YOU TOO CAN DO RESEARCH!!

1. YOU TOO CAN DO RESEARCH!! Sheri Watson BSN RN CPAN

3. Goals for Today:Research can be FUN !!Research validates and supports our nursing practice and our profession.Research is good for our patients and is good for Nurses !!

4. Benefits of Published Research Papers:Speaking Invitations both locally and internationallyReceived invitations to present our research and article inquiries from numerous countries such as Turkey, Austria, Canada, Mexico

5. The Roots of Nursing Research Began With Florence Nightingale !!

6. During the Crimean War 1854-56 Florence accumulated and analyzed complex information about her patients conditions. Her work was ignored by late 19th century training school administrators. WHY??

7. Nursing students were expected to be obedient and follow rigid discipline demands. They were encouraged to not questions or analyze nursing practices. Often our practices are handed down from one nurse to another base on opinion and tradition.

8. Nurses question current clinical practices and inconsistencies in their clinical areas.Are we doing the “best” for our patients?Does our practice align with current guidelines and recommendations?Professionalism, accountability, social relevance and best practice. Why do research?

9. Recent Nursing Research Topics:April 2010-Staffing: More nurses, less deaths, Nursing researchers reported that 11 to 14% fewer patients would have died in Pennsylvania and New Jersey if those states had patient-to-nurse ratios like those in California.

10. July 2012- More Burnout, More Infections.For every emotionally exhausted/burned out nurse that was assigned one extra patient the rate of catheter infection increased by 1 infection per 1,000 patients. Reducing nurse burnout from 30% to 10% could prevent 4,160 patient infections.

11. April 2011-More Nurses=Fewer Readmissions, Saved Costs and Improved discharge planning.Higher RN staffing decreased 30 day readmissions due to improved discharge planning, saved insurers $600 per hospitalization.

12. POP QUIZ Nursing Research journal was first published when? 1952 ? 1962 ? 1972 ? Google has how many “Nursing research hits? 1 million ? 10 million ? 18 million hits ? How many “Nursing research” books titles are on Amazon? 100? 1500? 23,000 ?

13. 1952 Nursing Journal Topics:“Attitudes of Student Nurses”.“Disinfection of Oral Thermometers”.“Nursing Student Evaluates Her Teachers”.2012 Nursing Journal Topics:“Social Media and Communicaitons in Health Care”.“High Frequency Percussive Ventilation Using VDR-4 Ventilation: An Effective Strategy For Patients With Refractory Hypoxemia”.

14. How do you start a research project?Invite the whole unit to participate.Committed staff membersPlan workable meeting time frames.Unit staffing needsBudget constraintsManagement “buy in”Obtain experienced research mentor.Decide on research topic.Realistic, interesting and cost contained?? Obtain IRB approval.IRB process IRB Consent

15. Ethical Issues Related To ResearchThe IRB examines research proposals to make sure that the ethical rights of those individuals participating in the research study are protected. Research participants must be assured that their right to privacy, confidentiality, fair treatment and freedom from harm is protected. They sign an informed consent that explains the study and may refuse to participate or withdraw from the study.

16. Historical Examples of Unethical Research1930’s -40’s Nazi experimented with untested drugs, sterilization, and euthanasia on prisoners of war.1930’s Tuskegee syphilis study was conducted for 40 years to determine the natural course of syphilis, participants did not receive treatment even after penicillin was determined to be effective. 1960’s a New York hospital injected cancerous liver cells into twenty-two patients without informing them that they were taking part in the research.

17. Types of Research:Qualitative: A systematic, subjective approach used to describe life experiences and give them meaning. Phenomenology Grounded theory Ethnography Interviews and case studies Examine the experience of those receiving or delivering nursing care and what meaning it holds

18. Quantitative Research: A formal, objective, systematic process used to describe and test relationships and examine cause-and-effect interactions among variables. Identify problem Review literature Develop a theoretical framework Specify the population Collect/analysis data Communicate results

19. PROVIDENCE PORTLAND MEDICAL CENTER PORTLAND, OREGON

20. POST ANESTHESIA PATIENTS WITH LARGE UPPER ARM CIRCUMFERENCE IS USE OF AN “EXTRA-LONG” ADULT CUFF OR FOREARM CUFF PLACEMENT ACCURATE?

21. Where do you put a BP cuff on this guy?

22. National guidelines for blood pressure (BP) measurement recommend use of the upper arm for BP cuff placement

23. Purpose • The purpose of this study was to determine if blood pressures obtained in the forearm or with an extra-long BP cuff in the upper arm accurately reflects BP measured in the upper arm with an appropriately sized BP cuff in patients with large upper arm circumference

25. Clinical observations • BP cuff size was ill-suited to the configuration of large circumference arms • Access to the upper arm was difficult on the gurney with the side rails up in the bariatric patient

26. Anesthesiologists often place the cuff on the forearm • Review of literature did not support the accuracy of forearm blood pressure in the PACU for this population of patients • The bladder of the Extra-long BP cuff is only marginally wider despite the longer length in relation to the standard adult BP cuff

27. Method-Comparison Study • Each subject served as their own control with random assignment • BP’s were taken with an automatic BP machine (MP50 Intellivue, Phillips Medical)

28. Inclusion criteria included • Age > 18 years • English speaking • No contraindications to obtaining a noninvasive BP in the upper arm and forearm • Upper arm circumference 34-43 cm • Forearm circumference 27-37 cm • Absence of intravenous vasoactive or topical NTG while in the PACU • Regular heart rate of 50 to 100 beats per minute • PACU discharge criteria met

29. Blood pressures were taken at least one minute apart but not to exceed six minutes • Primary dependent variables • Systolic BP • Diastolic BP • Two locations of BP measurement • Forearm • Upper arm • Extra-long BP cuff also compared to large adult cuff

30. Upper Arm Location

31. Forearm Location

32. Does YOUR forearm and upper arm BP correlate? Is there a variance in your readings? Is it significant??

33. Forearm vs. Upper Arm • Bias and precision for forearm • Systolic = 7.8 + 10.42mm Hg • Diastolic BP = 5.0 + 8.5mm Hg • 39% of patients had at least 10mm Hg difference in systolic BP between the upper arm and forearm

34. 27% of patients had at least 10mm Hg difference in diastolic BP between the upper arm and forearm • 14% of patients had at least 20mm Hg difference in systolic BP between the upper arm and forearm

35. Bland-Altman Graph for Forearm Systolic Blood Pressure

36. Bland-Altman Graph for Forearm Diastolic Blood Pressure

37. Extra Long Cuff vs. Standard Upper Arm • Bias and precision with the extra-long cuff • SBP = 6.3 + 8.2mm Hg • DBP = 2.7 + 7.7mm Hg • 31% of patients had at least 10mm Hg difference in SBP and 23% of patients had this difference with DBP • 10% of patients had at least 20mm Hg difference in SBP and 4% of patients had this difference with DBP

38. Bland-Altman Graph for Extra-long Blood Pressure Cuff SBP

39. Significant differences • Forearm and upper arm systolic (p<0.0001) and diastolic (p<0.0002) BP measurement • Differences between systolic measured with the extra-long cuff at the upper arm site compared to the upper arm with the forearm (p< 0.0001)

40. No significant difference • Diastolic BP (p< 0.019)

41. Magnitude of the discrepancies Clinicians could incorrectly identify or miss hypotension or hypertension in PACU patients, predisposing them to serious complications and inappropriate interventions. • Patients could potentially be treated, medicated and hospitalized for inaccurate BP measurements, extended lengths of hospitalizations and increased costs.

42. Conclusion • The results of this study indicated that the clinical practice of using the forearm or the extra-long cuff for BP measurements in PACU patients with large upper arm circumferences resulted in inaccurate BP values

43. NOT ALL ARMS ARE CREATED EQUALLY

44. Recommendations • Further studies to determine accurate BP measurement in the PACU patient • Bariatric BP cuffs are needed with adequate bladder size to accommodate this population

45. The PACU Research Team Nancy Foisy, RN, BSN; Larissa Yu, RN, BSN; Marita Aguas, RN, MS, CNL, CCRN ; Bonnie Jondahl, RN, BS, CCRN; Sheri Watson RN, BSN, CPAN; Pat Colegrove, RN, BSN; Mary Beth Yosses, RN, MN, CCRN; Tracy Bienapfl, RN

46. Acknowledgement • Thank you to the assistance of many people including our PACU nurse manager, Jill Heavey, RN, MSN, NEBC, our research mentor, Zoe Anastas, RN-BC, MPH and our research consultant, Marianne Chulay, RN, PhD, FAAN

47. Thank you for your time!Your PPMC PACU Research Team  Enjoy the Holidays!!