You have created a good evidence-based question. You have read all the applicable sets of standards and guidelines. Then you conducted a literature search on this question in PubMed, CINAHL, and read all the device or drug manufacturer’s instructions. Yet the answer to your question cannot be found. How do you make decisions about clinical practice issues when there is no evidence to guide that decision?
There are certainly many clinical practice questions without the needed evidence to guide that practice. What is the maximum length of time that a primary fluid container should be used for infusion? Should a needleless connector be attached to the catheter hub when the prescribed infusion is for continuous fluids for several days? Is an antiseptic impregnated dressing needed for short peripheral catheters? Should maximum barriers be used for midline catheter insertions? What is the risk of bloodstream infection when a central vascular access device (VAD) is routinely used to draw blood samples? What antiseptic agent and application technique should be used to disinfect the female hub of a VAD? These examples plus many others must be addressed by the experts in your facility. First, assess the basic principles that apply. Normal human anatomy and physiology such as normal skin flora and inflammatory processes could provide some guidance. Applicable principles of infection prevention are critical. For instance, manipulation of the entire infusion system and VAD should be minimized as much as possible. What is the effect of the patient’s medical diagnoses and prescribed medications on the issue? How do these basic principles apply to your specific practice question? Next, you need to collect data to monitor the outcomes of your current practices. This will determine where the problems are and guide what needs to be changed. Contact other similar healthcare organizations to benchmark with their practices. Contact the clinical or medical department of the device manufacturer in question. Conduct your own data collection on the specific question. This could be in the form of research for publication or quality improvement data for internal use. Finally, share this information with the applicable practice committees and decision-makers in your facility. As the infusion/vascular access expert, be available to address the additional questions from these committees. The outcome of this process should guide practice decisions in the absence of needed evidence. When you read available standards and guidelines, always know the ranking or grading system used in that document. These systems differ and have a wide range of statements about how to apply their evidence. Unfortunately, the need for clinical evidence will always exceed the research used to provide evidence-based answers for these questions.
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Author: Lynn HadawayLynn Hadaway is an international thought leader in infusion therapy and vascular access, having been in this practice for more than 40 years. Her experience comes from hospital-based infusion teams, device manufacturers, and continuing education services. Her journal and textbook publications are extensive. She also maintains board certification in infusion nursing (CRNI) and nursing professional development (RN-BC). Categories
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May 2019
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