KNH Clinical Practice Guidelines

Adaptation Methodology
Jhessie L. Abella, RN, RM, MAN, CPSO, SMRIN
Learning and Development, Acting Manager
KNH CPG Executive Secretary
Evidence Based Practice in Nursing

 Evidence-based practice (EBP) is the process of collecting,

processing, and implementing research findings to improve clinical
practice, the work environment, or patient outcomes.
 When you incorporate up-to-date information from new EBP
research, you'll be able to question current practices. You may ask
questions such as, “Are my current nursing interventions the most
effective or safest for my patients?” or “Could we utilize these
new EBP interventions in my work area?”
Knowing Where to Look

 Nurses can find EBP research published in scholarly single-blind or double-

blind peer-reviewed journals.
 Many universities, colleges, and formal nursing programs also conduct and
publish research findings in their newsletters or scholarly journals, or on
their websites.
 https://www.evidencealerts.com/
 https://www.evidence.nhs.uk/
 https://evidence.nihr.ac.uk/
 https://www.tripdatabase.com/
 Google search engine
 https://scholar.google.com/
Four Key Elements

When evaluating EBP nursing research studies, focus on these four criteria:

 Validity—the legitimacy, accuracy, and soundness of all aspects of the study

 Reliability—the extent to which a measurement's result is consistent
 Relevance—the logical connection between two ideas, tasks, or events
 Outcome—the conclusions reached through the process of research.
Strongest Source of Evidence

 Systematic Review
  Meta-Analysis
  Evidence-Based Guideline
Other Types of Evidence
 Randomized Controlled Trial
 Controlled Clinical Trial
 Case Control Studies 
  Cohort Studies
  Meta Synthesis (Qualitative Synthesis)
PICO Question (Example using Clinical
Guideline as a Source)

Population: Adult with complaints of Chest Pain in ED

Intervention of Interest: Immediate nursing actions in ED

Comparison Intervention: EKG only

Outcome: Improve patient outcome and appropriate intervention

Recommendations:
People presenting with acute chest pain
 Check immediately whether people currently have chest pain. If they are pain free, check when their last episode of pain was,
particularly if they have had pain in the last 12 hours. [2010]
 All chest pain/discomfort should be assumed to be cardiac in nature (ACS or MI) until determined otherwise. Some patients
may not have distinct chest pain, but may have arm, neck, jaw/throat or back discomfort, shortness of breath or dizziness.
Both severe and more subtle pain can indicate ACS. Women and men are equally likely to have coronary heart disease and
experience ACS. Women may report more symptoms than men, making diagnosis more difficult, but most research has shown
that as many women as men who are having ACS report chest discomfort.
 Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering:
 the history of the chest pain
 the presence of cardiovascular risk factors
 history of ischemic heart disease and any previous treatment
 previous investigations for chest pain. [2010]

 Initially assess people for any of the following symptoms, which may indicate an ACS:
 pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
 chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these
 chest pain associated with haemodynamic instability
 new onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and
with episodes often lasting longer than 15 minutes. [2010]
Recommendations:

People presenting with acute chest pain

 Clinical Decision Rule for Identifying Patients with Chest Pain Caused by CAD
Recommendations:

People presenting with acute chest pain

 Position in semi-Fowler’s position and measure O2 saturation (SaO2). If SaO2 is less than
94%,initiate O2 via suitable delivery system until 94% achieved. Oxygen therapy is not indicated
for SaO2 greater than 94%, and may cause harm.
 Initiate process for obtaining bloodwork (CBC, electrolytes, coagulation parameters [INR or
aPTT], cardiac enzymes or biomarkers).
 Monitor vital signs and SaO2 during episode of chest pain/discomfort in anticipation of further
orders or until help arrives.
 Initiate continuous ECG monitoring, if available. Review rhythm strip for ST deviation (elevation
or depression) and report to physician if deviation of greater than or equal to 1 mm present in
any lead. Multi-lead monitoring with arrhythmia recognition and continuous ST segment
monitoring preferred.
Recommendations:

People presenting with acute chest pain

 Position in semi-Fowler’s position and measure O2 saturation (SaO2).
 If SaO2 is less than 94%,initiate O2 via suitable delivery system until 94% achieved. Oxygen therapy
is not indicated for SaO2 greater than 94%, and may cause harm.
 Initiate process for obtaining bloodwork (CBC, electrolytes, coagulation parameters [INR or aPTT],
cardiac enzymes or biomarkers).
 Monitor vital signs and SaO2 during episode of chest pain/discomfort in anticipation of further
orders or until help arrives.
 Initiate continuous ECG monitoring, if available. Review rhythm strip for ST deviation (elevation or
depression) and report to physician if deviation of greater than or equal to 1 mm present in any
lead. Multi-lead monitoring with arrhythmia recognition and continuous ST segment monitoring
preferred.
PICO Question (Example using Research as a
Source)

Population: Adult with complaints of Chest Pain in ED

Intervention of Interest: Identification of Risk Assessment in Patients with Suspected ACS

Comparison Intervention: CTAS

Outcome: Improve patient outcome and appropriate intervention

Recommendation

 FDS should be used in AED for risk stratification as well as

prediction of outcome.
 Evidence: FDS was found to be positively correlated with adverse cardiac
outcomes, in terms of higher score with higher risk (Morris et al., 2006;
Chase et al., 2006; Pollack et al., 2006;Ramsay et al., 2007; Lyon et al.,
2007; Cullen et al., 2013; Lee et al., 2011).
 Triage nurses should integrate FDS with clinical judgment and
current 5-level triage scale when performing chest pain triage.
 Evidence: FDS can be used in combination with clinical judgment and be
incorporated to 5-level triage scale. In which resulting in improvement in
patient documentation, assessment, and interventions, as well as alleviates
the uncertainties in performing chest pain triage (Ho et al, 2013).
Recommendation

 Nurses should perform triage by obtaining the circumstantial

information and vital signs, and then perform FDS for eligible
patients. .
 Evidence: FDS cannot be used in isolation (Chase et al, 2006; Pollack et al,
2006). The likelihood of an adverse outcome in patients with a FDS score of
zero is not zero, FDS should therefore be used in conjunction with clinical
judgment (Ho et al, 2013; Pollack et al, 2006). Triage nurses should
integrate FDS with clinical judgment and current 5-level triage scale when
performing chest pain triage.
Front Door Score
Front Door Score