Development of an Evidence-Based Clinical Practice Guideline for Prone Positioning in Acute ...

126 Pages·2002·4.63 MB·English

Development of an Evidence-Based
Clinical Practice Guideline for
Prone Positioning in Acute Respiratory Distress Syndrome
For the Pediatric Patient
BY
Jannell Plouffe
A Practicum Project
Submitted to the Faculty of Graduate Studies
In Partial Fuffillment of the Requirements
For the Degree of
Master of Nursing
Faculty of Nursing
University of Manitoba
Winnipeg, Manitoba
O August, 2001
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Development of an Evidence-Based CIinical Practice Guidehe for Prone Positionhg in
Acute Respiratory Distress Syndrome for the Pediatric Patient
JanneU Plouffe
A Thesis/Practicam submitted to the Facdty of Graduate Stndies of The University
of Manitoba in partial îüüiiiment of the requirements of the degree
of
Permission has been granted to the Library of The University of Manitoba to lend or seU
copies of this thesis/practie~mt,o the National Liïrruy of Canada to microfilm this thesis nad
to lend or seii copies of the film, and to University Microfilm Inc. to publish an abstract of this
thesidpracticum.
The author reserves other publication rights, and neither this thesis/practicum nor extensive
extracts from it may be printed or otherwise reproduced without the author's written
permission
Abstract
Research utilization is the critical link in the integration of research and clinical
practice. Improvements in care delivery and patient outcomes are among the
pnmary reasons for conducting nursing research, but this scientific knowiedge
must be translated into practice to be of value (Titler, 1994). Prone positioning
for acute respiratory distress syndrome (ARDS) has been described in the
literature since 1974 (Froese & Byran), as a low cost, low risk, non-invasive
management strategy, yet the implementation of this modality has been slow to
enter the care plans in the management of ARDS. This practicum project
'Development of an Evidence Based Clinicai Practice Guideline for Prone
Positioning in Acute Respiratory Distress Syndrome for the Pediatnc Patient' will
examine and critique the research to date and formulate these findings into a
practice based document. The clinical practice guideline (CPG) will be examined
as to its' fit within the organization and culture of the Pediatric Intensive Care Unit
(PICU) at Children's Hospital. Research utilization must be inwrporated into the
climate of the organization to achieve a successful implementation. Knowledge
obtained from research is not 'patient ready'; it must be transfomed into clinical
innovations specific to the patient population, clinical situation and institutional
setting (Leske, Whiteman, Friechels & Pearcy, 1994).
Acknowledgements
I would like to thank each of my cornmittee members for their individual
expertise and unique contributions to the pracücum project, I thank my
chairpersun Deb Açkin, for her assistance in maintaining my perspective,
keeping me focused and inspiring me to the challenge of writing. Dr. Lesley
Degner offered her wealth of knowiedge on evidence-based nursing practice with
an appreciation of the clinical difficulties in this project Dr. Mumy Kesselman
provided his clinical expertise on ARDS, and an opportunity to cfiallenge me and
foster rny growth as Nurse Pracütioner in his role as a preceptor throughout the
practicum period.
I thank the staff of the Pediatnc Intensive Cafe Unit at Children's Hospital
for al1 the encouragement, support and envisioning the roIe of a Nurse
Practitioner; their contribution to the practicum projed extended far beyond the
informai evaluation.
Most importantly i thank my family. Geoff whose words in Septernber of
1999, "You can do if,w ere never far from my thoughts, as well as his
trernendous ability to run the house single-handedly over the past h oy ears. To
Brett, Courtney and Jocelyn, whose words of encouragement were inspirations.
They also allowed me to maintain a balance in my Me with daily rerninders of
what was really important, so 1 neverforgot.
ln addition I acknowiedge the financial support 1 received:
University M Manitoba Graduate Fellowsh ip
Child Health Graduate Studentship in Nursing
Winnipeg General Hospital and Heaith Sciences Centre School of Nursing
Jane A Malcolm Bursary
Manitoba Association of Registered Nurses Scholarship
Margaret Elder Hart Graduate Study Award
Manitoba Nurses Union Bursary
Table of Contents
Page Number
Abstract ............................................................................ i
Acknowledgements. ........................................................... ii
Table of Contents. ............................................................. iv
Chapter One: Introduction 2
Overview of the ProbIem. ............................................... 2
Background. ....................................................... 2
Purposes of the Pracücum Projec t ...........................5
Significance of the Pro blem .................................... 5
Frequency of the Probtem. ..................................... 5
Magnitude of the Consequences ............................. 7
Practicum Project Questions. .......................................... 8
Primary Question ................................................. 8
Secondary Questions ........................................... 8
Assumptions. ..................................................... -8
Limitations. ........................................................ 9
Chaoter Two: Critical Review of the Literature 1O
Availability of Research Evidence. ................................... 10
..................................................
Search Strategy 11
.............................................
Overview of the Literature -12
Primary Study Analysis ....................................... -13
Systematic Review AnaIysis ................................. 13
.......................................
Pediatric Considerations 16
Summary of the Lierature Review... ................................. 18
Chapter Three: Clinical Practice Guidelnie 20
Evîdence Based Clinicat Practice Guideline ........................ 20
Advantages. ........................................................ 21
Disadvantages. .................................................... 21
Likelihood the Problem May be Improved. .......................... 22
Chaoter Four MethodoIoav 25
Practicurn Project Model... ............................................. 25

References. .......................................................................... 67
Appendix A Summary of the PlCU Educaüonal Needs
........................................................
Assessrnent 79
Appendix B Etiologies of ARDS in Pediatn'c Patients. .................. 80
Appendix C Population Description of Pediatric
Patients in the PlCU ............................................. 81
.......
Appendix D Summary of Potential Harms, Beneffis and Costs 82
..............
Appentii E Description Of Barriers to Pmne Positioning 83
Appendix F Probability of Adoption Assessment Guide ................8 9 .
Appendix G Research Based Practice Mode1. ............................ 92
Appendk H Consent Form ..................................................... 93
Appendix I Clinical Practice Guideline. ....................................9 5
Appendix J Description of Critical Incidents ..............................1 10
Appendix K Data Base for Prone Positioning. ............................ 111
Appendix L Data Collection Tool ............................................. 112
Table 1 Critical Appraisal of Primary Research Studies .......... 113
Table 2 Critical Appraisal of Systematic Reviews. ................. 116
Table 3 Summary of the Findings of the Infotmal Evaluation
of the CPG ......................................................... 11 8
Development 2
Chapter One: Introduction
Ovewiew of the Problem
Backaround
Acute Respiratory Distress Syndrome (ARDS) is a clinical entii found in
the pediatric critical care environment, Pediatric patients who develop ARDS
suffer substantial rnorbidity and mortality and with this consume a trernendous
amount of health care resources. ARDS is thought to be a uniform expression of
a diffuse and overwhelming infiammatory reaction of the pulmonary capillary
membrane to a variety of triggers (Pittet, MacKenzie, Martin & Matthay, 1998 and
Bernard et al 1994). The American-European consensus conference on ARDS
(1994) developed criteria for the operational definition of ARDS. These include:
1. ) Acute onset of respiratory signs and syrnptoms. 2.) Hypoxemia: specifically
a Pa02lFi02 ratio less Vian 200. 3,) Radiologic evidence of diffuse bilateral
pulmonary infiltrates. 4.) No evidence of teft atrial hypertension (Bernard et al,
1994).
Pediatric ARDS patients require intubation and mechanical ventilation with
maximal M esupport measures. Care of these infants and children necessitates
the use of pharmacologie sedation and neuromuscuiar blocking agents agents to
allow for the optimization of gas exchange and ease of positive pressure
ventilation. This population frequently has multi-system organ dyskincüon as a
resuit of the pnmary etiotogy of ARDS or secondary to the insult of ARDS
causing impaired oxygenation and generalized tissue hypoxia.