Learning Objectives
By the end of this section, you will be able to:
- Analyze the foundations for evidence-based decision-making
- Apply the Institute for Healthcare Improvement (IHI) bundles to evidence-based nursing practice
Most nurses do not spend their day-to-day lives engaging in evidence-based research (EBR). However, all nurses make evidence-based clinical decisions daily as part of the ordinary course of their work. An evidence-based decision-making (EBDM) involves using evidence-based practice (EBP) when making decisions about caring for individual patients (Belita et al., 2020). Examples of EBDM include preventing falls by encouraging a patient to call before getting up to use the bathroom, asking a physician to order a medication in a liquid rather than pill form to make it easier for a patient to swallow, and determining what kind of dressing to put on a new wound. EBDM draws on the nurse’s experience, intuition, understanding of EBP, and knowledge of the patient (Nibbelink & Brewer, 2018).
Foundations for Evidence-Based Decision-Making
EBP and EBDM look similar because they both rely on the EBP triad of scientific evidence, clinical experience, and patient values Figure 15.7. However, EBDM must also include an understanding of the setting and environment in which the decision is made. The practical consequence of this understanding is that nurses always have a limited number of options to choose from (Nibbelink & Brewer, 2018). For example, even if the gold standard of care has excellent evidence to support it, aligns with a nurse’s clinical expertise, and meets a patient’s preferences, it still may be impossible to provide based on the agency’s policies, procedural concerns, or resource limitations. Thus, decisions must be made based on the EBP triad and the situational reality of what is possible within a given setting.
The EBP movement has decreased gaps between what nurses and other healthcare professionals do in practice and what they should do based on the best evidence. As a result, several tools are now available to bring the best EBPs to the bedside and make them easily accessible for clinicians and agencies. One commonly used tool is the ISBAR (sometimes abbreviated to SBAR) strategy for communicating information between healthcare team members. ISBAR stands for introduction, situation, background, assessment, and recommendation. It has been implemented effectively in many agencies throughout the United States as a way to communicate necessary patient information rapidly and succinctly among healthcare workers in a variety of situations (such as end-of-shift reporting and transferring patients between units or facilities). Figure 15.9 shows an example of an ISBAR communication between an emergency room nurse sending a patient to a unit and the nurse who is receiving the patient.
It can be confusing to apply the EBP triad in practice. Let’s further explore this process for each component of the triad.
Patient Preference
The importance of honoring patient preferences is a key tenet of both patient-centered care and shared decision-making. Patient-centered care (PCC) is the inclusion of patient preferences, values, and needs in healthcare activities. Nursing is always patient centered because our standard of practice encourages partnering and working collaboratively with our patients and considering their culture, beliefs, and values when making decisions (American Nurses Association, 2021). Thus, incorporating patient preferences and values into EBDM is a natural behavior for nurses and an expected standard of practice.
What does it mean to include patient preferences and values in decision-making? It may be as simple as asking patients what they want or need and hearing what they say and do not say (Nibbelink & Brewer, 2018). Alternatively, it may consist of learning about the expectations of a patient’s culture or ensuring the presence of a certified medical language translator when discussing their preferences or providing education. Some patients may have religious beliefs that influence their preference for one intervention. Others may have difficulty accessing outside resources, so decisions must include only resources the nurse can provide at the point of care. In short, incorporating patient preferences and values into EBDM requires assessing and understanding what matters to the patient (American Speech-Language Hearing Association, 2021).
Patient Conversations
How to Identify Patient Preferences
Scenario: Nurse enters the patient’s room shortly after the medical team has made their rounds. The patient is frowning and has balled his hands into fists.
Nurse: Mr. Hernandez, are you okay? You seem distressed.
Patient: Dr. Colling wants me to stay in the hospital for two more weeks for IV antibiotics. I don’t understand it. I’m feeling much better and can move around without pain. Why do I need to be here for that long?
Nurse: I know that staying here longer is disappointing. You have a bad case of cellulitis on your leg that has spread quite far. That takes a long time to heal.
Patient: My leg is starting to look better. Why can’t they switch me to an oral medication?
Nurse: In my experience, cellulitis is challenging to treat. IV antibiotics are stronger than oral ones because the medication goes directly into the bloodstream.
Patient: Oh, I didn’t realize that. But I really can’t stay here that long. I need to get back to work, and I help my mom out a lot. She doesn’t drive anymore, you know. She lives alone, and I don’t like her being alone for so long.
Nurse: Oh, I do understand that won’t be easy. Did you discuss any of these concerns with Dr. Colling?
Patient: No, he just seemed too busy today.
Nurse: Well, why don’t I call him and ask him to stop by again later? We can explain your situation and see if there are any other options.
Patient: Thank you. I would appreciate it. Can you help me talk to him? He makes me nervous.
Nurse: Of course I will.
Scenario follow-up: Dr. Colling came and spoke with Mr. Hernandez. When he realized the issue, he offered an additional treatment option, going home with a central line and having home health come daily to give the IV medication. While he was unwilling to have Mr. Hernandez return to his construction job due to the danger posed by having a central line in place, he agreed that Mr. Hernandez could provide his usual care for his mother.
The process of shared decision-making (SDM) empowers patients to actively make decisions and state their needs and limitations in conjunction with healthcare providers rather than passively receive care (Skelly et al., 2020). SDM should involve clear, comprehensible education and encouragement of patients and their families to be open and accurate about their abilities and skills in self-management (Nibbelink & Brewer, 2018). For example, sending a patient home with the expectation that they will give themselves shots mandates that the nurse supply thorough education about the process and evaluate the patient’s ability to perform the task satisfactorily. Failure to do so sets up the patient for a poor healthcare outcome.
The Agency for Healthcare Research and Quality (AHRQ) has developed a SHARE decision-making model to guide SDM. Many of the components are similar to those of other decision-making models; however, the SHARE model emphasizes the inclusion of the patient in the process (AHRQ, 2023a; Skelly et al., 2020). As Figure 15.10 shows, the SHARE model is a five-step process.
Link to Learning
The AHRQ offers extensive resources for using the SHARE model, including a video showing the SHARE Approach in action.
Best Evidence
One of the pitfalls nurses can fall into when seeking best evidence is an unconscious bias toward information that aligns with their clinical experience, regardless of the evidence for it (Nibbelink & Brewer, 2018). Locating high-quality evidence can be difficult and time consuming, but systematic and metareviews are excellent starting points (Pubrica, 2020). As discussed previously, these reviews are generally at the top levels of evidence hierarchies. Because they are rigorous in their methodology and provide an in-depth exploration of a given topic, they can be both a high-quality and quick resource—a one-stop shop, so to speak, of the best evidence compiled from many other researchers.
Clinical Expertise
Several components make up clinical expertise. In addition to critical thinking, it includes a nurse’s ability to recognize patterns based on their experiences over time and to evaluate those patterns and extrapolate alternative solutions or appropriate interventions based on similar but not identical experiences (Nibbelink & Brewer, 2018). Nurses must recognize their limitations and know when to ask for assistance if they do not have the clinical experience to make an informed clinical decision (Nibbelink & Brewer, 2018). Asking for help is never a flaw. It is a sign of a strong, self-confident nurse who recognizes their limitations, and it protects their patients—and their nursing license.
It has been previously mentioned that a nurse’s ability to make decisions about most issues becomes almost second nature. Nurses make many daily clinical decisions that become part of the muscle memory of nursing—practically automatic, like driving a car or riding a bike. However, other situations require reflection to determine the best course of action. Even with the decisions that nurses make every day, they must guard against cognitive bias: an unintentional error in judgment due to incorrect thought processes (The Joint Commission, 2016; Thirsk et al., 2022). Nurses must be aware of their own biases and seek to avoid them by engaging in regular self-reflection, particularly in situations that felt uncomfortable. Also, nurses must be willing to change, as nursing, medicine, and health care are constantly changing.
Clinical Decision Support and the Institute for Healthcare Improvement (IHI)
Due to the time-consuming nature of EBR and the structural difficulties associated with changing the practices of all healthcare workers within an agency, several clinical decision support tools are available to help nurses and other healthcare professionals access information about best practices more quickly (Pubrica, 2020). These tools combine evidence about specific best practice into an organized body of knowledge that is easily accessible. Many are electronic and integrated into electronic medical records or point-of-care informatics tools to enhance decision-making (HealthIT, 2018). Others are integrated into care pathways in different ways. The key advantage is that they provide a structured approach that is reproducible and repeatable across practice settings and patients.
The Institute for Healthcare Improvement (IHI), a not-for-profit organization, has been at the forefront of developing clinical decision support tools, particularly care bundles, to allow all patients in all environments to have the same high-quality level of care. For over three decades, the IHI has been working to improve the quality and safety of health care, both in the United States and globally (IHI, 2017).
Evidence-Based Practice Bundles
The evidence-based practice bundles are like nursing toolkits: small sets of evidence-based interventions that are used together to improve patient outcomes. They are rooted in EBR and have been shown to positively impact patient care (IHI, 2017). The IHI pioneered these bundles to address some common causes of hospital-based morbidity and mortality, such as ventilator-associated pneumonia (VAP), central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections, and surgical site infections. The use of bundles has expanded to other groups and even individual institutions. Bundles do not include all possible interventions for given situations or conditions; instead, they recommend a subset of highly effective interventions easily integrated into most hospitals (IHI, 2012a). All elements of a bundle should be used regardless of the specific situation: for example, a bundle for patients on ventilators in the intensive care unit should be used for all such patients, and all the components that make up the bundle should be used each time. Otherwise, the staff cannot count the bundle as complete. It is an “all-or-none measurement” (IHI, 2017).
Institute for Healthcare Improvement Ventilator Bundle
The IHI collaborated with thirteen Veterans Health Administration (VHA) ICUs to develop a bundle to decrease the risk of VAP in ICU settings. VAP is a healthcare-associated infection (HAI)—it is caused by medical treatments—that occurs as a new finding after a patient has been placed on a ventilator. Characteristics of VAP include abnormal chest x-ray findings, fever, leukocytosis (elevated white blood cell count), and thick tracheal secretions (Roch et al., 2017). Ventilator-associated pneumonia is the leading cause of death from HAIs. For patients who survive, it often increases the length of stay in the ICU, the length of time on the ventilator, and the overall costs of care (Roch et al., 2017). One incidence of VAP causes an estimated $40,000 in additional healthcare costs (IHI, 2012a).
The VAP bundle includes five elements of care (IHI, 2012a):
- Maintain the head of the bed elevated between 30° and 45°.
- Perform daily sedative interruption and assessment of readiness to extubate.
- Provide peptic ulcer prophylaxis (such as a proton pump inhibitor) to intubated patients.
- Provide deep vein thrombosis prophylaxis (such as sequential compression devices) on the lower legs.
- Provide daily oral care with chlorhexidine.
Using a daily checklist, maintained at the bedside, in the patient’s paper chart, or in their electronic health record ensures completion of these steps.
Even though VAP continues to be a problem in health care, the VAP bundle has been proven to reduce the incidence of VAP by 45 percent or more, resulting in improved patient outcomes and lower overall costs (Taplitz et al., 2017).
Link to Learning
To learn more about VAP and the Ventilator bundle, explore this How-to Guide from IHI.
Institute for Healthcare Improvement Central Line–Associated Bloodstream Infection Bundle
A central line is a catheter with a tip that ends (terminates) in a major vessel such as the aorta, superior vena cava, or femoral vein. While their use has become increasingly common in the last few decades, they are also the source of many HAIs and a great contributor to hospital-associated mortality rates, In the early 2000s, CLABSIs caused over 30,000 deaths yearly in U.S. hospitals (IHI, 2012b). In response, IHI developed a bundle to reduce the number of CLABSIs in the hospital setting; the bundle includes hand hygiene, barrier precautions, optimal catheter site selection, and daily review of need. Hospitals that have implemented this bundle have seen up to a 65 percent decrease in their rates of CLABSIs (IHI, 2012b; Taplitz et al., 2017).
Link to Learning
The AHRQ provides guidelines to prevent CLABSIs in their CLABSI bundle.
Surviving Sepsis Campaign and Bundles
Sepsis is a life-threatening inflammatory condition in which the body starts attacking its tissue and organs in response to an infection. Historically, the fatality rate of sepsis has been very high (van der Poll & Wiersinga, 2017). In the early 2000s, the IHI began to work on the Surviving Sepsis Campaign (SSC) in conjunction with the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) (SCCM, 2021). (SCCM and ESICM have subsequently taken over the SSC entirely.) Two sepsis-related bundles were initially developed from their work. However, as of the 2020 revision of the SSC guidelines, only one is being used: the Hour-1 bundle, for initial resuscitation for sepsis and septic shock (SCCM, 2021).
The Hour-1 bundle should be initiated immediately upon recognition of sepsis or septic shock (SCCM, 2021). The hour begins when providers recognize sepsis or septic shock (SCCM, 2021). While all components may not be completed within an hour, they should begin in the first hour. There has been some pushback concerning using this bundle, particularly from emergency room physicians concerned about unnecessary antibiotic treatment. However, the data strongly suggest that the sooner treatment begins, the better chances patients have of survival (SCCM, 2021).
Link to Learning
Here are resources produced for the Surviving Sepsis Campaign (SSC):
- This video about the SSC illustrates how practitioners should use the Hour-1 bundle to help patients survive sepsis.
- This Hour-1 bundle infographic illustrates how to provide initial resuscitation for sepsis and septic shock.