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Inquiring Minds

MUSC nurses are integrating research into service throughout the medical center

Brian T. Conner, PhD, RN, CNE
Brian T. Conner, PhD, RN, CNE

When Brian T. Conner, PhD, RN, CNE, an Assistant Professor at MUSC’s College of Nursing (CON), was pursuing his doctoral degree several years ago, he researched the pervasive problem of catheter-associated urinary tract infections (CAUTIs). He found in the scientific literature that duration of the indwelling catheter is the most important factor in UTI rates, so he launched his own research project at the MUSC medical center. During this study, nurses were able to determine whether a patient still needed a catheter and, if not, to remove it without a physician’s order. He studied the adoption of the protocol by staff nurses and its effectiveness in reducing CAUTI. His findings eventually led to MUSC’s adoption of a nurse-driven Foley catheter discontinuation policy that has been one of the contributing factors to a decline in CAUTI at the medical center.

Conner, now a mentor to other MUSC nurse investigators, points to research as the foundation for developing the kind of evidence-based practice (EBP) that drives better patient outcomes. With health care reform’s emphasis on quality and value, hospital administrators are encouraging clinical staff to investigate whether there is a better or faster or safer way to care for their patients. The Institute of Medicine has set a goal for 2020 that “90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence.” 1

Throughout the three MUSC hospitals, nurses and physicians are conducting research projects and developing new policies based on their findings. Nurses have been guided and educated primarily by the Nurse Alliance Research Council (NARC) and the Evidence-Based Practice Nurse Scholars Program.

Research at the Bedside

The NARC is one of five councils that make up the Nurse Alliance, the hospitals’ nursing collaborative governance structure that was created in 2006. (The other councils are Practice, Education, Leadership, and Quality.) Conner and Andrea Urbanski, RN, BSN are the co-chairs of the NARC. Its goal is to educate the nursing staff about research and encourage the use of EBP and nursing inquiry.

“We want nurses to ask, ‘Why are we doing it this way? Is there a better way?’ That’s what the Research Council is trying to promote,” says Conner.

In 2011, the NARC surveyed the medical center’s 2,500 nurses to assess their understanding of the difference between research, EBP, and quality improvement. Heather Craven, MS, RN, CMSRN is a member of the NARC who helped implement the survey and follow-up. “We found that a good proportion of experienced nurses didn’t understand the distinctions between these three, but nursing schools did not teach how to implement evidence-based practice until the last decade or so,” says Craven. So the NARC set out to do just that. NARC created educational resources and launched the Clinical Nurse Scholar Fellowship program in 2013 that mentors nurses in their research. Currently, three MUSC nurses are conducting studies in their units with Conner’s guidance.

Current Clinical Nurse Scholars

Barbara Cobb, MS, MHA, RNBarbara Cobb, MS, MHA, RN: Evaluating sedation methods after cardiac catheterization

Cobb is a nurse in the pediatric cardiology catheterization laboratory preparation and recovery area where 14 to 16 patients per week, aged six-months to teens, are managed. Post-catheterization patients must lie still and flat for at least an hour after the bleeding from the catheter site has stopped, but this can be difficult to ensure in youngsters. MUSC Hospital practice for these patients recommends using the sedative Precedex intraoperatively to reduce agitation and postoperatively as a bolus, but there is no consistent practice recommendation to use it for continued sedation for one hour post procedure. Cobb plans to compare the effectiveness of administering Precedex as a one-hour infusion vs administering it only as a loading bolus after extubation (which wears off in about 15 minutes).

With colleagues from the Cardiothoracic Anesthesia team, Cobb is currently preparing an application to the Institutional Review Board to lay the groundwork for actual clinical research: comparing a non-Precedex control group with a Precedex group. Her eventual goal is to establish a practice recommendation for using Precedex as a one-hour infusion. “I’m excited because I feel passionate that the recovery area should be a good experience for patients and their parents,” says Cobb. “If you take away the agitation time during which we have to hold children down, recovery will be better for all.”

Merrissa Searcy, BSN, RN RNC-NICMerrissa Searcy, BSN, RN, RNC-NIC: Reducing risk of a devastating disease in neonates

Searcy cares for some of the hospital’s most vulnerable patients, the infants in the Neonatal ICU (NICU). The most common life-threatening emergency experienced by premature infants is necrotizing enterocolitis (NEC), a gastrointestinal disease that is associated with severe sepsis, intestinal perforation, and significant morbidity and mortality.2 Of the NICU’s 36 beds, there are generally two or three babies with NEC, says Searcy. The introduction of enteral feedings in neonates plays a key role in the development of NEC, but hospital policies on when to feed, what to feed, and how quickly to advance enteral feedings in this population vary from institution to institution.

Studies have shown that giving low birth-weight, premature neonates blood transfusions while feeding them increases their risk of developing NEC. Searcy plans to compare two groups of babies: those who are fed during transfusions and those who receive only IV fluids during transfusions (with food given hours later). “I’ve been interested in this for a long time, ever since I wrote a paper on this subject during nursing school,” says Searcy. “It’s hard to do the blood transfusion and not stop feeds when you believe there is an association.”

Searcy is now gathering data from the medical records of every low-birth weight neonate who received a blood transfusion in the NICU during the last five years and will examine how many of these were being fed at the same time vs those who were not. Ultimately, Searcy will compile a report for the appropriate physicians that covers her findings and the findings from other institutions on this subject.

SDeidra Huckabee, MSN, RN, CCRNDeidra Huckabee, MSN, RN, CCRN: Improving patient and family communication

Huckabee is a staff nurse in the Medical ICU. Because her patients are often intubated and sedated, she feels that it is important to ensure good communication between the medical team and the family members. Huckabee’s research project seeks to determine whether changes in communication methods and the creation of structured meetings with families will improve the overall patient and family experience. She implemented three changes from earlier practice: the interdisciplinary team of medical professionals who round on the patient increased their meetings from once a week to twice; they hold their initial meeting at the bedside (no longer in a conference room); and meetings are now scheduled for family members and the attending physician and nurse for question-and-answer sessions. Huckabee has seen initial results of improved patient satisfaction scores compared with scores from a control ICU in which these specific methods are not used. When she concludes her study in 2015, she plans to share her results with the other ICUs in the MUSC medical center and publish in a professional journal.

Putting Research Into Practice

The Evidence-Based Practice Nurse Scholars Program was created in 2012 by Elizabeth A. Crabtree, MPH, PhD, Assistant Professor of Library Science and Informatics, and Andrea Coyle, MSN, MHA, RN, Nursing Excellence Manager. The program was designed to teach clinical nurses how to evaluate existing literature and integrate evidence into practice.

Together with Emily Brennan, MLIS, Research Informationist at the MUSC Library, Crabtree has conducted two twelve-week courses for MUSC staff nurses in which they learned how to frame answerable clinical questions, conduct systematic searches of the literature, and critically appraise and evaluate the evidence. Crabtree and Brennan also offered an EBP course to multidisciplinary teams at the Children’s Hospital. This kind of education reduces what Crabtree sees as the biggest barrier to EBP implementation: lack of skills in literature search, statistics, and data interpretation. The goal of her program is not only to generate new best practices for MUSC, but also to disseminate the findings in scholarly journals to encourage adoption.

“I think what we’re doing at MUSC is somewhat innovative,” says Crabtree. “There are other programs in the country that have developed EBP nurse mentoring programs, but ours is still unique, as is our drive to communicate the need for and value of doing it.”

Examples of nurse-led studies include:

  • a Heart and Vascular Center nurse’s evidence review of the recommended bed-rest time following certain procedures. Her finding led to a new policy that standardized and shortened the postoperative bed-rest times in her unit, enabling nurses to get patients up and moving sooner.
  • a pediatric nurse’s examination of topical analgesics that were most effective in minimizing discomfort for children receiving medications by IV. MUSC Children’s Hospital now has a standing order that all children who have an order for an IV will receive this analgesic prior to drug administration.

Prevention Pays

As the clinicians who are on the front lines of moment-to-moment patient care, nurses are key to preventing the kinds of outcomes that the Centers for Medicare and Medicaid Services will no longer pay for (e.g., hospital-acquired pressure ulcers and hospital-acquired infections). Their science-driven care will ensure high quality and value for patients, hospital administrators, and payers alike in the coming years.

References

1 Institute of Medicine: The Learning Health System and its Innovation Collaboratives: Update Report; 2011.

2 Gregory, KE, et al. Necrotizing enterocolitis in the premature infant: Neonatal nursing assessment, disease pathogenesis, and clinical presentation. Adv Neonatal Care. 2011 June;11(3): 155-166.