is external, providing less risk to the patient’s rectal sphincter and internal mucosa.40,57 When applied correctly, fecal collectors can prevent skin breakdown, minimize odor, track output accurately, decrease exposure to fecal material, minimize caregiver time, enhance patients’ comfort, and save money.40 In a study57 conducted in Europe, the fecal collector was evaluated in 120 hospitalized patients. The vast majority (96%) of nurses reported that the device preserved perineal skin integrity, and none of the patients had adverse skin breakdown while the device was in place. Additional benefits of a fecal collector include the following: it can be used indefinitely, as needed, to manage diarrhea; it will not interfere with gastrointestinal activity as 42 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org Table 5 Evidence-based management of fecal incontinence Assessment Evidence-based intervention Assess patient’s risk for fecal incontinence; anticipate fecal incontinence associated with disease, medications, interventions40,42,44,48 Protect the skin with moisture barrier products in anticipation of diarrhea Assess the patient for risk of pressure ulcers and excessive moisture and prolonged immobility by using a valid and reliable risk assessment tool39,46 Complete a risk assessment daily and with a change in patient’s condition39; implement interventions based on specific findings on risk assessment Assess skin during the cleansing process Cleanse the skin with no-rinse cleanser, moisturize and protect the skin with each episode of incontinence38,42,45,50 Using soap and water with a washcloth is not optimal for basic skin care40,42 Soaps are frequently alkaline and further damage the protective acidic mantle of the skin40,42 Washcloths may increase friction and damage fragile skin40,42 No-rinse bathing/perineal cleansing wipes are pH balanced, gentle on the skin, and enhance removal of organic debris38,42,45,51 Research shows that no-rinse bathing products are effective in reducing bacteria on the skin50 Incontinence overhydrates skin but removes essential oils that need to be replenished by applying moisturizers and moisture barrier products38,40,41,51 Assess the need for moisture absorbing incontinence pad to wick effluent away from the skin42,44 Assess the need for air flow near the skin and advanced bed redistribution technology (follow hospital protocol for advanced bed therapy); avoid excessive linen52,53 Use a single moisture-absorbing or wicking underpad under the patient to pull effluent/moisture and liquid stool away from skin38,51,54-56 Avoid the use of diapers, especially with immobile patients, as diapers trap fecal material against the skin and exacerbate skin damage40,51 Limit layers of linens beneath the patient; multiple layers of linen can inhibit bed redistribution technology and air flow from reaching the skin39,52,53 Excessive linen entraps moisture, creates crinkles and pressure, and may increase the risk of pressure ulcers52,53 Assess patient’s mobility and encourage toileting Obtain bedside commodes and implement a toileting schedule to minimize incontinence epidose47 Assess nutritional needs and evaluate tolerance of tube feeding Consider consult a nutritionist for diarrhea believe to be related to tube feeding49 Evaluate skin for fungal infection associated with fecal incontinence38,51 Fungal infection may be managed effectively with the application of topical antifungal barrier creams Assess skin, development of incontinence-associated dermatitis, as well as frequency and consistency of stool to determine need for a fecal containment device42,44,57-62 Consider fecal collectors or bowel-management system42,44,57-62 Assess resolution of cause of diarrhea, changes in diarrhea flow, consistency, and skin condition to determine need for ongoing fecal containment device57-62 Remove fecal containment devices when liquid stool resolves57-62 diarrhea resolves; and it will not compromise the rectal sphincter and mucosa. The nasopharyngeal airway (nasal trumpet) has been studied as a device to contain fecal incontinence in critically ill patients.58 With this method, a soft nasopharyngeal airway is inserted into the rectum and connected to a drainage collection system. Research on this method of fecal containment is limited; however, initial results www.ccnonline.org indicate that the device was well tolerated by patients, was practical for nurses, and effectively contained fecal matter without untoward effects for patients.47 Traditional rectal tubes (eg, mushroom catheter with a soft flared tip, urinary catheter with a balloon) for management of liquid stool are considered the least safe approach for management of diarrhea.38,40,44 These devices are inserted into the rectal vault and held in place by inflating the balloon or mushroom tip of the catheter. Table 6 outlines the advantages and disadvantages of these traditional devices for fecal diversion. The use of balloon tubes or mushroom catheters is an adaptation of the device for fecal containment, and because of the lack of evidence to support their safe and effective use and the availability of other fecal containment systems, these devices should be avoided in current practice.38,40,42,44 CriticalCareNurse Vol 31, No. 2, APRIL 2011 43 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 Table 6 Advantages and disadvantages of traditional rectal tubes (mushroom catheter with soft flared tip, urinary catheter with a balloon)a Advantages Disadvantages Diverts liquid stool away from skin Fecal material must be liquid to pass through tube Tubes may leak and create perirectal skin damage As diarrhea resolves, the tube may block stool Ballooned devices require strict periodic deflation to prevent rectal mucosal injury Injury of anal sphincter is not easily assessed Duration for use of the device has not been established a Based on evidence from Gray et al,38,41 Wishin et al,40 Petterson,41 Beitz,42 Beekman et al,44 and Grogan and Kramer.58 Bowel management systems (BMSs), also called fecal management systems, are medical device systems designed to direct, collect, and contain liquid stool in immobile patients. Several BMSs are commercially available and approved by the Food and Drug Administration for up to 29 days of use for management of liquid stool.42,59 BMSs have unique characteristics and specific insertion techniques (readers are referred to device instructions for insertion); however, the indications and contraindications are similar across device manufacturers. BMSs are soft flexible catheters with containment drainage systems. The balloon used to inflate and secure the catheter within the rectum is soft and conforms to the rectal vault, reducing the risk of anorectal trauma.42,44 When used properly, the BMS contains liquid stool, allows accurate measurement of output, decreases health care providers’ exposure to body fluids, and may protect perirectal skin or denuded perigenital skin or wounds, thus enhancing healing.38,42,44,59 Several studies have been conducted to evaluate the effectiveness and safety of using BMSs for diarrhea management. Padmanabhan and colleagues60 evaluated the outcomes of 42 patients in whom a BMS was used to contain diarrhea. The researchers found that the device did not harm the rectal mucosa (by performing endoscopy at baseline and after removal of the BMS), perigenital skin condition improved in 92% of the patients, and the health care providers reported that the system was easy to manage. Keshava et al61 conducted a prospective study of inpatients admitted for burn management or to the geriatric unit. Twenty-two patients with diarrhea were managed with a BMS. Mean duration of therapy was 14 days. Proctoscopy after tube removal showed normal rectal tissue, and the health care providers in that study also reported ease of use of the device. In a quality improvement study,62 researchers found that the combination of interventions to prevent pressure ulcers along with the introduction of a BSM in their critical care unit resulted in a significant decrease in the frequency of pressure ulcers. Although a direct correlation cannot be made between the BMS and the reduction in frequency of pressure ulcers, use of a BMS to contain diarrhea and manage excessive moisture combined with strategies for preventing pressure ulcers resulted in good outcomes for patients. Critical care nurses should assess the need for a BMS to manage severe diarrhea with the goal of removing the devices as soon as possible. Recommendations for Practice Management of fecal incontinence to minimize incontinenceassociated dermatitis and pressure ulcers begins with an accurate nursing assessment of the patient’s risk for fecal incontinence, early proactive perineal skin hygiene to protect skin and minimize irritation, and critical evaluation of when an external fecal containment device or BMS is needed. Evidence-based interventions (Table 5) should be used in the care of patients with fecal incontinence. Gastric Residual Volume and Aspiration Risk Little evidence supports the use of measurement of GRV to assess gastric emptying and tolerance of tube feeding, yet the practice of assessing GRV while a patient is receiving tube feeding persists.63,64 Several assumptions may exist related to the assessment of GRV.65-67 First, the nurse may assume that GRV provides information about normal and abnormal gastric emptying. Second, the nurse may think that an elevated GRV indicates delayed gastric emptying and intolerance of enteral tube feeding. Third, a high GRV may be believed to result in a higher risk 44 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org for aspiration that may lead to aspiration pneumonia. In fact, the evidence has demonstrated that checking a GRV in enterally fed patients does not improve patients’ outcome or reduce complications.65-71 So why do we continue to check GRV, and what evidence supports continuing this practice? Related Beliefs and Current Evidence The lack of definition of how to measure GRV accurately creates a challenge in clinical practice.68,69 Most guidelines suggest the use of a large-volume syringe (60 mL) for aspiration of fluid because smaller syringes may collapse the gastric tube.64,66 However, use of a syringe may not consistently result in aspiration of the total volume of fluid present in the stomach.70,73 GRV is more easily obtained from large-bore gastric tubes (eg, 14F-16F diameter) than small-bore gastric tubes (8F-12F diameter). Metheny and colleagues74 reported that larger GRVs were detected 2 to 3 times more often with large-bore gastric tubes than with gastric tubes with a smaller bore. Other variables that affect measurement accuracy include the position of the tube port in the gastric antrum, the patient’s position, and the tube’s location near the gastroesophageal junction.68,72 GRV with enteral feeding tubes placed beyond the pylorus is questionable because of the small size of these tubes and the physiological properties of the small bowel to continuously propel gastric contents forward, unlike the gastric antrum.66 Similarly, if a gastric tube migrates near the gastroesophageal junction, GRV will be negligible in most www.ccnonline.org cases.69 Frequent monitoring (eg, every 4 hours) of GRV is indicated as one method to monitor gastric tube location. After obtaining radiographic confirmation of accurate placement of a gastric tube, observing the appearance and changes in the volume of gastric aspirate may assist in monitoring for migration of the gastric tube.75 Another debate about the monitoring and interpretation of GRV is defining what constitutes a high gastric residual.64,66-68 Under normal conditions, saliva and gastric fluids accumulate at approximately 188 mL/h in the stomach; thus any order to withhold tube feedings for a GRV less than 188 mL is inappropriate.64 Published reports vary in providing guidance for what constitutes a high gastric residual, ranging from 150 mL to 500 mL of aspirate.64,65,66,68,71,72 Best evidence suggests that a single high GRV should be monitored for the following hour, but enteral feeding should not be ceased or withheld for an isolated GRV greater than 250 mL.65,68 Serial hourly elevated GRVs greater than 250 mL may require withholding enteral feeding for an hour in conjunction with evaluation for prokinetic agents to promote gastric motility and assessment of possible causes for decreased gastric tolerance, including a change in the patient’s acuity.64,66,68 Elevation of GRV is anticipated to be greatest in the first few days of enteral feeding. Questions remain unanswered on when to stop checking GRV to evaluate tolerance of enteral feeding. The greatest concern with withholding enteral feeding because of GRV or concern for aspiration is underfeeding critically ill patients. Elpern et al76 studied enteral feedings in an intensive care unit and found that tube feedings were frequently withheld or stopped for procedures, changes in patients’ body positions, high GRV, and diarrhea. Of the patients studied, a mean of 64% of the patients had their nutrition goals met, and the mean length of interruptions for enteral feeding was 5.23 hours per patient per day. McClave and colleagues67 reported similar results. In their study, only 14% of the patients received 90% goal feeding within 72 hours of starting enteral feeding. Reasons reported in this study for stopping enteral feeding included the following: placement of the patient supine for procedures or nursing care, high GRV, and preprocedure protocols. Little evidence supports the practice of stopping or withholding tube feeding to reposition patients or when placing patients supine briefly for routine care.67 Current evidence suggests reducing the time that enteral feedings are withheld before procedures to minimize underfeeding critically ill patients.66,67 The primary belief associated with high GRV is risk for aspiration by the patient. Aspiration has been demonstrated with GRVs from 5 mL to 500 mL.67 Aspiration is often clinically silent. No reliable clinical marker has been found for risk of aspiration, including GRV assessment.65,68,72,76 Risk for aspiration is increased with hemodynamic instability, increased acuity or critical illness (eg, sepsis), altered level of consciousness, neurological compromise, sedation, and mechanical ventilation. Interventions to minimize aspiration include elevating CriticalCareNurse Vol 31, No. 2, APRIL 2011 47 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 the head of bed more than 30º, initiating continuous enteral feedings, using medications to promote gastric motility, and consideration of postpyloric feeding.64-66,68,69 Ongoing evaluation of patients’ tolerance of enteral feeding is also necessary to interpret GRV. Signs of intolerance may include bloating, abdominal pain, nausea, vomiting, and emesis. Implementing and adhering to enteral feeding protocols (Figure 1) to minimize unnecessary cessation of enteral feeding is needed to optimize nutrition in critically ill patients. Isolated high GRVs should be reassessed in subsequent hours and accepting higher GRVs in the absence of signs of intolerance is necessary in clinical practice.65 Increasing GRV may be a symptom of another underlying problem manifesting itself as delayed gastric emptying.68 If serial measurements of GRV remain elevated, the cause should be explored rather than simply withholding enteral feeding, which is likely to result in underfeeding of critically ill patients.67,68,76 Recommendations for Practice Critically ill patients are at risk of aspiration because of severity of illness and interventions that compromise the gag reflex. Variables that increase a patient’s risk for aspiration include sedation, mechanical ventilation, neurological compromise/ altered level of consciousness, hemodynamic instability, and sepsis. Preventing aspiration begins with accurate and ongoing assessment of feeding tube placement (see AACN Practice Alert: Verification of Feeding Tube Placement75), maintaining the elevation of the head of the patient’s bed at greater than 30º, and evaluating the patient’s tolerance of tube feeding.65,66,71 Assessment of GRV is not an effective method of determining aspiration risk.64-68,70,74 Table 7 outlines the evidence for GRV monitoring and interventions to prevent aspiration. Implementing an evidence-based enteral feeding protocol inclusive of increased acceptance of higher GRV along with physical assessment of the patient’s tolerance and intolerance of tube feeding will maximize the delivery of adequate nutrition to critically ill patients. Restricted Visiting Policies: A Thing of the Past? Restriction of visitors for hospitalized patients has been practiced for many decades. For example, in the late 1800s, restricted visiting hours were implemented in some hospitals and applied to nonpaying patients to establish order in general wards. In the early 1900s, paying patients were permitted to have visitors anytime, anywhere. The advent of intensive care units during the 1960s saw restricted visiting implemented to protect patients and family from exhaustion caused by too many visitors.77 The spectrum of “visiting” can be thought of as a continuum (Figure 2). Current attitudes and practices in critical care units span this continuum.78,79 Related Beliefs and Current Evidence Evaluation of the evidence related to friends and family visiting patients reflects both practitioner preferences and a focus on patientand family-centered care.80 A landmark study by Molter81 in 1979 began to change the attitudes and practices of nurses with regards to visitation. Using the Critical Care Family Needs Inventory, the primary needs of families of critically ill patients were identified to be related to the need for information, support, comfort, assurance, and proximity to the patient. A subsequent study reported that in addition to these needs, families also have a need to be present in order to provide reassurance and support to the patient and to protect the patient.82 The needs, preferences, and stressors of critically ill patients also have been examined.83 In a survey of critical care patients, 40 stressors were identified; number 4 was “missing your spouse,” and number 8 was “only seeing family and friends for a few minutes each day.”83(p100) These investigators concluded that although some visiting restrictions were appropriate, the policies should be modified and flexibility should be exercised. Perceived barriers to liberalized visiting and the rationales for restricting visiting in critical care units are multifactorial (Table 8).80,84-86 These concerns were distilled into 3 major groups in a recent study87 of 171 hospitals, of which 32% had unrestricted, open visiting. The categories are (1) Space: interference with patients right to privacy and confidentiality in instance of shared rooms; (2) Conflict: crowding and traffic, hindering the ability to care for patients and loss of structure and authority for nurses; and (3) Burden: to provide care for both patients and their visitors. In the past several decades, many studies have been conducted related to the psychological and 48 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org ENTERAL NUTRITION (EN) FEEDING GUIDELINE UNIVERSITY OF COLORADO H OSPITAL EN may be contraindicated with: Mesenteric ischemia, SBO, paralytic ileus, or GI fistula Goals: 1) Initiate EN within 24-48 hours of admission*♦ 2) Deliver >90% of required calories on a daily basis. Elevate HOB to 30-45°.♦ Initiate Osmolite 1.2 (unless formula otherwise specified) at 25 mL/hour. 1st residual > Maximum GRV? 1) Refeed residual to maximum 400 mL; discard excess 2) Go to PROKINETIC GUIDE (Box A). 3) Continue feeds at same rate. 2nd consecutive residual > Maximum GRV? 1) Continue below YES Q4H residual > Maximum GRV (350 mL♦)? NO 1) Refeed gastric residual. 2) Continue feeds at same rate if at goal rate; ↑feeds by 25 mL every 4 hours if not at goal rate. MAXIMUM GASTRIC RESIDUAL VOLUME (GRV): 350 mL (unless otherwise specified by physician) 1) Refeed gastric residual to maximum 400 mL; discard excess 2) Hold feeds; recheck residual in 1 hour. NO Rechecked residual > Maximum GRV? BOX A: PROKINETIC GUIDE 1) Initiate metoclopramide*#♦ 10 mg IV Q6H (5 mg Q6H if↓ renal function) 2) Continue metoclopramide if already receiving. 3) Do not stop feeds; continue ‘Enteral Nutrition Feeding Guideline’. 4) If residuals > Maximum GRV after 4 doses of metoclopramide, consider combination prokinetic therapy and/or small-bowel feeding tube. Refer to SMALL-BOWEL FEEDING GUIDE (BOX B). YES 1) Discard gastric residual. 2)↓feed rate by 50% (ie, 100→50 mL) to a minimum of 25 mL / hour. 3) Do not stop feeds. 4) If residuals > Maximum GRV after 4 doses of IV metoclopramide consider combination prokinetic therapy and/or smallbowel feeding tube. Refer to SMALLBOWEL FEEDING GUIDE (Box B) Refer to “Enteral Nutrition Problem Solving Guide” on UCH Critical Care QI Committee Web site for further EN practice guidelines and recommendations. BOX B: SMALL-BOWEL FEEDING GUIDE 1) Placement: Insert postpyloric feeding tube*#♦ 2) Feed resumption: Following confirmation of postpyloric tip position, resume feeds at previous rate,↑feeds by 25 mL Q4H if not at goal rate. 3) Aspiration prevention (In sedated/intubated patients only): Insert a large-bore nasogastric tube (NG) for gastric decompression.*# Clamp NG and discard gastric residuals Q4H (or place on straight drainage). 4) Tube maintenance: Flush postpyloric tube with 10-30 mL water every 4 hours If tube clogs,*# instill pancreatic enzyme mixture (8000 units crushed pancrelipase; 650 mg crushed sodium bicarbonate; 5-15 mL water) into postpyloric tube per policy. Resume feeds at previous rate, ↑feeds by 25 mL Q4H if not at goal rate. Notify physician after 3 unsuccessful attempts. 5) If EN contraindications (above) or significant N/V or abdominal distention develop, notify physician and consider stopping smallbowel tube feeds. # Requires MD order * Unless contraindicated ♦ Evidence-based recommendation; all other information opinion-based. Developed by: J Greenwood (Vancouver General Hospital) in collaboration with the CCCCPGC 7/2003. Revised by: B Fulmer, L Kassel, R Saucier, G Vigue. P Wischmeyer (University of Colorado Hospital) 7/2009. Figure 1 University of Colorado Hospital’s protocol for enteral nutrition. Abbreviations: CCCCPGC, Critical Care Clinical Practice Guidelines Committee; EN, enteral nutrition; GI, gastrointestinal; GRV, gastric residual volume; HOB, head of bed; IV, intravenous; MD, physician; N/V, nausea/vomiting; Q4H, every 4 hours; Q5H, every 5 hours; QI, quality improvement; SBO, small-bowel obstruction; UCH, University of Colorado Hospital. Reprinted with permission of the University of Colorado Hospital, Aurora, Colorado. www.ccnonline.org CriticalCareNurse Vol 31, No. 2, APRIL 2011 49 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 Table 7 Best evidence for monitoring enteral feeding Follow an evidence-based enteral feeding protocol65,68 Verify correct placement of enteral feeding tubes on a radiograph, with ongoing monitoring every 4 hours and as needed75 When possible, use a large-bore gastric tube for enteral feeding and evaluate gastric residual volume (GRV) the first few days after initiating enteral feeding with a 60-mL syringe68 Maintain head of bed at 30° elevation or higher Monitor trends in GRV; repeatedly high GRV (ie, >1 high GRV; high GRV is defined as a range between 250 and 500 mL) may require additional interventions65-68; consider use of promotility/prokinetic agents64-66,71 Follow institutional protocol for reinstilling gastric aspirate; to reduce tube occlusions if GRV is reinstilled, increase routine water flushes of the feeding tube64; if aspirate is discarded, record volume in output measurements Evaluate patient for signs of intolerance to tube feeding (eg, bloating, abdominal pain, nausea, vomiting, and emesis) Consider postpyloric feeding in patients with consistently high GRV65,68 en Op led rol t n ed co act nt tie ntr a o P C le xib Fle ive lus c n I d ure uct r t S d icte str e R Figure 2 Spectrum of visiting policies. Table 8 Perceived barriers to liberalized visitinga Barriers related to patients Adverse physiological effects Hinder patients from getting sufficient sleep or rest Interrupt and interfere with the provision of care Barriers related to clinicians Uncomfortable providing care or conducting procedures in front of family members Create a sense of loss of control or structure during emergency situations Feel intimidated Concerns regarding litigation Uncomfortable interacting with family members Tax limited health care provider resources Worries that family members might ask multiple questions Increased stress, physical and mental exhaustion of family and friends thus becoming more of a burden and requiring more time of the staff Concerns for maintaining the privacy of other patients Concerns for safety of self and other patients because of a fear of increased gang violence a Based on evidence from Sims and Miracle,80 Fernandez et al,84 Petterson,85 and Roll.86 physiological effects of visitors on patients and staff. If patients’ wishes regarding visiting are to be considered, nonstressful and flexible visiting is of primary importance. In one study,88 researchers reported that patients preferred usually no more than 3 visitors, for about 35 to 55 minutes, on average 3 or 4 times per day and that visitors offered reassurance, comfort, and calming. Regarding the physiological effects of visitors on patients, research results indicate that visitors have no effect on patients’ blood pressure or heart rate.89-92 In a randomized study91 of a coronary care population, patients having a visitor at a frequency and length of time of the patient’s choosing had fewer cardiovascular complications than did patients whose visitors were permitted to visit only twice a day. The lower complication rate may be due to reduced anxiety and lower cortisol levels associated with time spent with their families and visitors.91 Similarly, no physiological rationale exists for restricting visitors of patients with brain injuries. No deleterious effects on 50 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org neurological status related to visiting have been reported, and some patients experience a reduced intracranial pressure associated with visits by loved ones.93,94 Patients with traumatic brain injury were monitored during family conversations at the bedside. These patients experienced no change in intracranial pressure; systolic, diastolic, and mean blood pressure; heart rate; respiratory rate; arterial saturation; or restlessness when listening to family voices.95 The beneficial effects of liberal visiting policies on patients’ families are well supported. These effects include reduced family stress and burden; lower anxiety96; family’s ability to serve as a historian, protector, coach, facilitator, and voluntary caregiver97; providing basic care such as baths, mouth care, or massage improves respect, collaboration, perceived support of health care providers, and scores on a family-centered care survey.98 Another mechanism that supports flexible visiting and increases families’ participation in care of loved ones is including patients’ families in daily rounds with the health care team.99,100 Benefits of daily family rounds include the following: decrease in unexpected calls or disruptions of physician team rounds; structured time for clinicians to focus on one patient with that patient’s family; increased participation and active, constructive engagement with the staff; identification of families who may benefit from more formal care conferences; and greater satisfaction of patients and their families with the critical care experience.99 The total time commitment for nurses and physicians on a www.ccnonline.org Table 9 Recommendations for family visiting from the American College of Critical Care Medicinea Open visitation to provide flexibility for patients and their families is permitted and established on a case-by-case basis A visitation schedule that is determined collaboratively between patient, patient’s family, and nurse, taking into account the best interest of the patient Whenever possible, family presence and participation is encouraged at rounds, and family presence is permitted during resuscitation Family participation in patients’ care is encouraged as much as the patient’s condition and the family’s comfort level will allow Clean and immunized pets are allowed to visit in the intensive care unit a Based on evidence from Davidson et al.103 Table 10 Practice implications for family visiting Assess and consider the needs of the patient and the patient’s family Support flexible visiting hours through the development and implementation of less restrictive and more collaborative visiting protocols Include patient’s desires and signage regarding accepting visitors in the protocols Develop family presence on rounds program Encourage family members to participate in patient care as much as possible when they are visiting Address staff security concerns in visiting protocols Educate patients’ families about the intensive care unit and visiting protocols, and have the family identify a key spokesperson/contact Educate health care providers about evidence that supports open, flexible family visiting 12-bed neurotrauma unit was 1 hour or less per day.99 Daily rounds and early and routine family meetings can provide an opportunity to assess the family and foster communication, understanding, and collaboration between the family and health care providers.101,102 The American College of Critical Care Medicine charged an interdisciplinary group of physicians, nurses, and a clinical pharmacist to develop evidence-based guidelines for support of family-centered care. The authors reviewed numerous studies and made 43 recommendations for practice.103 Table 9103 outlines the key recommendations relating to family visiting. Recommendations for Practice Critical care nurses, in their roles as advocates for patients and their families, are in a pivotal position to support patient- and familycentered care, which includes open, flexible visiting. Table 10 lists evidence-based practice implications. The Joint Commission recently acknowledged the importance of family-centered care and visitation in providing support to patients. As of 2011, the Patient Rights Standard regarding hospitals’ respect, protection, and promotion of patients’ rights (RI.01.01.01) will have a new element of performance: “The hospital allows a family member, friend or other individual to be present CriticalCareNurse Vol 31, No. 2, APRIL 2011 51 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 Table a11 Evidence-based guidelines for placement of indwelling urinary catheters Clear Indications Contraindications Urinary obstruction/retention Fall prevention Alteration in blood pressure or volume status Routine urine specimens Need accurate measurements of fluid input and output but the patient cannot use urinal or bedpan Staff/patient request Emergency surgery Excoriated skin Altered mental status Major trauma Urologic procedures Bladder irrigation Management of stage III or greater pressure ulcer Comfort care for terminally ill patients a Based on evidence from Hooton et al,106 Greene et al,108 Gould et al,109 and Saint et al.110 with the patient for emotional support during the course of stay.”104 This new element should provide further impetus to develop and implement flexible visiting protocols in the critical care areas. Perhaps the endorsement of open, flexible visiting is best stated by McAdam and colleagues: “families need to be recognized for contributions they make and invited ‘into the world and work’ of ICUs.”97(p1100) Nursing Interventions to Prevent Catheter-Associated Urinary Tract Infections Improving patients’ outcomes often requires rethinking practice, systems, and the “why” behind common interventions and devices used in the management of critically ill patients.105 The insertion of a urinary catheter device is one example in which reexamining the evidence and nursing care associated provides an opportunity to improved patients’ outcomes. Catheter-associated urinary tract infections (CaUTIs) are the most common hospital-acquired infection, accounting for almost 40% of all nosocomial infections. An estimated 80% of CaUTIs are associated with indwelling urinary catheters.106-109 Related Beliefs and Current Evidence Obviously the easiest way to prevent a CaUTI is to avoid insertion of the device. When an indwelling urinary catheter is needed to monitor a patient, however, prevention of CaUTIs begins by understanding the clinical indication for the device and removing the catheter when the clinical condition has resolved. The primary use of a urinary catheter is for close monitoring of a patient’s hemodynamics and fluid balance, surgical procedures, and urologic diseases.106,108,109 The literature suggests that urinary catheters are not indicated to prevent falls, for management of patients with altered mental status, to avoid skin excoriation, or to obtain urine specimens.106,108,110 Table 11 provides a list of clear indications for insertion of urinary catheters as well as a list of conditions in which a catheter is not indicated. Delirium in critically ill patients, especially older hospitalized patients, is an increasing concern that is associated with poor outcomes for patients.111 Multiple factors contribute to delirium, and indwelling urinary catheters have been identified as a specific risk variable.112 Bladder catheters can act as an informal restraint, limiting patients’ movement, especially when the clinical indication for the device is no longer evident.113 The presence of an indwelling urinary catheter in a delirious patient increases the risk of falls and the risk for traumatic dislodgment of the catheter and subsequent urethral trauma. Early removal of urinary catheter devices and implementation of normal toileting practices (eg, bedside commode, offering urinal), frequent rounds, use of moisture wicking underpads, reorientation with specific questions concerning elimination needs, and review of medications that may increase urgency/need to void are important nursing interventions in the management of patients with acute delirium.114,115 Similarly, indwelling urinary catheters are not indicated as a primary intervention to manage moisture-related skin breakdown.106,108,109 Skin care interventions to manage incontinence, such as moisture barrier creams and moisture wicking products, should be explored before insertion of a urinary catheter. In the presence of stage III or IV pressure ulcers in the perineal region, an indwelling catheter may be necessary to assist with wound healing.106 The need for a bladder catheter with concomitant thoracic patientcontrolled epidural analgesia is 52 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org another area for opportunity to reexamine practice and reduce CaUTIs. Research results indicate that an indwelling urinary catheter can be safely removed in conjunction with thoracic patient-controlled analgesia therapy.116,117 Early removal of the catheter in these studies was associated with earlier ambulation, shorter length of hospitalization, lower CaUTI rate, and lower incidence of postoperative urinary retention.117,118 Once a patient with a thoracic patient-controlled epidural for analgesia is hemodynamically stable, the evidence suggests that removal of the bladder catheter should be considered.116-118 Knowing the clear indication for the bladder catheter and minimizing catheter duration are important first steps in preventing CaUTIs. Exploring options for elimination when an indication for an indwelling catheter is not clear is essential to reduce unnecessary insertion of devices. Daily reevaluation of the need for the indwelling device, discussing a discontinue order with the prescribing provider, and prompt removal are also important steps to reduce the risk for infection. Many critically ill patients need an indwelling urinary catheter to monitor fluid balance and hemodynamic status. In the event that a bladder catheter is necessary, nursing interventions in the management of the bladder catheter may assist in the reduction of CaUTIs. Table 12 summarizes current evidence to help prevent CaUTIs. Placing an indwelling urinary catheter device is a fundamental skill taught to all nurses. Opinions vary on whether to use sterile or aseptic technique for the placement www.ccnonline.org Table 12 Recommendations for practice to reduce occurrence of catheterassociated urinary tract infections Know the indication for the indwelling urinary catheter. Use automatic stop orders and reminders to request an order to remove the device when the indication is resolved.119 Use aseptic technique with sterile equipment to insert the device.106,108,109 Aseptic technique is most often defined as the use of sterile gloves, mask, sterile barriers, perineal washing using an antiseptic cleanser, and no-touch insertion technique.120 Perform routine meatal care with soap and water during daily bathing.106,108,109 Use of antiseptic cleansers, creams, lotions, or ointments is no better than perineal care provided with soap and water.106,118,120-122 Antiseptic agents may irritate the urethral meatus and increase the risk of infection.120 Maintain a closed system106,108,109 with the drainage bag below the level of the bladder.106,108-110,123 Use a catheter securement device.124,125 Explore elimination options to prevent reinsertion (eg, bladder scanner, bedside commode, urinal, moisture wicking underpads, nursing rounds).120-127 of the device to reduce CaUTIs.108,118 Part of the challenge is defining sterile and aseptic technique within the clinical context of the skill.121 Willson and colleagues120 conducted a review of the literature and found that aseptic technique for urinary catheter placement was most often defined as the use of sterile gloves, mask, sterile barriers, perineal washing using an antiseptic cleanser, and no-touch insertion technique. Current recommendations suggest that maintaining aseptic technique and using sterile equipment while inserting the catheter are both important elements to minimize infection.106,108,109 Part of urinary catheter care includes care of the urethral meatus. Research on meatal care with antiseptic cleansers, creams, lotions, or ointments found them to be to be no better than routine perineal care provided with soap and water at reducing CaUTIs.106,118,120-122,124 Some evidence suggests that antiseptic agents may actually increase the risk of infection by irritating the urethral meatus.120 Current guidelines suggest “routine hygiene” (eg, cleansing of the meatal surface during daily bathing) is all that is needed to maintain an indwelling urinary catheter.106,108,109 Securing the indwelling urinary catheter is strongly recommended in the guidelines of the Centers for Disease Control and Prevention.109 Research evidence describing the effectiveness of securing a urinary catheter and the prevention of CaUTIs is limited.109,120,122,124,125 The practice of securing a catheter is primarily based on clinical experience and expert opinion (ie, Society of Urologic Nurses and Associates),125 which suggests that securing the urinary catheter prevents urethral trauma, erosion, and inadvertent removal and increases patients’ comfort.124 A number of devices for securing catheters are available, and many experts recommend applying the device to the upper thigh in women and the abdomen in men.124,125 Maintaining a closed system to prevent CaUTIs is supported by current guidelines.106,108-110,120 Catheter and drainage systems are designed with prepackaged seals to prevent inadvertent disconnection and act CriticalCareNurse Vol 31, No. 2, APRIL 2011 53 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 as a physical barrier to the migration of microbes.120 If drainage system seals are broken in practice, a systems analysis of the most common barriers to maintaining the closed system should be explored. For example, if the emergency department uses bladder catheter systems without metered drainage collection devices, the critical care nurse may need to break the system to obtain a metered urometer for hourly monitoring. System analysis could suggest a change to all metered catheter kits, streamlining products and enhancing compliance with evidence-based practice guidelines. Maintaining the collection bag below the level of the bladder is another important practice recommendation, as it minimizes reflux into the catheter itself and prevents retrograde flow of urine.106,108,109 Emptying the drainage bag frequently and before all patient transports is a simple and effective strategy to reduce CaUTIs. Resist the habit of placing the drainage bag between the patient’s legs during transport. All health care providers need to work together to keep the drainage bag below the bladder.123 The effectiveness of ultrasound bladder scanners as a strategy to reduce CaUTIs is not well studied, and further research is needed to demonstrate effectiveness of this monitoring intervention. However, the clinical benefits of bladder scanners include effective diagnosis of urinary retention, reduction of unnecessary intermittent catheterizations, enhanced comfort for patients, and cost savings associated with inappropriate catheterizations.126,127 Ultrasound bladder technology provides an assessment tool to assist with early removal of indwelling invasive urinary catheters. The evidence to support the use of urinary catheters coated with an antimicrobial agent (silver alloy or antibiotic) to reduce CaUTIs is inconclusive.106,128 The clinical evidence defining the safety, efficacy, and appropriate use of silver-coated urinary catheters in randomized controlled trials supports the use of such devices in reducing CaUTI in patients with short catheter durations128; however, the magnitude of reduction in infection did not differ significantly from uncoated catheters in all trials.127 Current guidelines do not recommend routine use of coated catheters in all hospitalized patients to reduce CaUTI.106,108,109,128-130 In a recent systematic review and meta-analysis, Meddings et al119 found that urinary catheter reminders and stop orders appeared to reduce CaUTI rates. Implementing systems that provide physicians and nurses with routine reminders to evaluate the need for the bladder catheter reduced the rate of CaUTIs by 56% (P=.005). Automatic stop orders in this study reduced the rate of CaUTIs by 41% (P<.001). Overall use of urinary catheters was also found to be decreased in several of the studies analyzed in that meta-analysis. Recommendations for Practice Indwelling urinary catheters are commonly used devices in the management of critically ill patients, and evidence-based nursing interventions are needed to prevent infection. One intervention, in isolation, is less effective than a bundle of interventions in preventing CaUTIs.110 Focusing nursing care on the basis of best-practice interventions is necessary to minimize critically ill patients’ risk for developing a CaUTI. Using a multidisciplinary approach to prevent CaUTIs is the most effective method of improving patients’ outcomes. Several programs are available to assist organizations in developing CaUTI prevention programs (eg, from the Association for Professionals in Infection Control and Epidemiology Inc108). Using these programs along with frequent publication of the teams’ efforts in reducing CaUTIs will support the momentum of this change. Ensuring that management of indwelling urinary catheters is based on best evidence is essential to improving patients’ outcomes. Use of Cell Phones in Critical Care Areas Cellular phone technology is used every day by millions of people in all walks of life, businesses, and professions. Cell phones have become an integral tool of the medical community as a means of fast and convenient communication, yet cell phone restrictions remain in critical care units. What is the science behind the restrictions? Related Beliefs and Current Evidence In many hospitals, cell phones are used as a primary means of communication with medical staff in case of emergency and have become an essential clinical resource for accessing information in the care of critically ill patients.131 In a recent survey,132 70% of medical personnel indicated that they carry their mobile devices to areas such as the operating room and critical care 54 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org units despite strict restrictions, and 95% ranked their ability to use mobile phone technology in the hospital as very important or important. Despite the vast array of uses and popularity in the health care arena, mobile technology remains banned in many hospitals nationwide. These bans originated in the era of analog telephone devices and have remained in place despite numerous technological advances. Current policies often state that cellular telephones must be turned completely off when arriving in the hospital or in the critical care areas, a difficult policy to enforce. These rules are based on the premise that cellular devices when in the “on” position transmit detrimental electromagnetic interference. The examination of effects of electromagnetic interference are outlined in Table 13. Policies regarding patient safety concerns related to electromagnetic interference have been focused primarily on the distance between the cellular device and medical equipment. This has also been the focal point of clinical studies related to electromagnetic interference.133,134 Mechanical ventilators have been identified as one of the most critical pieces of medical equipment and therefore have been the most commonly examined biomedical technology. Most studies define cell phone interference as anything from a change in screen appearance, to false alarms, to complete shutdown of the ventilator.133,135-138 In several studies,135,136 researchers reported that the maximum distance between the cellular devices and various ventilators that would cause interference with the ventilator function was 100 cm. In another study,137 www.ccnonline.org Table 13 Electromagnetic interference: effects on medical technology Electromagnetic radiation is emitted intentionally or unintentionally by devices that generate electromagnetic fields, and such radiation may affect the functioning of medical devices.133 The reception of electromagnetic interference by biomedical technologies used throughout the hospital is a cause for concerns about patient safety. The effect of electromagnetic interference on biomedical technology is based on 3 key variables133,134 • Interference is associated with the distance between the cellular device and the medical equipment. • The degree of shielding that the medical device has against electromagnetic interference. • Amount of electromagnetic interference is closely linked to the characteristics of the cellular phone. Testing of effects of electromagnetic interference on biomedical devices in clinical studies most commonly involves testing the maximum level of frequency required to accept or receive a phone call and the radiation emitted toward the biomedical equipment and the corresponding reaction. Research is needed to explore The degree of shielding built into different pieces of medical equipment to protect against electromagnetic interference, with rigorous evaluation of each brand of equipment used within the hospital.131 Evaluation of characteristics of cellular devices and range of interference, minimal to maximal radiation release and proximity to cellular tower,131 and the location of cell phone use in the hospital. researchers identified 9 hazardous incidents involving ventilators that occurred at a median distance of 3 cm (range, 0.1-300 cm) from cellular device to ventilator. Only one of those incidents occurred when the cell phone was more than 100 cm away from the ventilator, and that incident was linked to older generation cellular technology.137 Other biomedical equipment that has been examined for the effect of electromagnetic interference includes devices such as pulse oximeters, cardiac monitors, carbon dioxide detectors, and defibrillators.138,139 For those items, it was determined that the maximum distance for interference was only 20 cm away. The evidence suggests that the range of electromagnetic interference with various types of medical equipment is 0 to 300 cm (9 feet).137-139 However, clinically significant electromagnetic interference with biomedical devices can occur when a cellular phone is less than 100 cm from the device.137,138,140 Based on analysis of the evidence, new guidelines must be developed that would change current hospitalwide bans of cell phone technology. Current evidence support the Medicines and Healthcare Products Regulatory Agency140 recommendations of 2004, which state that a total ban is not necessary. To address the concern of distance between the cellular device and biomedical equipment, the notion of a “1-meter rule” should be established. Using that rule, medical personnel as well as patients and family members would be able to use their mobile technology as long as they were more than 1 m away from critical care equipment. This practice provides extra safety, in that interference is most likely to occur when the cell phone is within 3 cm to 20 cm (1 to 8 in) of biomedical devices.138,139 CriticalCareNurse Vol 31, No. 2, APRIL 2011 55 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 Another recommendation is to create specific, well-marked “cell phone areas” in convenient locations throughout the hospital that afford use of cell phones without concern for electromagnetic interference. In a recent study,141 creation of rooms where cell phone use was acceptable on an adolescent inpatient unit increased satisfaction among patients. Adolescents rely heavily on their cell phones to remain connected to family and friends while hospitalized. Once allowed to go to a cell phone– friendly room, the patients were able to remain compliant with hospital rules while still staying in touch with their “outside lives.” Revision of current policies related to cell phone use that are based on research will be useful in increasing satisfaction of patients, patients’ families, and health care professionals. Recommendations for Practice Hospital policies that ban use of cellular phone devices are not only impractical to enforce, they also exclude a key tool that is used as a vital source of information for health care providers. A review of current evidence indicates that this position is outdated and unnecessary. Less restrictive guidelines such as the 1-meter rule and/or cell phone–friendly areas should be applied to new policies. Revising current policies can increase satisfaction of patients, visitors, and staff. Hospitals and the biotechnology industry will also benefit from more extensive testing of their equipment for sensitivity to electromagnetic interference, as there is tremendous variability between hospitals and the biotechnical equipment used in each. Accuracy of Assessment of Body Temperature Table 14 Temperature measurement sites and devices Sites for measurement of core temperature143,144,146,148 Distal part of esophagus Accurate Nasopharynx measurement of Tympanic membrane body temperature is essential in the management of critically ill patients. Unfortunately an accurate, noninvasive method to measure core temperature has yet to be established.142-144 Understanding the differences in body temperatures measured at various body sites, technology limitations, and “user error” is important when evaluating body temperature values in critically ill patients. Related Beliefs and Current Evidence In practice, assumptions may be made about the accuracy of the temperature measurement device and the relationship of the temperature measured to the core temperature. Physiological temperature can be defined as central (core) and peripheral temperatures. Central temperature is a stable temperature reflective of 60% of the body mass and is tightly regulated by the body.144-146 Near core temperatures, peripheral temperatures, may vary over time or be influenced by extreme environmental and physiological variables,143 but under normal conditions correlate closely with core temperature.144 The most accurate core temperature is obtained via a pulmonary artery catheter; although infrequently used, this method is considered the “gold standard.”143,144,146-149 Table 14 provides the evidence on which sites are used Sites for measurement of near core temperature144,149 Mouth Bladder Rectum Temporal artery Axilla for core and near-core temperature measurements. To interpret and track trends in body temperature correctly, clinicians should consider site-specific temperature as well as device limitations and accuracy in obtaining the temperature. Researchers comparing body temperature measured with various devices and methods with core temperatures considered the temperature device to be accurate if the mean difference in temperatures obtained was ±0.3ºC and to be precise if the standard deviation was from 0.3ºC to 0.5ºC.144,147,149,150 A mean difference in temperature greater than 0.5ºC between devices would represent a clinically significant difference.147 It is unclear whether critical care nurses in clinical practice differentiate the accepted difference in temperature measurements obtained with different devices and how the clinical interpretation of the measurement plays into subsequent clinical decisions. Errors in accurate temperature measurement are most often associated with choice of measurement site, instrument-related errors, and operator error.143,144,148 Temperature monitoring devices require accurate application to provide intended measurement data; however, user error causes erroneous temperature measurements.143,147 Device limitations 56 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org Table 15 Summary of different temperature modes, variation from core temperature, clinical advantages and disadvantagesa Site of temperature measurement Variation from core temperature Pulmonary artery Reference standard Best practice: advantages (+) and disadvantages (–) + True core temperature – Highly invasive Oral <0.4°C + Ease of use + Oxygen up to 6 L and endotracheal tube do not influence accuracy146,149,155 + Research has shown that administration of warmed gases and oxygen through an endotracheal tube does not cause significantly different oral temperature compared with core temperature153,155 – Accurate placement of probe in the mouth (posterior sublingual pocket) is necessary for correct temperature reading143,146,147,149 – May be influenced by fluids and tachypnea156 Esophagus <0.1°C + Correlates closely with pulmonary artery temperature.144,147,150 Optimal placement requires the esophageal temperature probe to be positioned at the point of maximal heart tones (left atrium) in the distal part of the esophagus144,146 and at an insertion depth between 32 and 38 cm.150 + Minimal lag time for temperature measurement144,147 – Temperature fluctuates according to depth of probe; accurate placement is key150 Bladder <0.2°C + Easy to perform with urinary catheterization; low risk of dislocation + Temperature is accurate during dates of increased diuresis154 – Accuracy of temperature influenced by low urine flow144,150 – Lag time estimated up to 20 minutes during therapeutic hypothermia interventions150 Rectum <0.3°C + Easy to perform – Invasive; placed in rectal vault; may be expelled with intestinal motility – Lag time estimated up to 15 minutes144,150 – Accuracy of readings influenced by stool in the rectum Temporal artery <0.4° C + Minimally invasive temperature closely correlated with core temperature + Temporal artery is not significantly affected by thermoregulatory changes; therefore perfusion should be stable in most conditions and closely reflect core temperature.144,156,157 – Current research has provided mixed results as to accuracy of this device in different practice settings, patient populations, and physiological conditions. – Diaphoresis may influence accuracy of temperature readings. – Accuracy of temperature measurement procedure required for correct temperature reading from the forehead and behind the ear.156,158 Not recommended for temperature monitoring143,144,147,149,151,159 – Tested in multiple populations of patients; however, user error and patient’s anatomy reduce accuracy of temperature obtained.143,144,147-149 Tympanic membrane a Based on evidence from Hooper and Andrews,143 Sessler,144 Crawford et al,145 Torossian,146 Forbes et al,147 Bridges and Thomas,148 Hooper et al,149 Polderman and Herold,150 O’Grady et al,151 Exacon Scientific,152 Konopad et al,153 and Fallis.154 include the range of temperatures in which the thermometer has been tested. Few devices have been rigorously tested in all populations of patients and during extremes in www.ccnonline.org temperature (hypothermic and hyperthermic states), yet multiple devices are used in these extremes of body temperature to assess patients. When sensing temperature “lag” in patients with therapeutic hypothermia, both the temperature-measuring device and the physiological temperature site are variables that should be considered with clinical trending of CriticalCareNurse Vol 31, No. 2, APRIL 2011 57 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 temperature and subsequent therapeutic interventions.150 In some practice settings, the measurement of a newly elevated temperature triggers an automatic order set that includes many tests that are costly and disruptive to the patient.151 Knowing which temperature measurement technique is best to assess a patient may minimize the frequency of obtaining inaccurate temperature readings. Also, it is important to remember that temperatures obtained from 2 different body sites should not correlate exactly but should be “close in range” (ie, <0.5ºC apart). Table 15 provides a summary of different temperature measurement modes, their advantages and disadvantages, and the mean variation in temperature from the core temperature measured in the pulmonary artery.143-145,148,150-153 Recommendations for Practice Despite how commonly body temperature is assessed in the management of critically ill patients, the best noninvasive device to measure core temperature accurately remains to be developed.142,145 Although no ideal device has been developed yet, critical care nurses can make good clinical decisions based on the type of device used to measure the temperature, the patient’s characteristics, and the user’s competence. Understanding device limitations and knowing that temperatures obtained from 2 devices should differ by less than 0.5ºC are important To learn more about evidence-based practice, read “Evidence-Based Practice, Rule-Following, and Nursing Expertise” in the American Journal of Critical Care, 2009;18:479-482. Available at www.ajcconline.org. to clinical interpretation of temperature measurement and assessment. Optimally, the same method of temperature assessment should be used throughout an episode of care to enable more accurate tracking of trends in temperature.148 Noting trends in temperature data, evaluating other vital signs, and assessing parameters in a patient with a new fever should guide clinical decisions, not a single temperature reading.148,151 Closing: Moving Evidence Into Practice As Thomas Paine said in 1776, “A long habit of not thinking a thing wrong, gives it a superficial appearance of being right.”160 The practices reviewed in this article are all within the domain of nursing, and it is important as nurses that we challenge tradition and “habits in our nursing practice.” As we continue to perfect the art of nursing, we must also remember the science of nursing. Science is dynamic and ever changing. Clinical practices should be based on evidence whenever possible. The challenge is in getting the evidence in the right hands and encouraging and empowering the clinicians at the bedside to make clinical changes, moving nursing practice away from habits of tradition. Practicing by best evidence improves patients’ outcomes,1,3 and critical care nurses are instrumental to the process of examining and implementing the evidence in practice, putting sacred cows out to pasture. CCN Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ccnonline.org and click “Respond to This Article” in either the full-text or PDF view of the article. Financial Disclosures None reported. References 1. Committee on Health Professions Education Summit. Greiner, AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003. Quality Chasm Series. 2. Rauen C, Chulay M, Bridges E, Vollman K, Arbour R. Seven evidence-based practice habits: putting some sacred cows out to pasture. Crit Care Nurse. 2008;28(2):98-118. 3. Houser J. Evidence-based practice in Health Care. In: Houser J, Oman K (eds). EvidenceBased Practice: An Implementation Guide for Healthcare Organization. Sudbury, MA: Jones-Bartlett Learning, LLC; 2011:1-20. 4. Titler MG, Kleiber C, Steelman VJ, et al. the Iowa model of evidence-based practice to promote quality care. Crit Nurs Clin North Am. 2001;13(4)497-509 5. Stetler CB, Updating the Stetler model of research utilization to facilitate eviencebased practice. Nurs Outlook. 2001;49(6): 272-279. 6. Rosswurm MA, Larrabee JH. A model for change to evidence-based practice. IMAGE J Nurs Sch. 1999;31(4):317-322. 7. Newhouse R, Darhold S, Poe S, Pugh LC, White KM. Evidence-based practice: a practical approach to implementation. J Nurs Adm. 2005;35;35-40. 8. Academic Center for Evidence-Based Practice, The University of Texas Health Science Center at San Antonio. The ACE: learn about EBP page. http://www.acestar.uthscsa.edu /acestar-model.asp. Accessed January 7, 2011. 9. Fineout-Overholt E, Melnyk BM, Schultz A. Transforming health care from the inside out: advancing evidence-based practice in the 21st century. J Prof Nurs. 2005;21(6): 335-344. 10. Evidence-based Practice Centers Overview. October 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epc/. Accessed January 13, 2011. 11. Rycroft-Malone J, Kitson A, Harvey G, et al. Ingredients for change: revisiting a conceptural framework. Qual Saf Health Care. 2002; 11:174-180. 12. Goode C, Fink R, Krugman M, Oman K, Traditi L. The Colorado patient-centered interprofessional evidence-based practice model: a framework for transformation. Worldviews Evid Based Nurs. doi: 10.1111 /j.1741-6787.2010.00208.x. 13. Armola R, Bourgault A. AACN levels of evidence: what’s new? Crit Care Nurse. 2009; 29(4):70-73. 14. Centers for Disease Control and Prevention. Modified HICPAC Categorization Scheme for Recommendations. http://www.cdc.gov /hicpac/guidelineMethod/008_methods _tables.html. Accessed October 30, 2011. 15. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008; 36(1):296-327. 16. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122: S345-S421. 58 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org 17. Hewer CL. The physiology and complications of the Trendelenburg position. Can Med Assoc J. 1956;74:285. 18. Bivins H, Knopp R, dos Santos PA. Blood volume distribution in the Trendelenburg position. Ann Emerg Med. 1985;14:641-643. 19. Weil MH, Whigham H. Head down (Trendelenburg) position for treatment of irreversible hemorrhagic shock. Ann Surg. 1965; 162(5):905-909. 20. Taylor J, Weil MH. Failure of the Trendelenburg position to improve circulation during clinical shock. Surg Gynecol Obstet. 1967;124: 1005-1010. 21. Sibbald W, Paterson, N, Holliday R, et al. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Crit Care Med. 1979;7:218-224. 22. Terai C, Anada H, Matsushima S, et al. Effects of mold Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area and flow. Am J Emerg Med. 1995;13:255-258. 23. Ostrow CL, Hupp E, Topjian D. The effect of Trendelenburg and modified Trendelenburg positions on cardiac output, blood pressure and oxygenation: a preliminary study. Am J Crit Care. 1994;3:382-386. 24. Gentili D, Benjamin E, Berger S, et al. Cardiopulmonary effects of head-down tilt position in elderly postoperative patients: a prospective study. South Med J. 1988;81: 1258-1260. 25. Reich D, Konstadt S, Raissi D, et al. Trendelenburg position and passive leg raising do not significantly improve cardiac performance in the anesthetized patient with coronary artery disease. Crit Care Med. 1989;17:313-317. 26. Reuter D, Felbinger T, Schmidt C, et al. Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance. Eur J Anaesthes. 2003;20:17-20. 27. Sing R, O’Hara D, Sawyer M, et al. Trendelenburg position and oxygen transport in Hypovolemic adults. Ann Emerg Med. 1994; 23:564-567. 28. Fahy BG, Barnas GM, Nagle SE, et al. Effects of Trendelenburg and reverse Trendelenburg postures on lung and chest wall mechanics. J Clin Anesth. 1996;8:236-244. 29. Fahy BG, Barbas GM, Flowers JL, et al. The effects of increased abdominal pressure on lung and chest wall mechanics during laparoscopic surgery. Anesth Analg. 1995;81:744-750. 30. Hirvonen E, Nuutinen L, Kauko M. Ventilatory effects, blood gas changes, and oxygen consumption during laparoscopic hysterectomy. Anesth Analg. 1995;80:961-966. 31. Frey C. Initial Management of the Trauma Patient. Philadelphia, PA: Lea & Febiger; 1976. 32. Clenaghan S, McLaughlin, RE, Martyn C, et al. Relationship between Trendelenburg tilt and internal jugular vein diameter. J Emerg Med. 2005;22:867-868. 33. McQuillan KA. The effects of the Trendelenburg position for postural drainage on cerebrovascular status in head injured patients [abstract]. Heart Lung. 1987;16:327. 34. Boulain T, Achard J, Teboul J, et al. Changes in passive leg raising predict fluid response to fluid loading in critically ill patients. Chest. 2002;121:1245-1252. 35. Monnet X, Rienzo M, Osman D, et al. Passive leg raising predicts fluid responsiveness in the critically ill. Crit Care Med. 2006;34: 1402-1407. www.ccnonline.org 36. Ostrow CL. Use of Trendelenburg position by critical care nurse: Trendelenburg survey. Am J Crit Care. 1997;6:172-176. 37. Bridges N, Jarquin-Valdiva A. Use of the Trendelenburg position as the resuscitation position: To T or not to T? Am J Crit Care. 2005;14:364-368. 38. Gray M, Ratliff C, Donovan A. Perineal skin care for the incontinent patient. Adv Skin Wound Care. 2002;15(4):170-177. 39. Maklebust J, Magnan MA. Risk factors associated with having a pressure ulcer: a secondary data analysis. Adv Wound Care. 1994;7:25-34. 40. Wishin J, Gallagher J, McCann E. Emerging options for the management of fecal incontinence in hospitalized patients. J Wound Ostomy Continence Nurs. 2008;35(1):104110. 41. Gray M, Bliss DZ, Doughty DB, et al. Incontinence-associated dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2007;34(1): 45-54. 42. Beitz JM. Fecal incontinence in acutely and critically ill patients: options in management. Wound Ostomy Manage. 2006;52(12):56-66. 43. Zulkowski K. Perineal dermatitis versus pressure ulcer: distinguishing characteristics. Adv Skin Wound Care. 2008;21(8):382-388. 44. Beekman D, Schoonhoven L, Verhaeghe S, et al. Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs. 2009;65(6):1141-1154. 45. Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence Nurs. 2007;34 (1):260-269. 46. Magnan MA, Macklebust JA. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care. 2009;22(1):83-92. 47. Zimmaro-Bliss D, Hehrer C, Savik K, et al. Incontinence-associated skin damage in nursing home residents: a secondary analysis of a prospective multicenter study. Ostomy Wound Manage. 2006;52(12):46-55. 48. Roach M, Christie JA. Fecal incontinence in the elderly. Geriatrics. 2008;63(2):13-21. 49. Dorner B, Posthauer ME, Thomas D. The role of nutrition in pressure ulcer prevention and treatment: NPUAP White paper. www.npuap.org/Nutrition%20White%20 Paper%20Website%20Version.pdf. Accessed January 13, 2011. 50. Ronner AC, Berland CR, Runeman B, et al. The hygienic effectiveness of two different skin cleansing procedures. J Wound Ostomy Continence Nurs. 2010;37(3):260-264. 51. Junkin J, Selekof JL. Beyond “diaper rash”: incontinence-associated dermatitis—does it have you seeing RED? Nursing. 2008; 38(11 suppl):56hn1-56hn10. 52. Williamson R, Sauser FE. Linen usage impact on pressure and microclimate management [white paper]. http://www.hillrom.com/usa /PDF/156445.pdf. Accessed January 13, 2011. 53. Janowski I.M. Tips for protecting critically ill patients from pressure ulcer. Critical Care Nurse. 2010;30(2):7-9. 54. Medline Underpad, Drypad, Ultrasorb AP. http://www.medline.com/irj/catalog/details /ULTRSRB2436LB/. Accessed January 20, 2011. 55. Covidien Maxicare Underpad. http:// biorelief.com/covidienkendall-maxicare -adult-underpad-super-large.html. Accessed January 13, 2011. 56. Padula CA, Osborn E, Williams J. Prevention and early detection of pressure ulcers in hospitalized patients. J Wound Ostomy Continence Nurs. 2008;35(1):66-75. 57. Palmieri B, Benuzzi G, Bellini N. The anal bag: a modern approach to fecal incontinence management. Ostomy Wound Management. 2005;51(12). http://www.o-wm .com/article/4979. Accessed January 13, 2011. 58. Grogan TA, Kramer DJ. The rectal trumpet: use of a nasopharyngeal airway to contain fecal incontinence in critically ill patients. J Wound Ostomy Continence Nurs. 2002;29(4):193-201. 59. Echols J, Friedman BC, Mullins RG, et al. Clinical utility and economic impact of introducing a bowel management system. J Wound Ostomy Continence Nurs. 2007;34(6):664-670. 60. Padmanabhan A, Stern M, Wishin J, et al. Cilinical evaluation of a flexible fecal incontinence management system. Am J Crit Care. 2007;16(4):384-393. 61. Keshava A, Renwick A, Stewart P, et al. A nonsurgical means of fecal diversion: The Zassi Bowel Management System. Dis Colon Rectum. 2007;50(7):1017-1022. 62. Benoit RA, Watts C. The effect of a puressure ulcer prevention program and the bowel management system in reducing pressure ulcer prevalence in an ICU setting. J Wound Ostomy Continence Nurs. 2007;34(2):163-175. 63. McClave S, Sexton L, Spain D, et al. Enteral tube feeding in the intensive care unit: Factors impeding adequate delivery. Crit Care Med. 1999;27(7):1252-1256. 64. Bourgault AM, Ipe L, Weaver J, et al. Development of evidence-based guidelines and critical care nurses’ knowledge of enteral feeding. Crit Care Nurse. 2007;27(4):17-29. 65. Martindale RG, McClave SA, Vanek VW, et al and the American College of Critical Care Medicine and the ASPEN Board of Directors. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patients: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med. 2009; 37(5):1757-1761. 66. Parrish CR, McClave SA. Checking gastric residual volumes: a practice in search of science? Nutritional Issues in Gastroenterology Series #67. Pract Gastroenterol. 2008; 32:33-46. 67. McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005;33(2):324-330. 68. Blankhead R, Boullata J, Brantley S, et al; ASPEN Board of Directors. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33:165-167. 69. Johnson AD. Assessing gastric residual volumes. Crit Care Nurse. 2009;29(5):72-73. 70. Metheny NA, Schallom L, Oliver, DA, et al. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care. 2008;17(6):512-520. 71. Dobson K, Scott A. Review of ICU nutrition support practices: implementing the nurse-led enteral feeding algorithm. Nurs Crit Care. 2007;12(3):114-123. 72. Kattelmann KK, Hise M, Russell M, et al. Preliminary evidence for a medical nutritional therapy protocol: enteral feedings CriticalCareNurse Vol 31, No. 2, APRIL 2011 59 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. for critically ill patients. J Am Dietetic Assoc. 2006;106(8):1226-141. Metheny NA. Preventing respiratory complications of tube feedings: evidence-based practice. Am J Crit Care. 2005;15(4):360-369. Metheny NA, Stewart J, Nuetzel G, et al. Effects of feeding-tube properties on residual volume measurement in tube-fed patients. JPEN J Parenter Enteral Nutr. 2005;29:192-197. Metheny NA. AACN Practice Alert: Verification of Feeding tube Placement. American Association of Critical Care Nurses. December 2009. http://www.aacn.org/WD/Practice /Docs/PracticeAlerts/Verification_of _Feeding_Tube_Placement_05-2005.pdf. Accessed January 13, 2011. Elpern EH, Stutz L, Peterson S.et al. Outcomes associated with enteral tube feeding in a medical intensive care unit. Am J Crit Care. 2004;13(3):221-227. Berwick D, Kotagal M. Restricted visiting hours in ICUs: time to change. JAMA. 2004;292(6):736-737. Simon S, Phillips K, Badalamenti S, et al. Current practices regarding visitation policies in critical care units. Am J Crit Care. 1997;6:210-217. Livesay S, Gilliam A, Mokracek M, et al. Nurses’perceptions of open visiting hours in neuroscience intensive care unit. J Nurs Care Qual. 2005;20(2):182-189. Sims JM, Miracle V. A look at critical care visitation: the case for flexible visitation times. Crit Care Nurse. 2006;25(4):175-181. Molter NC. Needs of relatives of critically ill patients: a descriptive study. Heart Lung. 1979;8:332-339. Burr G. Contextualizing critical care family needs through triangulation: an Australian study. Intensive Crit Care Nurs. 1998;14(4): 161-169. Ballard KS. Identification of environmental stressors for patients in a surgical intensive care unit. Mental Health Nurs. 1981;3:89-108. Fernandez R, Compton S, Jones K, Velilla M. The presence of a family witness impacts physician performance during simulated medical codes. Crit Care Med. 2009;37: 1956-1960. Petterson M. Process helped gain acceptance for open visitation hours. Crit Care Nurse. 2005;25(1):70-72. Roll F. Current healthcare security issues and countermeasures. In: International Hospital Federation Reference Book 2005 /2006. London, England: IHF Publications; 2005:45-48. http://www.ihf-fih.org/en /content/download/214/1367/file/45-2roll .pdf. Accessed January 13, 2011. Lee MD, Friedenburg AS, Mukpo DH, et al. Visiting hours policies in New England intensive care units: strategies for improvement. Crit Care Med. 2007;35(2):497-501. Gonzalez C, Carroll D, Elliott J, et al. Visiting preferences of patients in the intensive care unit and in a complex care medical unit. Am J Crit Care. 2004;13(3):194-198. Fuller VF, Foster GM. The effect of family/friend visitors vs staff interaction on stress/arousal of surgical intensive care unit patients. Heart Lung. 1982;11:457-463. Schulte D, Burrell L, Gueldner S. Pilot study of the relationship between heart rate and ectopy and unrestrictive verses restricted visiting hours in the critical care unit. Am J Crit Care. 1993;2:134-136. 91. Fumagalli S, Boncinelli L, Nostro A, et al. Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit. Circulation. 2006;113:946-952. 92. Kleman M, Bickert A, Karpinski A, et al. Physiologic responses of coronary care patients to visiting. J Cardiovasc Nurs. 1993; 7:52-62. 93. Hendrickson SL. Intracranial pressure changes and family presence. J Neurosci Nurs. 1987;19:14-17. 94. Hepworth JT, Hendrickson SG, Lopez J. Time series analysis of physiological response during ICU visitation. West J Nurs Res. 1994;16:704-717. 95. Walker J, Eakes GG, Siebelink E. The effects of familial voice interventions on comatose head-injured patients. J Trauma Nurs. 1998; 5(2):41-45. 96. Garrouste-Orgeas M, Philippart F, Timsit J, et al. Perceptions of a 24-hour visiting policy in the ICU. Crit Care Med. 2008;36(1):30-35. 97. McAdam, J, Arai1 S, Puntillo K. Unrecognized contributions of families in the intensive care unit. Intensive Care Med. 2008;34: 1097-1101. 98. Mitchell M, Chaboyer W, Burmeister E, et al. Positive effects of a nursing intervention on family centered care in adult critical care. Am J Crit Care. 2009;18(6):543-553. 99. Byrne A, Aumick J, Armstrong L, et al. Improved Patient/Family Satisfaction after Implementation of Family Rounds. American Association of Critical Care Nurses, National Teaching Institute 2010. Abstract CS74. ccn.aacnjournals.org/content/30/2 /e1.full.pdf. Accessed January 13, 2011. 100. Jacobowski NL, Girard TD, Mulder JA, et al. Communication in critical care: family round sin the intensive care unit. Am J Crit Care. 2010;19(5):421-430. 101. Kentish-Barnes N, Lemaile V, Chaize M, et al. Assessing burden in families of critical care patients. Crit Care Med. 2009;37(10): S448-S456. 102. Davidson JE. Family-centered care: meeting the needs of patients’ families and helping families adapt to critical illness. Crit Care Nurse. 2009;29(3):28-34. 103. Davidson J, Powers K, Hedayat, K, et al. Clinical practice guidelines for support of the family in the patient-centered ICU: ACCM Task Force 2004-2005. Crit Care Med. 2007;35(2):605-622. 104. The Joint Commission: New and Revised Hospital EPs to Improve Patient-Provider Communication. Jt Comm Perspect. 2010; 30(1):5-6. 105. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? JAMA. 2002;288(4):501-507. 106. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(6):625-663. 107. Saint S, Kowalki P, Kaufman SR, et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008;46(2):243-250. 108. Greene L, Marx J, Oriola S. Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CaUTIs). Washington, DC: Association for Professionals in Infection Control and Epidemiology, Inc (APIC). http:// 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. www.apic.org/Content/NavigationMenu /PracticeGuidance/APICEliminationGuides /CAUTI_Guide.pdf. Accessed January 13, 2011. Gould CV, Umscheid CA Agarwal RK, et al; and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Atlanta, GA: Centers for Disease Control and Prevention; 2009. http://www.cdc.gov/ncidod/dhqp/pdf /guidelines/CAUTI_Guideline2009final .pdf. Accessed January 13, 2011. Saint S, Olmsted RN, Fakih MG, et al. Translating health care associated urinary tract infection prevention research into practice via the bladder bundle. Jt Comm J Qual Patient Saf. 2009;35(9):449-455. http://search .jointcommission.org/search?q=cauti&site =All-Sites&client=jcaho_frontend&output =xml_no_dtd&proxystylesheet=jcaho _frontend. Accessed January 13, 2011. Ouimet S, Kayanagh BP, Gottfried SB, et al. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007; 33:66-73. Holroyd-Leduc JM, Khandwala F, Sink KM. How can delirium best be prevented and managed in older patients in hospital? CMAJ. 2010;182(5):456-470. Saint S, Lipsky BA, Gould SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-126. Dowling-Castronovo A, Bradway C. Urinary incontinence: nursing standard of practice protocol in older adults admitted to acute care. Hartford Institute for Geriatric Nursing. Updated January 2008. http://consultgerirn .org/topics/urinary_incontinence/want_to _know_more. Accessed January 13, 2011. Tullmann DF, Mion LC, Fletcher K, et al. Delirium: prevention, early recognition, and treatment. Hartford Institute for Geriatric Nursing. Updated January 2008. http://consultgerirn.org/topics/delirium /want_to_know_more. Accessed January 13, 2011. Ladak SS, Katznelson R, Muscat M, et al. Incidence of urinary retention in patients with thoracic patient-controlled epidural analgesia undergoing thoracotomy. Pain Manag Nurs. 2009;10(2):94-98. Chia YY, Wei RJ, Chang HC, Liu K. Optimal duration of urinary catheterization after thoracotomy in patients under postoperative patient-controlled epidural analgesia. Acta Anaesthesiol Taiwan. 2009;47(4):173-179. Basse L, Werner M, Kehlet H. Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Reg Anesth Pain Med. 2000;25(5):498-501. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: Reminder systems to reduce catheterassociated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010;51(5):550-560. Willson M, Wilde M, Webb ML, et al. Nursing interventions to reduce the risk of catheter-associated urinary tract infection: Part 2. J Wound Ostomy Continence Nurs. 2009;36(2):137-154. Joanna Briggs Institute. Management of short term indwelling urethral catheter to prevent urinary tract infections. http:// www.joannabriggs.edu.au/pdf/BPISEng_4 _1.pdf. Accessed January 13, 2011. 60 CriticalCareNurse Vol 31, No. 2, APRIL 2011 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 www.ccnonline.org 122. Gray M. What nursing interventions reduce the risk of symptomatic urinary tract infection in the patient with an indwelling catheter? J Wound Ostomy Continence Nurs. 2004;31(1):3-13. 123. Siegel T. The ins and outs of urinary catheters. Adv Nurse Pract. August 2008:57-60. www .advanceweb.com/np. Accessed January 13, 2011. 124. Gray M. Securing the indwelling catheter. Am J Nurs. 2008;(12):44-50. 125. Society of Urologic Nurses and Associates: Clinical Practice Guidelines Task Forces. Care of the patient with an indwelling catheter. Urol Nurse. 2006;26(1):80-81. 126. Sparks A, Boyer D, Gambrel A, et al. The clinical benefits of the bladder scanner: a research synthesis. J Nurs Care Qual. 2004; 19(3):188-192. 127. Lee YY, Tsay WL, Lou MF, et al. The effectiveness of implementing a bladder ultrasound programme in neurosurgical units. J Adv Nurs. 2006;57(2):192-200. 128. Cummings J. Silver-coated foley catheters for the prevention of urinary tract infections. Techflash: Illuminating Evidence to Aid Decision Making. Oak Brook, IL: University HealthSystem Consortium; August 2009. https://www.uhc.edu. 129. Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med. 2006;44(2):116-126. 130. Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S41–S50. http://www.journals.uchicago.edu/doi/pdf /10.1086/591066. Accessed January 13, 2011. 131. Dang B, Nel P, Gjevre J. Mobile communication devices causing interference. J Crit Care. 2007;22(2):137-141. 132. Ramesh J, Carter AO, Campbell MH, et al. Use of mobile phones by medical staff at Queen Elizabeth Hospital, Barbados: evidence for both benefit and harm. J Hosp Infect. 2008; 70(2):160-165. 133. Lapinsky S, Easty A. Electromagnetic interference in critical care. J Crit Care. 2006;21(3): 267-270. 134. Brodie M, Robertson D, Wyllie J. Interference of electrocardiographic recordings by a mobile telephone. Cardiol Young. 2007;17(3): 328-329. 135. Shaw CI, Kacmarek RM, Hampton RL, et al. Cellular phone interference with the operation of mechanical ventilation. Crit Care Med. 2004;32(4):928-931. 136. Jones RP, Conway DH. The effect of electromagnetic interference from mobile communication on the performance of intensive care ventilators. Eur J Anaesthesiol. 2005; 22(8):578-583. 137. van Leishout EJ, van der Veer SN, Hensbroek R, et al. Interference by new-generation mobile phones on critical care medical equipment. Crit Care. 2007;11(5):1-6. http://ccforum.com/content/11/5/R98. Accessed January 13, 2011. 138. Tat FH, Wah KC, Hung YH. A follow-up study of electromagnetic interference of cellular phones on electronic medical equipment in the emergency department. Emerg Med. 2002;14(3):315-319. 139. Tri JL, Severson RP, Hyberger LK, Hayes DL. Use of Cellular Telephones in the Hospital www.ccnonline.org 140. 141. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157. Environment. Mayo Clin Proc. 2007;82(3): 282-285. Medicines and Healthcare Products Regulatory Agency (MHRA). Electromagnetic compatibility of medical devices with mobile communications. Device Bulletin DB9702. London, England: MHRA; 2004. Bell J. Mobile phone use on a young person’s unit. Paediatr Nurs. 2009;21(7):14-18. Davie A, Amoore J. Best practice in the measurement of body temperature. Nurs Stand. 2010;24(42):42-50. Hooper VD, Andrews JO. Accuracy of Noninvaisve core temperature measurement in acutely ill adults: the state of the science. Biol Res Nurs. 2006;8(1):24-34. Sessler DL. Temperature monitoring and perioperative thermoregulation. Anesthesiology. 2008;109(2):318-338. Crawford DC, Hicks B, Thompson MJ. Which thermometer? Factors influencing best choice for intermittent clinical temperature assessment. J Med Eng Technol. 2006; 30(4):199-211. Torossian A. Thermal management during anesthesia and thermoregulation standards for the prevention of inadvertent perioperative hypothermia. Best Pract Res Clin Anaesthesiol. 2008;22(4):659-668. Forbes SS, Eskicioglu C, Nathens AB, et al. Evidence-based guidelines for prevention of perioperative hypothermia. J Am Coll Surg. 2009;209(4):492-502. Bridges E, Thomas K. Noninvasive measurement of body temperature in critically ill patients. Crit Care Nurse. 2009;29(3):94-97. Hooper VD, Chard R, Clifford T, et al. ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia. J Perianesth Nurs. 2009; 24(5):217-287. Polderman KH, Herold I. Therapeutic hypothermia and controlled normothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Crit Care Med. 2009;37(3):1101-1120. O’Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008;36(4): 1130-1349. Medical Temperature Measurement. Exacon Scientific. 2005. http://www.exacon.com /Global/Globalintro/GlobalintroFR.html. Accessed January 13, 2011. Konopad E, Kerr JR, Noseworthy T, Grace M. A comparison of oral, axillary, rectal, and tympanic membrane temperatures of intensive care patients with and without an oral endotracheal tube. J Adv Nurs. 1994; 20(1):77-84. Fallis WM. The effect of urine flow rate on urinary bladder temperatures in critically ill adults. Heart Lung. 2005;34(3):209-216. Fallis WM. Oral measurement of temperature in orally intubated critical care patients: state of the science review. J Crit Care. 2000; 9(5):334-343. Lawson L, Bridges EJ, Ballou I, et al. Accuracy and precision of noninvasive temperature measurement in adult intensive care patients. Am J Crit Care. 2007;16(5):485-496. Hebbar K, Fortenberry JD, Rogers K, et al. Comparison of temporal artery thermometer to standard temperature measurement in pediatric intensive care unit patients. Pediatr Crit Care Med. 2005;6(5):557-561. 158. Calonder EM, Sendelbach S, Hodges JS, et al. Temperature measurement in patients undergoing colorectal surgery and gynecology surgery: a comparison of esophageal core, temporal artery, and oral methods. J Perianesth Nurs. 2010;25(2):71-78. 159. Moran JL, Peter JV, Solomon PJ. Tympanic temperature measurements: are they reliable in the critically ill? A clinical study of measures of agreement. Crit Care Med. 2007; 35(1):155-164. 160. Paine T. Common Sense. 1776. http://www .ushistory.org/paine/commonsense. Accessed January 13, 2011. CriticalCareNurse Vol 31, No. 2, APRIL 2011 61 Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011 CE Test Test ID C1123: Evidence-Based Practice Habits: Putting Sacred Cows Out to Pasture Learning objectives: 1. Understand how embracing evidence-based practice can immediately improve patient care 2. Recognize 7 areas of clinical practice in which tradition and the evidence do not agree 3. Identify recommendations for practice related to 7 older practice issues or “sacred cows” 1. What is a physiological effect of Trendelenburg positioning in hypotensive patients? a. Increased right ventricular ejection fraction b. Increased lung compliance c. Increased abdominal pressure d. Increased tidal volume 7. What is considered a physiological effect of visitors on hospitalized patients? a. Decreased cortisol levels b. Increased systolic blood pressure c. Decreased arterial saturation d. Increased intracranial pressure 2. What is a potential benefit of passive leg lift for initial management of hypotension? a. Decreased aortic volume b. Decreased aspiration risk c. Baroreceptor activation d. Upper thorax volume shift of 500 mL 8. What is an appropriate indication for urinary catheter insertion? a. Fall prevention b. Routine urine specimen collection c. Skin excoriation management d. Comfort care for terminally ill patients 3. What is the least safe intervention to divert fecal material away from skin? a. Fecal pouches b. Traditional rectal tubes c. Bowel management systems d. Rectally-inserted nasopharyngeal airway 9. What is considered a best practice to prevent catheter-associated urinary tract infections in hospitalized patients? a. Minimizing catheter duration b. Using silver alloy-coated urinary catheters c. Routinely using ultrasound bladder scanners d. Performing daily urinary meatal cleansing with antiseptic agents 4. What is an evidence-based intervention to manage fecal incontinence? a. Cleanse the skin with a no-rinse cleanser b. Use soap and water with a washcloth for basic skin care c. Use diapers for immobile patients d. Use multiple layers of bed linen to pull liquid stool away from skin 10. The “1-meter rule” provides extra safety because electromagnetic interference is most likely to occur within what distance of biomedical devices? a. 3 to 20 mm c. 3 to 20 m b. 3 to 20 cm d. 3 to 20 km 5. What has evidence demonstrated about gastric residual volume (GRV) measurement in enterally fed patients? a. Elevated GRV indicates enteral tube feeding intolerance. b. Elevated GRV indicates delayed gastric emptying. c. A high GRV increases aspiration pneumonia risk. d. Measuring GRV does not improve patient outcomes. 11. What site of temperature measurement most closely correlates with pulmonary artery temperature? a. Bladder b. Rectum c. Temporal artery d. Esophagus 6. What is considered a best practice for enteral tube feedings? a. Withhold enteral feeding for an isolated GRV greater than 250 mL b. Use a 30 mL syringe to aspirate GRV c. Consider postpyloric feeding in patients with consistently high GRV d. Discontinue tube feedings to reposition patients 12. What is correct about monitoring urinary bladder temperature? a. It has a high risk of dislocation. b. Temperature is not accurate during periods of increased diuresis. c. Estimated lag time is up to 20 minutes during therapeutic hypothermia. d. Its accuracy is uninfluenced by low urine output. Test answers: Mark only one box for your answer to each question. You may photocopy this form. 1. K a Kb Kc Kd 2. K a Kb Kc Kd 3. K a Kb Kc Kd 4. K a Kb Kc Kd 5. K a Kb Kc Kd 7. K a Kb Kc Kd 6. K a Kb Kc Kd 8. K a Kb Kc Kd 9. K a Kb Kc Kd 10. K a Kb Kc Kd 11. K a Kb Kc Kd 12. K a Kb Kc Kd Test ID: C1123 Form expires: April 1, 2013 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Synergy CERP: Category A Test writer: Denise Hayes, RN, MSN, CRNP Program evaluation Name Yes K K K For faster processing, take this CE test online at www.ccnonline.org (“CE Articles in this issue”) or mail this entire page to: AACN, 101 Columbia Aliso Viejo, CA 92656. Objective 1 was met Objective 2 was met Objective 3 was met Content was relevant to my nursing practice K My expectations were met K This method of CE is effective for this content K The level of difficulty of this test was: K easy K medium K difficult To complete this program, it took me hours/minutes. No K K K K K K Member # Address City State Country ZIP Phone E-mail RN Lic. 1/St Payment by: RN Lic. 2/St K Visa K M/C K AMEX K Discover Card # K Check Expiration Date Signature The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure. Downloaded from ccn.aacnjournals.org at UNIVERSITY OF IOWA on April 11, 2011