Does an evidence-based sedation protocol improve practice and patient outcomes in critical care?

Learning Objective 1: compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care.

Learning Objective 2: explain the contrasting international research findings on sedation protocol implementation.
Minimization of sedation in critical care patients has recently received widespread support. Professional organizations internationally have published sedation management guidelines for critically ill patients to improve the use of research in practice, decrease practice variability and shorten mechanical ventilation duration. Innovations in practice have included the introduction of decision making protocols, daily sedation interruptions and new drugs and monitoring technologies. The aim of this study was to compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients in an Australian critical care setting.

A randomized, controlled trial design was used to study 312 mechanically ventilated adult patients in a general critical care unit at an Australian metropolitan teaching hospital. Patients were randomly assigned to receive protocol directed sedation management developed from evidence based guidelines (n=153) or usual clinical practice (n=159).

The median (95% CI) duration of ventilation was 58 hrs (44–78 hrs) for patients in the non-protocol group and 79 hrs (56–93) for those patients in the protocol group (p=0.20). Results were not significant for length of stay in critical care or hospital, the frequency of tracheostomies, and unplanned extubations. A Cox proportional hazards model estimated that protocol directed sedation management was associated with a 22% decrease (95% CI: 40% decrease to 2% increase, p=0.07) in the occurrence of successful weaning from mechanical ventilation.

Few randomized controlled trials have evaluated the effectiveness of protocol-directed sedation outside of North America. This study highlights the lack of transferability between different settings and different models of care. Qualified, high intensity nursing in the Australian critical care setting facilitates rapid, responsive decisions for sedation management and an increased success rate for weaning from mechanical ventilation.

Evidence based approaches to youth justice

This monograph was originally prepared as part of a review of services and programs offered in youth justice facilities in South Australia for the Office of the Guardian for Children andYoung People.

Using meta-synthesis to facilitate evidence-based practice

In a previous column, Fineout-Overholt et al. (2008) discussed the use of systematic reviews in decision making for clinical practice, focusing primarily on the quantitative studies, such as randomised controlled trials. Narrative reviews were included but in less detail; this was intentional because the synthesis of qualitative evidence is a complex process and has evoked significant discussion over the past 5 years. Consequently, this column addresses some of the process issues surrounding qualitative evidence synthesis, or meta-synthesis as it is more commonly known, and offers ideas for how evidence arising from these can be used to inform education, teaching, and practice.

How systematic reviews can foster evidence-based clinical decisions : part II

In the prior issue, we spoke about what a systematic review is and where a clinician can find this important evidence for decision making (Fineout-Overholt et al. 2008). In this column, we will address what is involved in conducting a systematic review, and how critically appraising a systematic review informs clinicians of the best evidence available to make decisions that impact outcomes.

Implementing a journal club in a palliative care setting : a link in the chain of evidence-based practice

This paper describes the implementation and evaluation of a journal club in a privately funded palliative care unit. Journal club meetings were initiated as part of a quality improvement process to foster the uptake of evidence-based practice. Nurses were presented with research articles each month and discussions were conducted focussing on methodological considerations of the research and implications of the research for patient care. The maximum number of attendees at any one meeting was nine and the minimum number was four. Overall, evaluations were positive about all aspects of the meetings. Attendees found that the selected articles were relevant, providing new information, stimulated discussion and reflection on clinical practice and encouraged further reading. One of the positive aspects of the meetings identified by participants was the facilitation style that enabled discussion in a safe and supportive environment. An important outcome of the meetings is the potential to explore evidence-based practices relevant to palliative care and to implement new practices or revise existing ones. As part of this process practice changes and clinical guidelines have been implemented. A dedicated facilitator with university links and a supportive organisational culture promoted club meetings as a practical way to provide clinical nurses with the opportunity to explore evidence-based research in the area of palliative care.

Quantifying the impact of transient joint symptoms, chronic joint symptoms, and arthritis : a population-based approach

Objective : To estimate the prevalence and co-occurrence of self-reported doctor-diagnosed arthritis, chronic joint symptoms (pain, aching, stiffness, or swelling on most days for a month), and transient joint symptoms (pain, aching, stiffness, or swelling but not on most days for a month), and to compare the sociodemographic characteristics, activity limitations, and health-related quality of life (HRQOL) of people with joint conditions with those who have no self-reported doctor-diagnosed arthritis and no joint symptoms.
Methods : Data from the 2004 population-based South Australian Health Omnibus Survey (n = 2,840, ages 18-96 years) were used in the study. Activity limitations were assessed using 10 activity limitations questions from the Short Form 36 health survey. HRQOL was assessed using the Assessment of Quality of Life scale.
Results : Half of all respondents reported having joint problems, with 26%, 11%, and 13% reporting self-reported doctor-diagnosed arthritis, chronic joint symptoms, and transient joint symptoms, respectively. Chronic joint conditions (self-reported doctor-diagnosed arthritis and chronic joint symptoms) accounted for 74% of all joint problems and were associated with higher odds of activity limitations and poorer HRQOL. The frequency of transient and chronic joint symptoms was highest among middle-aged participants (ages 45-54 years for transient and 45-64 years for chronic joint symptoms) and those who had a body mass index in the obese range. Prevalence of self-reported doctor-diagnosed arthritis increased with age and was higher among women and those who were overweight or obese.
Conclusion : This study documented the high prevalence and impact of joint conditions in the community. Chronic joint conditions affect daily life and are substantial barriers for effective public health interventions aimed at reducing obesity and inactivity.