Clinical inquiry and question

Table of Content

The initial step in implementing evidence-based practice is to engage in clinical inquiry and questioning. This paper aims to utilize PICO to define the clinical question, discuss two models of evidence-based practice, outline the search terms used to formulate the question, describe the number of articles found during the search, and establish the correlation between levels of evidence and grades of recommendations based on an evidence grading system. PICO underscores that formulating a specific clinical question is essential for obtaining evidence-based responses.

The PICO question is a helpful model for formulating clinical questions. The evidence-based practice paradigm suggests that healthcare providers should frame clinical questions by considering the population, intervention, comparison, and outcome (Hung, Line, & Bushman, 2006). By following the PICO method, we formulated the following clinical question: In emergency department patients who need procedural conscious sedation, how effective is spectrograph monitoring in early identifying acute respiratory depression compared to standard pulse geometry?

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Population: patients in the emergency department who need procedural conscious sedation

Intervention: monitoring with a phonograph

Comparison: standard pulse geometry

Outcome: early detection of respiratory depression

Evidence-Based Practice Models

Evidence-based practice nursing models contribute conceptually to the implementation of evidence based nursing practice. These models help support and organize the implementation of evidence-based practice, prevent incomplete implementation, encourage the use of resources, and improve outcome evaluation (Shaffer, Sandal, & Derrick, 2012).

The ACE Star Model, a commonly used framework, is utilized to comprehend the connection between various stages of knowledge transformation. This transformation involves converting research findings, starting from primary research results, into different stages and forms with the aim of positively impacting health outcomes through evidence-based care (Houses & Oman, 2011). The model consists of five steps: knowledge discovery, evidence summary, practice recommendation translation, practice integration, and evaluation.

The ACE model and the Johns Hopkins Nursing Evidence-Based Practice (JENNET) Model both aim to facilitate effective practice improvement through the research star model. The JENNET Model specifically focuses on translating evidence for clinical nurses to use at the bedside when making care-related decisions. It consists of three stages: identifying and developing a practice question, locating and collecting evidence, and translating the evidence into practice.

This model was created specifically for nurses and nursing students at Johns Hopkins to help them answer practice questions related to clinical, administrative, and education. It offers user-friendly tools to address these questions and guide the evidence-based practice process. Evidence-based practice models play a crucial role in evaluating current practice and driving improvements in healthcare and outcomes.

The Academic Center for Evidence Based Practice Star Model and the Johns Hopkins Nursing Evidence-Based Practice Model are two exemplary models used for translating evidence into practice. Both models can be used in various settings, provide guidance for practice change, and emphasize translation. However, the JENNET model offers tools for thoroughly evaluating evidence, which is not emphasized in the ACE Star model.

The clinical question pertains to the use of procedural conscious sedation in the emergency department. This practice is commonly used to alleviate pain and anxiety in patients undergoing certain medical procedures. Procedural sedation and analgesia involve administering sedatives or dissociation agents, with or without analgesics, to induce an altered state of consciousness that allows patients to tolerate painful procedures while maintaining bodily function (Godwin, Burton, Gerard, Heathen, Mace, Silvers, & Smile, 2014, p. 248). However, drug-induced respiratory depression remains the primary cause of morbidity in conscious sedated patients (Reworks, 1999).

Continuous monitoring for respiratory depression requires both skilled healthcare providers proficient in critical care and a range of extensive monitoring equipment. The standard method of monitoring includes pulse oximetry, which is a continuous measurement of oxygenation by detecting arterial hemoglobin saturation (SpO2) and heart rate. However, spectrography provides continuous measurement of end-tidal carbon dioxide (ETCO2) levels throughout respiration, which can be more effective in identifying the presence of HyperCard and detecting early signs of hyperventilation and respiration issues.

The text explores whether there are better outcomes for emergency department patients receiving procedural conscious sedation when they are monitored with spectrograph instead of the standard pulse geometry. The author conducted searches on the Pumped and OBESE databases to find relevant research on spectrograph monitoring for emergency department procedural sedation, which are summarized in Appendix A.

The initial search of Pumped using the keywords “emergency department,” “spectrograph,” and “procedural sedation” produced 27 results. After narrowing the search to include only randomized controlled trials and articles published within the last 10 years, there were 25 relevant findings. From these, three articles were chosen for the literature review.

Next, the same key terms were used to search OBESE, resulting in 14 articles published within the last 10 years. Many of these articles overlapped with the findings from Pumped. From the OBESE search, one article was selected for the literature review.

The evidence grading system is used to evaluate the quality of the studies included in the literature review.

After conducting an assessment and evaluation of four articles summarized in Appendix B, the Evidence-Based Review Matrix, it can be concluded that spectrograph has the potential to enhance monitoring for respiratory depression in the emergency department during procedural sedation. Out of the three articles reviewed, it was evident that the use of spectrograph allowed for earlier detection of respiratory depression compared to standard monitoring alone. However, one article highlighted that pulse geometry could recognize destination sooner than spectrograph but faced challenges due to software issues and difficulty in establishing a baseline ETC.

Furthermore, in this particular randomized-controlled trial, every participant in the study was observed using both pulse geometry and spectrograph. The randomization process was employed with regards to the sedation medication. Out of the four research articles exploring the application of spectrograph during procedural sedation in the emergency department, only one systematic review was conducted. This systematic review assimilated data from multiple studies and organized them into tables to evaluate and prioritize each article based on their level and quality of evidence, as well as their relevance and applicability to real-world practice.

The review concluded that end-tidal CO is a more responsive indicator of respiratory depression than Esp in emergent procedural sedation. This systematic review, with a level of “B,” strongly recommends spectrograph as an additional monitoring tool for patients undergoing procedural sedation in the emergency department. In one of the final two randomized-controlled trials, 132 patients were randomly assigned to either the control group (blinded spectrograph) or the study group (spectrograph), and underwent procedural sedation in the emergency department.

The use of a spectrograph in standard monitoring led to a 17% reduction in hypoxia, a 1% increase in interventions to improve respiratory status, and the identification in advance of all instances of hypoxia (Ditch, Miner, Shutdown’s, Dominic, & LATA, 2009). Similarly, a blind spectrograph study was conducted on 59 patients receiving emergent procedural sedation at a tertiary care center. In this study, researchers reported that 33% of patients experienced an acute respiratory event, and of those patients, 85% exhibited ETC findings that indicated hyperventilation or apneas (Burton, Hurrah, German, & Dillon, 2005).

It was found that abnormal ETC results were identified prior to changes in Esp., which supports the conclusion that phonograph monitoring of patients sedated during procedures detected important respiratory events earlier than standard emergency department monitoring. To effectively incorporate clinically relevant research into clinical practice, healthcare providers must assess the level of evidence based on study design hierarchy and determine the quality of evidence.

The Oxford Centre for Evidence-Based Medicine (CUBE) has categorized studies into different levels to assist providers in addressing clinical inquiries (Medina, McKeon, & Hurter, 2006). The levels range from one, the highest, to five, the lowest. Level one evidence is obtained from randomized-controlled trials, systematic reviews of randomized controlled trials, or diagnostic or cost-analysis studies. During the assessment of the four chosen articles, all four maintained a consistent level of one for clinical evidence and study design.

The CUBE has created a method for rating the recommendation for evidence used in clinical practice, based on the levels of evidence and the quality of available evidence (Medina, McKeon, & Hurter, 2006). The recommendation is graded A, B, C, or D. While the four chosen articles had strong evidence, limitations were identified in the Evidence-Based Review Matrix, resulting in a grade “B” recommendation.

Grade B recommendations demonstrate a reasonable level of confidence in making a recommendation and may be supported by level one evidence indicating potential (Medina, McKeon, & Hurter, 2006). In summary, the demand for evidence-based healthcare and quality improvement highlights the importance of effective and safe care. Nurses have heeded this call by embarking on practice improvement through clinical inquiry and research advancement. By utilizing evidence-based practice models as a framework, nurses can conduct an evidence review search to address a clinical query and determine the appropriate recommendation for pertinent clinical practice.

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