Critical Care Nursing Practicum AssignmentRachel TuffnerDurham College100704267Evidence based practice (EBP) in clinical decision making is a technique that has been shown to result in improved patient care (Majid et al., 2011). Rather than utilizing authoritative opinions as has been done in the past, EBP focuses on data obtained from research to make reasonable and effective choices (Majid et al., 2011). Black, Balneaves, Garossino, Puyat, & Qian (2015) identify that through utilization of EBP patient safety is increased as evidenced by better patient outcomes and a reduction in the variation of patient outcomes. According to an evaluation done by Dang & Dearholt (2018), nurses were eager to participate in EBP as it led to feelings of accomplishment and professionalism.Two EBP models that were prevalent in my clinical experience include the Ventilator Acquired Pneumonia (VAP) bundle and the Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle. Canadian ICU Collaborative Faculty (2012) identifies the following VAP bundle components: ensure the head of the bed (HOB) is at least 45 degrees, daily evaluation of readiness for extubation, use of endotracheal tubes (ETT) with subglottic secretion drainage, oral care with Chlorhexidine for decontamination, and within 24-48 hours of admission to the critical care unit begin safe enteral nutrition. In my clinical setting for mechanically ventilated patients I am diligent at keeping the HOB at 45 degrees or 30 degrees when pressure ulcers/skin integrity are an issue. Every day shift I try to wean sedation and assess the patient’s tolerance with the goal of reducing usage of sedation and earlier extubation; some patients tolerate this well while other become asynchronous with the ventilator. All ETTs in my critical care setting have a subglottic secretion drainage device hooked up to low suction to remove secretions that pool above the cuff which are a possible source of infection. Also, in an effort to reduce bacteria, I use suction toothbrushes to clean patient mouths with Chlorhexidine every six hours. I provide enteral nutrition via a nasogastric or orogastric tube up to a goal rate to all my mechanically ventilated patients (when tolerated) as best practice evidence indicates that early initiation maintains gut integrity and moderates the systemic immune response leading to reduced length of stay and mortality (Canadian ICU Collaborative Faculty, 2012). The ABCDE bundle has also been developed from EBP and is compromised of the following components: spontaneous awakening trial (SAT), spontaneous breathing trial (SBT), choice of sedation and analgesia, delirium prevention and management, and early physical mobility (Balas et al. 2012). In my critical care setting I aim to follow best practice by performing SATs and SBTs daily if appropriate given the patient’s current status. Additionally, I follow a sedation protocol for mechanically ventilated patients to ensure optimal management of agitation and pain. Balas et al. (2012) explains that by following a protocol for sedation and analgesia, patients have less asynchrony with the ventilator and a lower incidence of VAP. Performing daily SATs in combination with a sedation protocol helps to reduce the amount of sedation used and has also been linked to a decreased incidence of PTSD (Balas et al., 2012). Additionally, daily SBTs are correlated with a shorter amount of time mechanically ventilated and a decreased length of stay in the ICU (Balas et al., 2012). In accordance with recommendations by Balas et al. (2012), I utilize the Confusion Assessment Method in my critical care setting as a tool to screen for delirium. Delirium can be managed by identifying possible causes such as over sedation, hypoxemia, infection, or electrolyte abnormalities followed by treatment of the cause; earlier identification of delirium leads to a reduced incidence of self extubation, a reduction in usage of sedation and physical restraints, a reduced length of stay in the critical care setting, and a reduced mortality rate (Balas et al., 2012). Lastly, I always try to promote early mobility with patients in the critical care setting when appropriate. This can include passive range of motion, dangling at the bedside, sitting up in a chair, or walking. Balas et al. (2012) explains that early mobility leads to a reduction in delirium and sedation and a reduced length of stay in the hospital. Evidence indicates that implementation of the ABCDE bundle leads to better patient outcomes and a faster recovery (Balas et al., 2012). Though there is a strong unified effort in my critical care setting to adhere to evidence based practice, there are barriers to its implementation. Majid et al. (2011) identifies two barriers that I believe are applicable in my critical care setting; they include a lack of authority to invoke change in policies and procedures as well as inadequate time to implement the changes. Through personal experience in the acute and critical care setting, I have seen first hand the length of time it takes for authoritative figures to make policy changes; there are many organizational levels with which information needs to be passed through in order to officially make change. This process can take months to years. A critical care nurse on the unit also has a limited amount of time. In my experience nurses are able to identify a variety of areas where EBP would be beneficial in improving patient care but there is often not enough time to conduct a literature search to identify the best possible evidence, analyze the results, implement changes, and evaluate the efficacy of the interventions (Majid et al., 2011). Other relevant barriers to implementing EBP in my critical care setting include a lack of knowledge regarding the various resources available for educational needs, fellow staff that do not support your goal to implement EBP, and a feeling that nurses lack the authority to apply EBP in their daily practice (Black, Balneaves, Garossino, Puyat, & Qian, 2015). There are a variety of recommendations that could be utilized to overcome the identified barriers in the critical care setting. Black, Balneaves, Garossino, Puyat, & Qian (2015) explain how a point-of-care research training program has been shown to effectively impact attitude and engagement in implementing EBP. Nurses could partake in a program to not only identify clinical issues but to also utilize resources to develop realistic policy changes that would benefit patient care; this would empower nurses to be the face of change in their workplace and promote confidence in their ability to provide the best possible patient care (Black, Balneaves, Garossino, Puyat, & Qian, 2015; Dang & Dearholt, 2018). Similarly, Wallen et al. (2010) suggests implementing a mentorship program that pairs individuals who have a desire to implement EBP with mentors that have experience in EBP. To allow nurses to partake in these programs, employers could adjust work schedules to allow for dedicated time for these projects. Education sessions could also be held by nurse educators and managers for nurses to teach or review effective methods of retrieving relevant and current material to identify strong evidence related to clinical issues. Majid et al. (2011) recommends that all healthcare facilities promote nursing skills related to identifying and integrating EBP into the clinical setting. ReferencesBalas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., … Ely, E. W. (2012). Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Critical Care Nurse, 32(2), 35-28, 40-48.Black, A. T., Balneaves, L. G., Garossino, C., Puyat, J. H., & Qian, H. (2015). Promoting evidence-based practice through a research training program for point-of-care clinicians. The Journal of Nursing Administration, 45(1), 14-20.Canadian ICU Collaborative Faculty. (2012). Prevent ventilator associated pneumonia: Getting started kit. Retrieved from www.saferhealthcarenow.caDang, D. & Dearholt, S. (2018). Johns Hopkins nursing evidence-based practice: Model and guidelines (3rd ed.). Indianapolis, IN: Sigma Theta Tau International.Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses’ perceptions, knowledge, and barriers. Journal of the Medical Library Associated, 99(3), 229-236.Wallen, G. R., Mitchell, S. A., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C., Yates, J., & Hastings, C. (2010). Implementing evidence-based practice: Effectiveness of a structured multifaceted mentorship programme. Journal of Advanced Nursing, 66(12), 2761-2771.