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Asking the Clinical Question

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Evidence-based practice helps healthcare clinicians provide quality care based on knowledge and evidence rather than because of “this is the way we have always done it,” or based on customs, colleagues, or out-dated textbooks. In response to the startling report by the Institute of Medicine in 2001 that major deficits in healthcare caused preventable harm, a proposal for healthcare redesign was introduced recommending healthcare providers to implement evidence-based practice in order to improve quality outcomes (Stevens, 2013). In order to employ evidence-based practice, development must begin with clinical inquiry and question. The purpose of this paper is to utilize PICO to identify the clinical question, describe two evidence-based practice models, identify search terms which determined the clinical question, describe the number of articles retrieved from searching, and the relationship between levels of evidence and grades of recommendations based on an evidence grading system. PICO

Asking a focused clinical question is the first step to obtaining evidence-based answers. The PICO question is a useful model is used to formulate clinical questions. The evidence-based practice paradigm recommends that healthcare providers frame clinical questions in terms of the population, intervention, comparison, and outcome (Huang, Lin, & Fushman, 2006). Using the PICO method, the following clinical question was formulated: In emergency department patients requiring procedural conscious sedation, how does capnography monitoring compare to standard pulse oximetry in the early identification of acute respiratory depression? Population: emergency department patients requiring procedural conscious sedation Intervention: capnography monitoring

Compare: standard pulse oximetry
Outcome: early recognition of respiratory depression
Evidence-Based Practice Models
Evidence-based practice nursing models contribute conceptually to the implementation of evidence based nursing practice. The evidence-based practice models help support and organize the implementation of evidence-based practice, prevent incomplete implementation, encourage the use of resources, and improve outcome evaluation (Shaffer, Sandau, & Diedrick, 2012). The Academic Center for Evidence Based Practice (ACE) Star Model is a frequently used framework for understanding the relationship between the stages of knowledge transformation, defined as the conversion of research findings from primary research results, through a series of stages and forms, to impact on health outcomes, by way of evidence based care (Houser & Oman, 2011). The five model steps are: knowledge discovery, evidence summary, translation into practice recommendations, practice integration, and evaluation. The ACE model allows investigators to cycle familiar processes through the research star model in order to implement and guide effective, quality practice improvement.

The major focus of the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model is translation evidence for clinical nurses to use at the bedside when making clinical decisions pertaining to care. The model was designed in three key stages, including: identifying and developing a practice question, locating and collecting the evidence, and translating the evidence into practice. This model provides comprehensive user-friendly tools to address the practice question and guide each aspect of the evidence-based practice process. This model was developed for use by the nurses and nursing students at Johns Hopkins to answer clinical, administrative, and education practice questions (Cannon & Boswell, 2012).

Evidence-based practice models provide the framework to guide the evaluation of current practice and methodically progress toward improvement in healthcare and outcomes. The Academic Center for Evidence Based Practice Star Model and the Johns Hopkins Nursing Evidence-Based Practice Model, are two exemplary models used to translate evidence into practice. Both models have the potential to be used across a variety of settings, include guidance for practice change, and emphasizes translation. However, the JHNEBP model
furnishes tools to thoroughly evaluate the evidence, which is not highlighted by the ACE Star model. Clinical Question

Procedural conscious sedation has become a common emergency department clinical practice used to lessen pain and anxiety for patients requiring certain medical procedures. “Procedural sedation and analgesia refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate painful or unpleasant procedures while preserving cardiorespiratory function” (Godwin, Burton, Gerardo, Hatten, Mace, Silvers, & Esmire, 2014, p. 248). However, the primary cause of morbidity in conscious sedated patients is drug-induced respiratory depression (Roskowsky, 1999). Monitoring for respiratory depression requires not only healthcare providers proficient in critical care, but also extensive monitoring equipment. Standard monitoring includes pulse oximetry, which is a continuous method of monitoring oxygenation by measuring arterial hemoglobin saturation (SpO2) and heart rate. However, capnography is the continuous measurement of end-tidal carbon dioxide (ETCO2) throughout respiration to determine if hypercarbia is present and may be more useful in determining early hypoventilation and respiration. Consequently, do emergency department patients undergoing procedural conscious sedation who are monitored with capnography, as compared to the standard pulse oximetry, have better outcomes due to earlier detection of respiratory depression? Evidence Search

In order to reveal what research exists regarding capnography monitoring for emergency department procedural sedation, searches were performed and recorded of the PubMed and EBSCO databases, as summarized in Appendix A. The first search of PubMed using the key search terms “emergency department,” “capnography,” and “procedural sedation” yielded 27 results. Further refinement to include only randomized controlled trials and articles less than 10 years old generated 25 hits. Of those results, three articles were chose to be included in the literature review. Next, EBSCO was searched using the same key terms and limited to articles less than 10 years old, 14 articles resulted many of which were overlapping from PubMed. Of these findings, one article was selected for the literature review. Evidence Grading System

Upon assessment and evaluation of the four selected articles, as summarized in Appendix B, the Evidence-Based Review Matrix, it is evident that capnography can be used to augment monitoring for respiratory depression during procedural sedation in the emergency department. Three articles reviewed clearly demonstrated that capnography use recognized respiratory depression earlier than standard monitoring only. The one article that weakly proved that desaturation was recognized with pulse oximetry sooner than capnography had software problems and providers had difficulty determining a basline ETCO2. Also, in this randomized-controlled trial all subjects in this study were monitored with both pulse oximetry and capnography, the randomization was of the sedation medication.

One systematic review existed among the four research articles investigating the use of capnography during procedural sedation in the emergency department. This systematic review took the data from multiple studies and combined them into tables, in order to assess and rank each article in terms of the level and quality of evidence, and relevance and applicability to practice. The review was effective in concluding end-tidal CO2 is a more responsive indicator of respiratory depression than SpO2 throughout emergent procedural sedation. Based upon the level of “B,” this systematic review presents a strong recommendation for capnography as a useful additional monitoring tool for patients undergoing procedural sedation in the emergency department.

Of the final two randomized-controlled trials, the first investigated 132 patients, randomly assigned to the control group (blinded capnography) or study group (capnography), undergoing procedural sedation in the emergency department. The addition of capnography to standard monitoring reduced hypoxia by 17%, increased interventions to improve respiratory status by 18%, and identified in advance all occurrences of hypoxia (Deitch, Miner, Chudnofsky, Dominici, & Latta, 2009). Similarly, the final randomized control trial was a blind capnography study of 59 patients undergoing
emergent procedural sedation in a tertiary care center. Investigators documented 33% of patients as having an acute respiratory event, of those patients 85% demonstrated ETCO2 findings indicative of hypoventilation or apnea (Burton, Harrah, Germann, & Dillon, 2005). Abnormal ETCO2 results were recognized before changes in SpO2, supporting the conclusion that capnography monitoring of procedurally sedated patients detected significant respiratory events before standard emergency department monitoring.

In order for providers to understand clinically relevant research and how to include it into clinical practice, identifying the level of evidence on the hierarchy of study design and determining the quality of evidence are critical aspects to assessing evidence. The Oxford Centre for Evidence-Based Medicine (CEBM) has separated the types of studies into categories intended to guide providers in answering clinical questions (Medina, McKeon, & Hertel, 2006). The levels range from one, the highest, to five, the lowest. Level one evidence is derived from randomized-controlled trials, systematic reviews of randomized controlled trials, or diagnostic or cost-analysis studies. In the evaluation of the four selected articles, all four articles maintained a consistent level of one for clinical evidence and study design.

Along with the levels of evidence, the CEBM has developed a systematic method for grading the recommendation for evidence to be used in clinical practice, in other words, how well the evidence answers the clinical question of interest (Medina, McKeon, & Hertel, 2006). The recommendation is graded as A, B, C, D or I based on level of evidence and qualities of available evidence. Although the four selected articles maintained a high level of evidence, there was also a degree of limitations noted in the Evidence-Based Review Matrix giving rise to a grade “B” recommendation. Grade B recommendations represent a fair level of confidence for making a recommendation and may be based on level one evidence that shows promise (Medina, McKeon, & Hertel, 2006). Summary

The call for evidence-based healthcare and quality improvement emphasizes the necessity for care that is effective and safe. Nurses have responded to this call by initiating practice improvement through clinical inquiry and research development. Using evidence-based practice models as a guide, an evidence review search may be conducted to answer a clinical question and determine the recommendation for relevant clinical practice. Essentially, the reviewed evidence suggests that capnography use may augment standard monitoring to allow for earlier recognition of respiratory depression in patients undergoing procedural sedation. Additional advanced studies will help to promote translating this suggestion to a recommendation.

Burton, J. H., Harrah, J. D., Germann, C. A., & Dillon, D. C. (2006). Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? Academic Emergency Medicine, 13(5), 500-504. Cannon, S., & Boswell, C. (2012). Evidence-Based Teaching in Nursing. Sudbury, MA: Jones & Bartlett Learning, LLC. Deitch, K., Miner, J., Chudnofsky, C. R., Dominici, P., & Latta, D. (2010). Does end-tial CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Annals of Emergency Medicine, 55(3), 258-264. Godwin, S. A., Burton, J. H., Gerardo, C. J., Hatten, B. W., Mace, S. E., Silvers, S. M., et al. (2014). Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine, 63(2), 247-255. Houser, J., & Oman, K. S. (2011). Evidence-Based Practice. Sudbury, MA: Jones & Bartlett Learning, LLC. Huang, X., Lin, J., & Demner-Fushman, D. (2006). Evaluation of PICO as a knowledge representation for clinical questions. AMIA Annual Symposium Proceedings Archive, 359-363. Medina, J. M., McKeon, P. O., & Hertel, J. (2006). Rating the levels of evidence in sports-medicine research. Athletic Therapy Today , 11(5), 38-41. Proehl, J., Arruda, T., Crowley, M., Egging, D., Walker-Cillo, G., Papa, A., et al. (2011). Emergency nursing resource: The use of capnography during procedural sedation/analgesia in the emergency department. Journal of Emergency Nursing, 37(6), 533-536. Roskowsky, D. (1999). Is ETCO2 analysis indicated during conscious sedation? Anesthesiology News. Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2013). Evidence-based practice models for organizational change: overview and practical applications. Journal of Advanced Nursing,
69(5), 1197-1209. Silviotti, M. L., Messenger, D. W., Vlymen, J. v., Dungey, P. E., & Murray, H. E. (2010). A comparative evaluation of capnometry versus oximetry during procedural sedation and analgesia on room air. The Journal of the Canadian Association of Emergency Physicians, 12(5), 397-404. Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. OJIN: The Online Journal of Issues in Nursing, 18, (2).

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