Name of the patient: Mrs. Linde
Age: 76 years
Mrs. Linde was a patient who was admitted to a surgical unit at Ocala Regional Medical Center where I worked as a nurse. While attending to her, I realized that she as well as most of the patients in my surgical unit developed a high level of acuity that could easily result into severe cardiac arrest and sudden death. Mrs. Linde was therefore transferred to the Intensive Care Unit (ICU) following her critical condition. I decided to talk to my Nurse Manager about rapid response team and how it can be helpful in reducing increasing cases of the contraction of cardiac arrest by the in-patients and unexpected admissions to the ICU. I believed this could be of great help to the hospital. Researchable and answerable is a significant step in the Evidence Based Practice (Fineout-Overholt and Johnston, 2005). Therefore, my manger suggested that I conduct more research to find solid evidence on the contribution of rapid response team in healthcare system. This prompted me to formulate a clinical question.
I used PICOT (Patient’s population, issue of Interest, Comparison, Outcome and Time) format to formulate a research question. My PICOT question was derived from the prevailing aspects of the clinical issue at my surgical unit. These aspects include the increased level of acuity among the hospitalized patients in the surgical unit, increased number of in-patients contracting cardiac arrest, unexpected admissions into the ICU, and the intervention by the rapid response team. Since there was no team to provide rapid response to such patients and the hospital was not planning to address the issue of patient’s acuity prior to the impending crisis, element of the comparison (C component) in the PICOT was lack of rapid response team. The outcomes or the results in the question were constant admission into the ICU and in-patients contracting cardiac arrest. Other possible outcomes included prolonged hospitalization and deaths. My proposed picot question therefore was; “Among the adult in-patients in the surgical unit, how does the presence of a rapid response team compared with the absence of rapid response team influence the cases of cardiac arrests among the hospitalized patients and the unexpected admissions to the intensive care unit for patients hospitalized for three months? In this question, the components of PICOT include
· Patient Population (P) - the adult in-patients
· Issue of Interest (I) - the presence of a rapid response team
· Comparison(C) - the absence of rapid response team
· Outcome (O) - influence the cases of cardiac arrests among the hospitalized patients and the unexpected admissions to the intensive care unit for patients
· Time (T) - hospitalized for three months
According to Stillwell et al. Evidence-Based Practice involves solving a problem in the health care delivery system by integrating the available evidences from the data of the patients and studies with the expertise of medical practitioners and values. From the above scenario, it is clear that various aspects affect personal experiences of patients throughout their stay in the hospital. Additionally, social aspects may influence and surpass curative variables without necessarily involving antiretroviral measures. However, Melnyk et al. 2009 suggests that it is important for nurses and medical practitioners to understand that the formulated question influences any attempt to find evidence to achieve a desirable outcome in patients so as to support a practical change. It is also evident from the previous studies that Rapid Response Teams are the best weapon to curb cardiac arrests since they evaluate the patients at an early stage of the disease thus reducing mortality rate (Dacey et al. 2007). Another study also pointed that while therapeutic interventions have been successfully administered to the patients, such interventions may not be helpful for long-term health care processes (Cheng, 2011).
Dacey MJ, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007;35(9):2076-82
Background: Rapid Response Teams (RRTs) assess patients during early phases of deterioration to reduce patient morbidity and mortality. Objectives: This study aimed to evaluate the ability of earlier medical intervention by an RRT prompted by clinical instability in patients to reduce the incidence of and mortality from unexpected cardiac arrest at our hospital. Patients and Methods: A nonrandomized, population-based study before 2008 and after 2010 introduction of the Rapid Response Teams in a 300-bed private hospital. All patients were admitted to the hospital in 2008 (n = 25348) and 2010 (n = 28024). RRT (One doctor, one senior intensive care nurse and one staff nurse) attended to clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response was activated by the bedside nurse or doctor according to predefined criteria. Main outcome measures were incidence and outcome of unexpected cardiac arrest. Results: The incidence of unexpected cardiac arrest was 17 per 1000 hospital admissions (431 cases) in 2008 (before RRT intervention) and 12.45 per 1000 admissions (349 cases) in 2010 (after intervention), with mortality being 73.23% (274 patients) and 66.15% (231 patients) respectively. After adjustment for case mix the intervention was associated with a 19% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.81, 95% confidence interval 0.65-0.98). Conclusions: The RRT was able to detect preventable adverse events and reduce the mortality and incidence of unexpected cardiac arrests
Stillwell SB et al, Evidence-based practice, step by step: asking the clinical question: a key step in evidence-based practice. 2nd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams and Wilkins.
The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we've scheduled "Ask the Authors" call-ins every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May's Evidence-Based Practice, Step by Step
Melnyk BM, et al. Igniting a spirit of inquiry: an essential foundation for evidence-based practice. Am J Nurs2009;109(11):49-52
This is the third article in a series from the Arizona State University College of Nursing and Health Innovation's Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.
Cheng, H. Y. Evidence-Based Medicine (EBM): What t Long -Term Care Providers Need to Know
Evidence-based medicine (EBM) has been exponentially disseminated to every field of medicine over past 2 decades.1–7 EBM is now a part of postgraduate competency through practice-based learning.8 However, its potential use in the long-term care setting was only recently appreciated in the literature.1,9,10 EBM may play an important role in reforming nursing homes and improving quality care.1–5,9,10 The simple search term “EBM,” limited to English and human in Medline, generated 49,304 citations, which narrowed to only 173 when “nursing homes” was added, indicating that EBP is not rare and is being implemented in long-term care. It has been a great effort that each article in this special issue presents evidence-based recommendations to long-term care providers to guide their daily practice. In contrast to the evidence-based approach to individual geriatric conditions addressed in the other articles in this issue, this article briefly introduces the basic concept of EBM; addresses some potential benefits, harms, and challenges of its practice in a long-term care setting; and promotes its appropriate use among providers of long-term care. For those who already know the EBM basics and are interested in becoming experts, several textbooks on EBM are recommended.11–13 Attending an EBM workshop, such as one run by McMaster University,14 could also be helpful. Many Internet resources are also useful, including PIER: The Physicians’ Information and Education Resource (pier.acponline.org), Clinical Evidence.