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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000371066.54785.ef
In the News

Is the Evidence-Based Train on the Right Track?

Moser, Jennifer

Section Editor(s): Pfeifer, Gail M. MA, RN

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Data supporting remote monitoring and rapid response teams are weak.

In a surprise to many, neither ICU telemonitoring (tele-ICU) nor rapid response teams have demonstrated the strong benefits that clinicians expected.

Figure. Nurse Kathy ...
Figure. Nurse Kathy ...
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In the observational tele-ICU study, researchers analyzed mortality and length of stay in patients before and after implementation of remote monitoring and found little benefit to the practice. However, onsite physicians were granted the decision over how much responsibility the remote teams would have, and only a third gave them full decision-making authority; others authorized only emergency intervention. In addition, remote intensivists didn't have real-time access to medical record and chart information. Post hoc analysis showed that severely ill patients benefited more than less severely ill patients. Lead author Eric J. Thomas, director of the University of Texas-Memorial Hermann Center for Healthcare Quality and Safety in Houston, speculated that tele-ICUs might have a greater impact if remote intensivists were given more responsibility or if tele-ICUs were used with only the sickest patients.

Thomas thinks hospitals have rushed to use expensive tele-ICUs despite relatively weak evidence. He pointed out via e-mail that leaders of hospitals and ICUs want to provide better care, and remote monitoring seems to make sense. Thomas suggested that hospitals using tele-ICUs might compare their effectiveness with lower-tech interventions, like checklists.

Likewise, a review of studies of rapid response teams (teams of physicians, nurses, and respiratory therapists who respond to signs of deterioration in patients in order to prevent cardiopulmonary arrest) showed that although the teams reduced the rates of cardiac arrest outside the ICU by about a third, they didn't reduce in-hospital mortality rates. Early studies of rapid response teams did show a mortality benefit, but the authors' cumulative analysis, which included more recent studies, suggests that this benefit may be disappearing. According to lead author Paul S. Chan, assistant professor of internal medicine at the University of Missouri–Kansas City, a diminished rate of cardiopulmonary arrest outside the ICU may not reflect actual code prevention because teams may order ICU admission or discuss end-of-life options with patients who subsequently choose to sign do-not-resuscitate orders. "Hospital leadership needs to ask, 'How much energy are we devoting to these teams, and are we accomplishing what we think we're accomplishing?'" Chan said.

The rush to implement. Evidence-based practice begins with acceptance of the idea that "knowledge is dynamic," and tomorrow's discoveries may trump today's certainties, said Kathleen R. Stevens, professor of acute care nursing and director of the Academic Center for Evidence-Based Practice at the University of Texas Health Science Center San Antonio School of Nursing. Stevens pointed out that translational science — the use of research findings to develop clinical applications and improve practice— is still young, and not all the tools are in place to make evidence-based practice easy. New initiatives, such as the Health Care Innovations Exchange from the Agency for Healthcare Research and Quality, which allows nurses to share their units' successful practices, can help, Stevens said. She also said that nurses should be able to read clinical guidelines and discern the odds that an intervention will help a particular patient.

Research and practice. Research studies should be considered along with clinicians' own observations, combining evidence-based practice with "practice-based evidence," according to Ellen Fineout-Overholt, clinical professor of nursing and director of the Center for the Advancement of Evidence-Based Practice at Arizona State University. In appraising a study that evaluates the effect of rapid response teams on mortality rates, for example, nurses need to consider the many factors that influence mortality rates, said Fineout-Overholt. A major role of the rapid response team is to stabilize patients before they code, which can prevent or delay ICU admission. Research showing the number of patients who code in ICUs after being sent there by the rapid response team—and research describing those patients—would be useful in further understanding the impact of rapid response teams.

Fineout-Overholt also said that nurses' ability to blend externally generated research data with internally collected practice data is growing; however, "One article does not change make." All articles, she said, should spur discussion among hospital staff — from nurses to policymakers. She urges nurses to search for the research that answers the questions raised in their specialties, seeking markers of strong methodology that are appropriate to the study type. "Interpreting statistics is more valuable than knowing how to calculate them," she said.

Jennifer Moser

Thomas EJ, et al. JAMA 2009;302(24): 2671-8; Chan PS, et al. Arch Intern Med 2010;170(1):18-26.

© 2010 Lippincott Williams & Wilkins, Inc.


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