Evidence-Based Practice in Nursing Free-Samples for Students

Question: Determine whether rapid Intravenous rehydration is better in Improving Hydration and Clinical outcomes as compared to Standard Intravenous rehydration in children with Gastroenteritis. Answer: Introduction Title of the research paper is matching with the content of the paper. In this study, comparison of the rapid versus standard intravenous rehydration in pediatric gastroenteritis was performed and the same is mentioned in the title. Objective of the study was to determine whether rapid intravenous rehydration is better in improving hydration and clinical outcomes as compared to standard intravenous rehydration in children with gastroenteritis. Abstract of the research paper contains information about research design, sample and findings; however there is no mention of aims and hypothesis of the research in the abstract. Structuring of the study: This study was designed after carrying out literature review. In the literature, it has been mentioned that rapid rehydration has the potential to reduce agitation and clinical signs in the children. Moreover, it is useful in improving alertness and appetite. This can useful in reducing length of stay of children in the hospital. However, there is lack of extensive efficacy data for rapid intravenous administration. In the studies, it is also evident that, rapid intravenous administration is associated with risks like mortality, hyponatraemia or hypernatraemia (Nager and Wang, 2013, pp. 123-9; Freedman et al., 2011, pp. 38-45; Nager, 2010, pp. 971-5; Maitland et al., 2011, 2483-2495). Few of the mentioned references are older than 10 years. Literature review for this research is not comprehensive. Numbers of studies incorporated in the literature are less. Studies should be incorporated from the different geographical areas, from different pediatric hospital settings and children fro m different socioeconomic class. Mentioned literature in the research paper also didnt incorporated details of the studies like number of participants, types of studies and evaluation parameters. Pragmatic randomized, blinded, comparative effectiveness trial was performed in the children, in whom oral rehydration failed previously in emergency department. Ethical approval was taken from The Hospital for Sick Childrens research ethics board for conducting this study. Informed consents were taken from caregivers, and participants. In this paper neither null hypothesis nor scientific hypothesis was mentioned. Research can be conducted in two ways like testing of relationship and comparison among two groups (Nishishiba and Jones, 2013, p. 41). In this study comparison among two groups was studied. These two groups were rapid and standard intravenous rehydration. The sample: In this study total 226 children were enrolled. Rapid intravenous group comprises of 114 children and standard intravenous group comprises of 112 children. Sample size is clearly mentioned in the paper along with significance of this sample size. Selection criteria for these children include : age of these children should be above 90 days, diagnosed with gastroenteritis and subsequent dehydration, however not responding to oral rehydration and prescribed with intravenous rehydration. Dehydration should be 3 on the dehydration scale. This dehydration scale is considered as valid score for dehydration. Cut-off criteria of body weight was 5 kg and 33 for inclusion in the study. Data collection: In such research studies, data can be collected by different methods like observation, using instruments, and questionnaires (Chen et al., 2015, pp. 313-315). In this study, it is evident that clinical physicians collected the data. In evidence based nursing practice, validity of the data can be decided based on the qualified person involved in the data collection. Primary outcome was described in the text and it was also presented in the graphical form. These types of representations of the data would have been helpful for reader. Percentage of rehydration was mentioned for both rapid and standard intravenous treatment. This rehydration was not categorized further based on the scale of dehydration. It could have been categorized based on number of children in the different dehydration scales like 1, 2 and 3. Data for the primary outcomes like prolonged capillary refill, abnormal skin turgor, and abnormal respiratory pattern were not described in the text and presented in the graphic al or tabular form. Secondary outcomes were presented in detailed manner in the table however these outcomes were not described properly in the text. In text, secondary outcomes would have been explained for all the outcome measures like length of emergency department stay, revisit admission, adequacy of oral intake at different volumes and time points and values for change in the biochemical parameters including electrolytes. There should be use of instrument for electrolyte and biochemical parameters evalution, however it was not mentioned in the paper. Scoring for clinical rehydration was properly described in the research paper. This scoring was validated in the validation studies. This scoring of clinical dehydration was correlated with length of stay in the hospital. Hence, this evidence of clinical dehydration scoring can be considered as clinically valid scoring. In case of secondary data collection, method of recording and documentation was not mentioned. There was no menti on, whether data was recorded in the book or entered in the software. Hence, question can arise on the validity of the secondary data collection. Baseline values were mentioned for all the electrolytes and biochemical parameters estimation. However, method of estimation of electrolytes and biochemical parameters is not evident in the research paper. Outcome measures of the electrolytes and biochemical parameters were compared with the baseline data; however it is not evident whether same method was applied for estimation of these parameters for baseline data and data obtained for the participants. Hence, it is difficult evaluate validity of this data (Sheridan, 2016). Data analysis: Follow-up results can be considered as valid results because in rapid intravenous all the participants are available for the follow-up outcome. In case of, standard treatment less than 5 % participants are unavailable for the follow-up outcome. This 5 % is in the acceptable range. Hence, follw-up results can be considered as credible results. This study can be considered as double-blinded study because in this study nurse, attending physicians, and participants were blinded for the intervention. However, bedside nurse was unblinded for setting intravenous rate. Bedside nurse was instructed not to communicate this information to other stakeholders in the study. Articles required for the conduct of study were blinded. Clinical scoring was performed in the blinded fashion because clinical physicians were blinded for clinical dehydration scoring. From this study, author stated that there was no clinical difference in dehydration between rapid and standard intravenous administration. Author made a point that, rapid intravenous administration was being increasingly used in the clinical practice. However, authors didnt get expected results of reduction in dehydration score after rapid intravenous administration. Moreover, children of rapid intravenous administration had more index visit to the hospital and longer duration rehydration treatment. There was no significant adverse effect observed in this study. Dysnatraemia and oedema were observed in the children, however these numbers were negligible. Hence, there was no question of not considering this evidence in the clinical practice. In this study inferential statistics is used. Inferential statistics can be used to make conclusion about the source population by using results obtained from the sample. Confidence interval is mentioned for comparison between rapid and standard intravenous administration (Sahu et al, 2015, pp. 5-7). Results of the primary outcome were presented in the form of number of participants, its percentage and confidence interval. It reflects, author presented comprehensive data for the mentioned parameters. There were no clinical and statistical significant differences observed between rapid and standard intravenous administration. Logistic regression analysis can be used when more than two independent variables are present. In this study, logistic regression analysis was done to find relation between treatment and rehydration at 2 hours. However, there was no significant association between treatment and rehydration at 2 hours. It reflects authors efforts to represent data with variety of dimensions to get more output from the study. Findings: These results were not expected from this study because this study was designed based on the evidence. Earlier evidence, clearly mentioned that there was improvement in the clinical dehydration of the children. Author planned this study to replicate the outcomes observed in earlier evidence. There is no information available to judge the results of this study. Authors should have mentioned results of the previous studies for standard intravenous administration. If, results of standard intravenous administration of this study would have been in the range of previously studied standard intravenous administration, results of this study could have been considered as valid results. Results obtained in this study cannot be generalized to all the population of children. This is the most significant limitation of this study. Another limitation of this study was, physician responsible for electrolyte estimation was not blinded. However, in the study design, study was mentioned as blinded study. Even tough, authors didnt get expected outcome in this study, authors didnt mention about extension of this study. Authors didnt mention suggestions for the future research. Even if, other researchers wish to do future research in this filed, almost all the information required to replicate this study is available in this study. Information about the method of electrolyte estimation is not available in this study. There are abundant protocols are available for the estimation of electrolytes. Authors mentioned implication of the study for the clinical setting. Author mentioned that, rapid intravenous administration should not be used in haemodynamically stable children with g astroenteritis because this method didnt exhibited positive results and this method has potential risks associated with it. Relevance of nursing practice and case study: It is evident from the literature that, integration of available evidence with clinical expertise and patient value are the important factors responsible for efficient execution of the evidence based practice. Research carried out in this study, followed all the steps for evidence based practice. Steps involved in the evidence based practice comprises of formulation of the clinical question which can be answerable, literature search of evidence for the question, implementation of the evidence and assessment of the outcome of the evidence in response to question. In evidence based nursing practice, value should be given to the patient and family members of the patient. Patients and family members opinion should be considered while addressing clinical questions. In this study, attention was given to the patients other conditions which can be exaggerated by rapid intravenous administration. These conditions include chronic systemic disease, abdominal surgery, or bilious or bloody vomit, had hypotension, hypoglycaemia or hyperglycaemia. In evidence based medicine, there should be little discomfort to the patient and in this study also precautions were taken to avoid discomfort to the patient. In evidence based practice, procedures to be followed should be discussed with patient and consent should be taken. In this study also, these things were followed (Burman et al., 2013, pp. 231-41). In evidence based nursing practice, healthcare provider should be open minded, skilled and trained to search evidence for clinical question and implement it in their own facility. In this study also, authors implemented evidence of rapid intravenous administration in their setting. Clinical expertise is required for the implementation of the evidence in the practice. In this study, clinical physicians were incorporated for the evaluation of dehydration scale and electrolytes. Stephen B Freedman, first author of the article is having vast experience in gastroenteritis however he is not having experience in formulated clinical question. Other authors of this article have experience in pediatrics; however they dont have experience neither in gastroenteritis or formulated clinical question. Validity of the evidence can be decided based on the clinical expertise. However, none of the authors of the research paper have expertise in the clinical question formulated by them. Implemented evid ence should be able to validate the applicability and generalizability of the evidence. However, this evidence cannot be generalized on all the children (Earle-Foley, 2011, pp. 38-44; Stevens, 2013, p. 4). References: Burman, M.E., Robinson, B., and Hart, A.M. (2013). Linking evidence-based nursing practice and patient-centered care through patient preferences. Nursing administration Quarterly, 37(3), 231-41. Chen, Z., Aiyi, L., Qu, Y., Tang, L., Ting, N., and Tsong, Y. (2015). Applied Statistics in Biomedicine and Clinical Trials Design. Springer. 313- 315. Earle-Foley, V. (2011). Evidence-based practice: issues, paradigms, and future pathways. Nursing Forum, 46(1), 38-44. Freedman, S.B., Sivabalasundaram, V., Bohn, V., Powell, E.C., Johnson, D.W., and Boutis, K. (2011). The treatment of pediatric gastroenteritis: a comparative analysis of pediatric emergency physicians practice patterns. Academic Emergency Medicine, 18, 38-45 Maitland, K., Kiguli, S., Opoka, R.O., Engoru, C., Olupot-Olupot, P., Akech, S.O., et al. (2011). Mortality after fluid bolus in African children with severe infection. New England Journal of Medicine, 364(26), 2483-2495. Nager, A.L., and Wang, V.J. (2010). Comparison of ultrarapid and rapid intravenous hydration in pediatric patients with dehydration. American Journal of Emergency Medicine, 28, 123-9. Nager, A.L. (2010). Fluid and electrolyte therapy in infants and children. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinallis emergency medicine: a comprehensive study guide. 7th ed. McGraw-Hill, 971-5. Nishishiba, M., and Jones, M. (2013). Research Methods and Statistics for Public and Nonprofit Administrators: A Practical Guide. SAGE Publications. 41. Sahu, P. K., Pal, S., and Das, A. K. (2015). Estimation and Inferential Statistics. Springer. 5-7. Sheridan, D. J. (2016). Evidence-Based Medicine: Best Practice or Restrictive Dogma. World Scientific. Stevens, K.R. (2013). The impact of evidence-based practice in nursing and the next big ideas. Online Journal of Issues in Nursing, 18(2), 4.