How to conduct an evidence-based practice investigation
The authors describe how they conducted a clinical inquiry into their own practice on cardiac monitoring lead placement in CCU patients.

By Susan B. Fowler, PhD, RN, CNRN, and Bonnie S. Forshner, MSN, RN, CCRN-CMC

When leafing through a nursing journal these days, you’re likely to see an article on evidence-based practice (EBP). The higher profile gained recently by EBP indicates both the importance of this topic and nurses’ vast interest in it. EBP in nursing refers to integration of the best evidence available, combined with nursing expertise and the values and preferences of the patients, families, and communities being served.

So how does a nurse embark on an EBP project? By starting with clinical inquiry. Martha Curley, PhD, RN, FAAN, Director of Critical Care and Cardiovascular Nursing Research at Children’s Hospital Boston, defines clinical inquiry as an ongoing process of questioning and evaluating, followed by providing informed practice.

EBP also is about promoting clinical innovation by applying evidence and experiential learning. Clinical inquiry identifies knowledge gaps, which helps move practitioners away from ritualistic practice toward change and ongoing evaluation. Nurses who value EBP ask questions, exhibit curiosity, and wonder continually if there’s a better way to provide patient care.

Use PICO to formulate your question

When nurses seek answers based on the best evidence, they’re using an EBP approach. When they ask questions about clinical practice, they’re demonstrating clinical inquiry.

Formulating the perfect question can be the most difficult part of an EBP investigation. To make it easier, you can use the PICO framework:

• P: Population of interest, such as elderly hospitalized patients with a temperature of 38.3° C (101° F) or higher
• I: Intervention in question; for example, a cool sponge bath
• C: Comparative intervention, such as a cooling mattress
• O: Outcome that results from the intervention; in this example, it might be a temperature decrease of 16.6° C (2° F) within 4 hours.

Some questions are relatively simple; others need to be more complex to capture the essence of the issue and focus each aspect of the question on the appropriate population, intervention, comparison, and outcome.

As a registered nurse on a coronary care unit (CCU), one of the authors of this article started to question her own practice on cardiac monitoring lead placement in patients with frequent tachycardia episodes marked by a wide QRS complex. Her clinical inquiry led her to formulate the following question: Is one monitoring lead better at differentiating wide-complex ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with a narrower complex whose aberrant conduction makes it wider? After many attempts, revisions, and suggestions from experts, she was able to formulate the question using the PICO framework, as follows:

In adult CCU patients who experience runs of tachycardia with a wide QRS complex (P), will use of lead V₁ (I) compared to lead II as a standard for all patients (C) result in more effective differentiation of VT from SVT with aberrancy (O)?

Reviewing the literature

Once you’ve formulated the question, the next step in the EBP process is to review the literature. The John Hopkins Nursing EBP (JHNEBP) model can provide direction for this review, which can help you collect and critically appraise the evidence. Experts recommend conducting both internal and external evidence searches, critiquing all types of evidence, summarizing the evidence, and rating its quality and strength. (An internal evidence search involves gathering locally obtained quality and outcome data; it includes consensus opinions, clinical expertise, and experiential information from healthcare professionals. An external search refers mainly to gathering all research available on a specific topic.)

Rating the strength of evidence

Strength of evidence ranges from level I (the highest) to level V (the lowest). See the box below.

RCTs are considered the most reliable form of evidence because they allocate treatments at random, resulting in statistically equivalent groups of subjects. However, in electrocardiography (the topic of the coauthor’s EBP project), RCTs are almost nonexistent. Thus, expert opinions are based on clinical experience and related research. The coauthor’s search of the literature over the past 5 years yielded limited information, and consequently was extended to the past 10 to 15 years.

At any level of evidence, the quality of the evidence may be rated as high (A), good (B), or low (C). See the box below.

In the coauthor’s project, level III evidence consisting of nonexperimental and qualitative studies and studies with evidence of good quality included the following: Lead V₁ is clearly superior to lead II in differentiating VT from SVT with aberrancy because recordings from that lead contained:

• visible P waves to identify AV dissociation, which indicates VT
• the widest QRS interval, which if greater than 0.16 seconds indicates VT
• valuable QRS morphology criteria.In the JHNEBP model, systematic reviews fall into the level IV strength-of-evidence category. A systematic review by Hebra in 1994, deemed to yield level IV evidence of good quality, concluded that lead II is an inferior monitoring lead, V₁ should be the primary lead used, and care goals and anticipation of possible changes in a patient’s condition should drive lead selection.In addition, level IV evidence of high quality from the American Association of Critical Care Nurses (AACN) suggests that:
  • nurses should select the monitoring lead based on the patient’s specific arrhythmia
  • lead V₁ should be used to distinguish VT from SVT with aberrancy
  • lead V₁ should be used for primary monitoring if the patient lacks a history of or potential for atrial arrhythmias.

  Finally, level IV evidence of high quality was found in a guideline endorsed by the American Heart Association (AHA), AACN, and the International Society of Computerized Electrocardiography. This guideline recommends lead V₁ as the best lead for distinguishing VT from SVT with aberrant ventricular conduction.

  Relating findings to clinical practice

  Next, you must consider how your findings relate to clinical practice. For instance, based on the evidence, the coauthor concluded lead II is an inferior monitoring lead and shouldn’t be used routinely as the standard lead for all coronary care patients. In addition, lead V₁ is preferred for distinguishing VT from SVT with aberrancy.

  Applying these conclusions to a nurse’s individual practice setting takes investigation, development, and implementation of appropriate strategies. Initially, a baseline audit was done at the central monitoring station of the coauthor’s eight-bed CCU in a tertiary acute-care hospital to examine the use of lead V₁. It found a 12.5% rate of lead V₁ use.

  Immediately, a performance improvement project was initiated using the PDSA (plan-do-study-act) process, with the ultimate goal of achieving 90% or greater compliance with lead V₁ use. The entire CCU staff (nurses, residents and attending physicians) were educated on the use of lead V₁ via a PowerPoint presentation. Staff members were asked to sign a form as evidence they received this education.

  Next, a competency tool was developed for all staff involved in continuous cardiac monitoring to ensure patient safety and accurate monitoring. A follow-up audit done 1 month after the educational presentation showed 62.5% compliance. To improve compliance, a laminated sign (“Are you using lead V₁?”) was placed over the central monitors as a visual reminder.

  Two months after the initial audit, compliance reached 75%. For reinforcement, a global e-mail was sent to all CCU nurses, and those who’d been struggling with compliance received one-on-one counseling. One month later, compliance reached 100%; these results held the next month, with 100% compliancy sustained.

  Time, thought, and critique

  EBP investigation takes a great deal of time and thought to arrive at the best PICO question and critique the available literature. But the biggest challenge occurs in the practice setting, where you must convince colleagues that change is needed to ensure best practices.

  Ultimately, knowing you’re an integral part of implementing the most current evidence and best practices makes it all worthwhile.

  Susan Fowler is director of Education, Research, and Practice at the Visiting Nurse Association of Central Jersey in Red Bank, New Jersey. At the time the EBP project described in this article was conducted, she was a clinical nurse researcher at Morristown Memorial Hospital in Morristown, New Jersey. Bonnie Forshner is a Cardiovascular Clinical Specialist at Gagnon Cardiovascular Institute at Overlook Hospital in Summit, New Jersey. When this project was conducted, she was a unit educator and staff nurse in the coronary care unit at Morristown Memorial Hospital.

  Selected references

  American Association of Critical Care Nurses. (2008). AACN practice alert: Dysrhythmia monitoring. http://www.aacn.org/WD/Practice/Docs/PracticeAlerts/Dysrhythmia_Monitoring_04-2008.pdf. Accessed July 8, 2010.

  Curley MAQ. Patient-nurse synergy: Optimizing patients’ outcomes. Am J Crit Care. 1998;7(1):64-72.

  Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MM et al. Practice standards for electrocardiographic monitoring in hospital settings: An American Heart Association Scientific Statement. Circulation. 2004;110(17):2721-2746.

  Hebra JD. (1994). The nurses’ role in continuous dysrhythmia monitoring. AACN Clin Issues Crit Care Nurs. 1994 May;5(2):178-85.

  Newhouse RP, Dearholt S, Poe S, Pugh LC, White KH. Evidence-based practice: A practical approach to implementation. JONA. 2005;35(1):35-40.

  Newhouse RP, Dearholt SL, Poe SS, Pugh LC, White KM. Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines. Sigma Theta Tau International; 2007.

  Poe SS, White KM. Johns Hopkins Nursing Evidence-Based Practice: Implementation and translation. Sigma Theta Tau International; 2010.

  Sigma Theta Tau International. Position Statement on Evidence-Based Nursing; 2005. http://www.nursingsociety.org/aboutus/PositionPapers/Pages/EBN_positionpaper.aspx. Accessed July 5, 2010.