Evidence-Based Practice: Is it enough?

 

Over the years, I have worked on many projects to improve practice in the NICU.  From performance improvement projects to writing policies and procedures, to providing education and bedside consultation, it is always important to find the best evidence upon which to base our practice.  However, the challenge in neonatology is that the best evidence we have is still often not very good evidence.

Even though we always make every effort to do what seems best for the infant, we have found by past history that some well-intentioned interventions or care measures result in harm much later in life.  Anecdotal information that may show an improvement or no difference in a few babies doesn’t provide sufficient evidence that this is applicable to all babies or even most babies in the NICU.

I remember an experience I had as a relatively new nurse in the NICU.  I had been practicing in one unit for about a year when I moved to another unit in a different state.  Our practice in my first unit was to place all gastric tubes nasally.  So, as an orientee at the new hospital, I began to measure for and place the gastric tube nasally.  The nurse who was precepting me became alarmed and asked what I was doing.  In all innocence, I replied, placing a nasogastric tube.  That was my first introduction to the distinct cultural differences between units, sometimes based on evidence but often based on culture and what has become accepted practice due to isolated experience or a particular physician.  That experience was many, many years ago now and then as well as now, there is not good research upon which to base this practice!  There are assumptions and some evidence but no randomized controlled trial has ever been done to inform us about who does best with which type of placement and why.

There are various levels of evidence available in the literature upon which recommendations or guidelines can be based. For a review of several of these levels of evidence, refer to http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=guidelines   It is helpful to know what, if any, scale is used when reviewing recommendations such as in policies, guidelines and so on.  Some evidence scales place systematic reviews (the highest level of evidence) at the highest end i.e. A or 1 and others rank the evidence as the lowest level of evidence, expert opinion in most cases, as A or 1.

There are so many examples of when additional research would be helpful to inform our practice.  Earlier this week, I was reviewing literature lecture related to wound management.  While there is a lot of information about wounds in general, there is little research related to managing infusion extravasation.  Many case studies have been published with use of various types of wound management, including some that later have been found to be less than ideal.  A Cochrane review of saline washout did not find any studies that met their criteria for inclusion in the review.  While this practice may not be common, it does occur.  Perhaps it is helpful, but we need the research to better inform us about what practices work best.

Other examples include use of high level oxygen for pneumothorax treatment also known as the nitrogen washout.  While some have abandoned this procedure due to concerns about use of high levels of oxygen administration to newborns, it has not been abandoned universally.  However, this is usually used in infants with minimal distress and no research-based proof exists whether this hastens resolution of the pneumothorax or it would have resolved in the same amount of time without treatment.  What side effects does the excessive administration of oxygen have on the newborn in this situation?  These are generally not preterm newborns where there is good evidence of the damage of high oxygen levels but it is unknown what long term effect this might have on a mature infant.  In fact, in performing a quick PubMed search, no neonatal articles returned using the key words “nitrogen washout.”

Part of the reason research to support or refute our practices is so lacking is because of the challenges in doing research in such a vulnerable population.  In addition, the effects may not be evident for so long, requiring long term follow up which is difficult for practitioners and families alike.  Numbers of infants who, first of all, qualify for a particular study criteria and then are available for long-term follow up, make it particularly challenging.  There have been several reports in the literature recently regarding a complication of whole body cooling, subcutaneous fat necrosis, that was difficult to recognize in the early studies due to the infrequency with which it occurs.  Follow up studies are still ongoing in ECMO patients who are now reaching early adulthood to determine what complications they may be facing and if there are practices that could prevent or lessen these effects.  Another example of the challenges and benefits of important research can be found in a recent editorial in the New England Journal of Medicine (Oxygen-Saturated Targets in Extremely Premature Infants).

I’m sure readers will also think of many other examples of everyday practices that are taken for granted until challenged by new information, new staff entering the unit or just inquiring minds.  In spite of the challenges in performing both medical and nursing research in the neonatal population, it is imperative that it be done.

References:

1. Gopalakrishnan PN, Goel N, Banerjee S. Saline irrigation for the management of skin extravasation injury in neonates. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD008404. DOI: 10.1002/14651858.CD008404.pub2.

2. Hogeling M, Meddles K, Berk DR, Bruckner AI, Shinotake TK, Cohen RS, Frieden BJ.  Extensive subcutaneous fat necrosis of the newborn associated with therapeutic hypothermia.  Pediatric Dermatology. 2012;29(1):59-63.

3. Oza V, Treat J, Cook N, Tetzlaff MT, Yan A.  Subcutaneous fat necrosis as a complication of whole-body cooling for birth asphyxia.  Arch Dermatol.  2010;146(8):882-885.

4 Strohm B, Hobson A, Brocklehurst P, Edwards AD, Azzopardi D.  Subcutaneous fat necrosis after moderate therapeutic hypothermia in neonates.  Pediatrics.  2011;128e450.

5. Gupta P, McDonald R, Chipman CW, Stroud M, Gossett JM, Imamura M, Bhutta AT.  20-year experience of prolonged extracorporeal membrane oxygenation in critically ill children with cardiac or pulmonary failure.  Annals of Thoracic Surgery.  2012; 93(5):1584-1590.

6. Carlo WA, Bell EF, Walsh MC.  Oxygen saturation targets in extremely preterm infants.  The New England Journal of Medicine.  2013;DOI: 10.1056/NEJMc1304827.

 

Looking for additional reading on this topic?
View Sandy Beauman’s related blog entry, Evidence-Based Practice: Why It’s Important to You.