Final EBP Paper: Patient Safety
Evidence-Based Practice Project Written Summary Paper
Postoperative pain is a prevalent issue in healthcare. According to a 2014 survey, out of 300 surgical patients, 86% of patients report moderate/extreme pain postoperatively (Gan et al.,
2014). Physiological and psychological consequences may occur if the pain is left untreated. Physiological consequences include “higher stress hormones, tissue loss due to catabolism, [and] compromised immune functions” (Málek et al., 2017). Patients may also experience psychological effects such as fear, anxiety, and depression (“Understanding the effect of pain and how the human body responds”, 2020). Opioids are typically the first line of treatment for postoperative pain, which has contributed to the development of the opioid crisis. A 2017 study from the Journal of the American Medical Association reported that 36,177 surgical patients were found to have an increase in 5.9% to 6.5% of new chronic opioid use after major and minor surgeries (Brummett, 2017).
Transcutaneous electrical nerve stimulation (TENS) is a noninvasive and nonpharmacological therapy that uses mild electrical currents to provide pain relief. TENS has been found to be effective in treating various types of acute pain (Vance et al., 2014). Based on the state of the evidence of TENS, we wanted to assess if TENS can be helpful in managing postoperative pain, which may reduce opioid usage. In adults with post-operative pain (P), what is the effect of transcutaneous electrical nerve stimulation (I) on short-term pain relief (O) compared with pharmacological therapy (C)?
Review of the Literature
We developed inclusion and exclusion criteria to select studies to answer our PICOT question. Inclusion criteria consisted of adult patients, a postoperative setting, a moderate sample size of 10 to 20, clearly defined frequencies of TENS, and explicitly described pain assessment tools and set time intervals for pain reassessment. Lastly, we only included academic journals of professional organizations published between 2015 to 2020, with mainly primary studies. The exclusion criteria further allowed us to narrow our search. The exclusion criteria included the presence of researcher bias related to receiving funding for the promotion of TENS, surgical procedures that did not require opioid use, and qualitative studies. Several factors contributed to the overall quality of the research collected. We selected studies with a high level of evidence. We had a total of four randomized controlled trials, which are Level II evidence, and two meta-analyses of randomized controlled trials, which are Level I evidence. Auditability is present in our studies because of the clear explanations given regarding the course of action when providing the intervention. In addition, each study demonstrated statistical significance of TENS through a p-value of less than 0.05. Furthermore, the studies had confidence intervals for the TENS intervention group that did not contain the null value of one, indicating statistical significance. Lastly, each study utilized appropriate measurement tools such as the Visual Analog Scale (VAS) or Visual Numeric Scale (VNS) that displayed inter-rater reliability and test-retest reliability (Quah & Cockerham, 2017).
There were a few limitations that affected the overall research quality. The majority of our studies were based in foreign countries, such as Sweden, Turkey, Israel, and Taiwan. This can affect applicability to the US because of the varying cultural influences on pain. Also, most of our research articles had a small sample size and did not conduct a power analysis to calculate the minimum sample size to demonstrate an effect. This is limiting and decreases the study’s generalizability because it may not be representative of the population if treated with TENS therapy. Lastly, several of our studies did not blind the patients; blinding is essential to decrease bias. Quality is impacted due to the control group still receiving a non-therapeutic frequency, which may influence the subject’s pain perception. This is because the patients can feel the electrical impulses. Collective findings demonstrated that TENS is effective in reducing postoperative pain as an adjunct therapy. Some studies found a reduction in opioid use and some studies did not. Our studies concluded that TENS is most effective for treating postoperative pain at a higher frequency, ranging between 50-100 Hz. Besides pain outcomes, our studies demonstrated an association of TENS with an improvement in ambulation, mobility, arthritis, and reduced recovery time. TENS was also found to lower inflammatory markers in patients with postoperative pain by decreasing inflammatory markers that would stimulate nociceptive receptors.
Clinical Practice Guidelines
The American Pain Society created a CPG in 2016 for the management of postoperative pain. This CPG recommends TENS as an adjunct therapy to postoperative pain management. In addition, the American Pain Society’s CPG concludes that TENS is most effective when placed near the surgical site and at acupoints. Furthermore, they report that there is not enough evidence to recommend a particular TENS frequency for post-operative pain (Chou, et al., 2016). In 2010, the American Society of Anesthesiologists created a CPG for pain management that recommended the use of TENS as part of a multimodal approach for chronic pain, but other conditions as well, which may include acute postoperative pain. The American Society of Anesthesiologists supports this CPG with literature concluding increased effectiveness in the use of multidisciplinary treatment in comparison to conventional treatment (Hsu, et al., 2019). The last CPG we found was written by the Orthopedic Trauma Association in 2019 for the management of pain in acute musculoskeletal injury. The Orthopedic Trauma Association’s CPG advises TENS as an adjunct to postoperative pain management as well. After the panel completed a systematic review of TENS studies, they found that the application of TENS at strong, sub painful frequencies is most effective for musculoskeletal pain (Hsu et al., 2019). All in all, the clinical practice guidelines determined TENS to be effective as an adjunct therapy, which is part of a multimodal approach to postoperative pain management.
Cedars-Sinai created a policy called “Cedars-Sinai Medical Network Opioid Prescribing Treatment of Acute Non-Cancer Pain” (“Cedars-Sinai Medical Network Opioid Prescribing”, n.d.). This policy states nonpharmacologic therapy and non-opioid pharmacologic therapy is the preferred treatment for acute pain. They urge clinicians to consider opioid therapy only if the expected advantages for pain and function are greater than the risks to the patient. If opioid therapy is used, it should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy. Nonpharmacologic therapies the policy recommends are physical treatments, behavioral treatments, and interventions. Because of Cedars-Sinai’s policy on using nonpharmacologic therapy for acute pain, TENS can be considered as a treatment for postoperative pain. Overall, Cedars-Sinai’s policy is up to date, supports the research, and reflects the CPGs. The research and CPGs advocate for a multimodal approach to pain management. The policy demonstrates this by emphasizing the institution’s approach to treating acute non-cancer pain with non-opioid medications as well as nonpharmacological therapy. Lastly, the policy is clear because it specifically details various types of nonpharmacological methods.
For the usage of TENS, we recommend that TENS is administered at high frequencies of at least 50 Hz with attention to avoid contraindications such as pacemakers, pregnancy, placement on the carotid sinus, and application to the anterior neck. Moreover, we advise that TENS applied near the surgical site or at acupoints. In addition, we recommend proper assessment of the patient’s response to TENS, such as muscle twitching or lack of tingling, which may indicate over stimulation or under stimulation and warrant a change of frequency or site of administration. Finally, we encourage reliable tools for rating pain, such as VAS or VNS. To implement TENS on the hospital unit, we advise specialized training for the nurses. Nurses should be educated on the advantages and contraindications of TENS, various modes of the TENS unit, specific placements of the pads, and how to monitor the effect of the treatment. We suggest that a small number of nurses on each floor are trained instead of all the nurses, similar to the availability of an intravenous or wound ostomy care nurse. We urge that each shift should have at least two nurses who obtained specialized training on the TENS unit.
The average cost of an at-home TENS unit ranges from $35-$100 according to an overview of the units on Amazon.com. If hospitals prefer to purchase a higher quality TENS unit with additional functions, such as interferential therapy and neuromuscular electrical stimulation, the cost may be upwards of $2453 per unit (Murphy, 2019; SourceOrtho, n.d.). However, our studies did not include high-tech TENS units so we believe that the cheaper, at-home TENS unit would suffice. To address the cost of training the nurses, it would cost roughly $75 per nurse (“TENS Unit Training”, n.d.). To possibly lower the cost of training nurses for TENS use competency, hospitals could seek group rates for training sessions, similar to Basic Life Support or Advanced Cardiac Life Support.
Need for Future Study
Future research should include studies conducted in the United States of America with large sample sizes to promote generalizability. Furthermore, future studies should be double blinded to decrease bias. Lastly, we believe that more randomized controlled trials should be performed to determine the most effective frequencies of TENS for postoperative pain management to create a standardization of TENS settings.
Postoperative pain has various physiological and psychological consequences if inadequately managed. As postoperative pain is widely treated with opioid analgesics that may potentiate adverse effects, there is a need to determine alternative treatment therapies for postoperative pain. TENS is a nonpharmacological option that should be considered for the treatment of postoperative pain. We created our PICO question: In adults with postoperative pain (P), what is the effect of transcutaneous electrical nerve stimulation (I) on pain relief (O) compared with pharmacological therapy (C)? To answer this question, we gathered research from four high-quality RCTs and two high-quality meta-analyses as well as CPGs from the American Pain Society, the American Society of Anesthesiologists, and the Orthopedic Trauma Association. Cedars-Sinai’s policy regarding pain management treatment encourages the use of nonpharmacologic therapy, which supports the use of TENS. Our research findings and CPGs answered our PICO question by demonstrating that TENS effectively treats postoperative pain as adjunct therapy. To implement TENS, we detailed various application recommendations as well as suggestions for training the nurses. In an attempt to minimize costs, hospitals may explore cost-efficient TENS units and implement group training. Future studies should explore the potential of TENS in the US with larger sample sizes to create a standardized protocol for administering TENS to be used as an adjunct treatment for postoperative pain.8
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Bedside Reporting Vs Traditional Reporting: In Adults Receiving Hospital Care (P), Is the Bedside Report (I) More Effective Than Traditional Report (C) At Increasing Patient Safety (O) Between Shifts (T)?
Whether it be a patient in the hospital, a school setting with new teachers, or a sporting event between athletes of vastly different skill levels, what is often the most effective method at ensuring that the proper actions are taken is having an active report of events happen in-person. This can be done through either role-playing for example (i.e.; playing doctor), or recording on regular paper and providing to anyone who should need to review it. This paper explores whether or not providing bedside reports to substitute nurses and doctors who take over care of patients between shifts leads to an increase in patient safety as compared to traditional report methods.
Synthesis of Literature
The current literature suggests that traditional paper-based report methods (i.e.; I) do not improve patient safety, but in-person reporting (i.e.; C) does. The nurse participates as a consultant rather than as an observer, and focuses on providing direct feedback to the physician about what he is doing wrong and how to fix it. Procedural training using bedside reports has also been shown to be effective at increasing patient safety when compared to traditional forms of teaching such as lecturing.
According to Dorvil (2018), bedside reporting, as opposed to traditional methods of report, was shown to be significantly effective in increasing patient safety. They also suggest that a more traditional report using a “checklist” format is less effective than both bedside reporting and video-based reporting at increasing patient safety (Dorvil, 2018). A check list is simply a series of questions related to the care occurring between two nurses or doctors.
Williams (2018) suggests that the most important factor in ensuring patient safety within an ICU setting is frequent communication between staff members, probably through a combination of oral and non-oral forms. Their study also found that patient safety outcomes were significantly in favor of ICU staff who received regular bedside reports from their attending physicians as opposed to comparing them to those who instead received a traditional written report. Maxson et al. (2012) also found that bedside reporting was significantly better than traditional report methods at promoting increased patient safety within an intensive care unit.
The qualitative data in the literature is largely in favor of bedside reporting as well. The detailed, active listening that comes with hearing a report first hand allows for better communication, which is essential for patient safety (Maxson et al., 2012). When comparing two different ways of reporting (i.e.; face-to-face vs traditional written reports), some studies show that the former improves patient outcomes and is superior to the latter in terms of promoting effective learning (i.e., improved patient safety) (Maxson et al., 2012), while others find no significant differences between them.
In another study by Groves et al (2016), found that handing off safety at the bedside was best achieved by using a combination of all three communication modes, but showed that the "bedside agreement report" (I), was no less effective than traditional, face-to-face reports. However, it is important to note that in this study, all patient outcomes were equally favorable between both groups. Furthermore, the bedside agreement report itself was only utilized when a bedside or bedside nurse had not been present for any length of time (i.e.; <90 min) (Groves et al., 2016).
Other studies have shown that any form of "bedside reporting" has been shown to be no more effective than traditional forms of report at promoting patient safety in several different medical settings ((Groves et al., 2016, Dorvil, 2018). However, in many of these studies, the definition of "bedside report" varies greatly across their populations (i.e.; what does or doesn't qualify as a bedside report). For example, in one study, it is defined by any type of report that can be done either at the bedside or remotely (i.e., via telephone), but also includes any form of "teaching report" (Dorvil, 2018). It can be assumed that at least some of these reports were a combination of face-to-face and traditional written reports.
Clinical Practice Guidelines
The Joint Commission National Patient Safety Goals (NPSGs) specifically mention the importance of patient safety across all facets of the healthcare system and makes recommendations as to how hospitals might improve said areas (The Joint Commission, 2021). They recommend that hospitals have a process in place that encourages staff to report problems and concerns, raises awareness of potential problems either within their organization or at other organizations in the community and provides education regarding patient safety (The Joint Commission, 2021). However, specific mention is made of bedside reporting only when it is done properly (i.e.; quality reporting), and no mention of traditional written report methods directly.
The American Nurses Association (ANA) has set several priorities for improving patient safety and bedside reporting is included as one of these. The ANA suggests that hospitals have a process in place for reporting concerns and problems, including strategies for facilitating reporting (McAllen et al., 2018). ANA policy has also recommended that nurses and other staff members be trained in the essentials of patient safety, and regularly receive an annual review or recertification to assure competence. This includes opportunities to participate in hospitals' quality improvement projects, which includes bedside/patient safety.
Other organizations such as the Institute for Healthcare Improvement (IHI) have developed patient safety programs, but no specific mention of bedside reporting is made in their recommendations regarding patient safety (Sand-Jecklin & Sherman, 2013). Overall, bedside reporting is not specifically mentioned in any national or state organization's patient safety policy.
Hospitals should develop and maintain a process for encouraging staff to report problems and concerns, including strategies for facilitating reporting (Sand-Jecklin & Sherman, 2013). Standards such as the Joint Commission National Patient Safety Goals (NPSGs) provide some recommendations regarding the development of a reporting system, but do not specifically mention bedside reports. Each hospital is free to develop their own process however, and some hospitals may have processes that rely solely on face-to-face communication (Sand-Jecklin & Sherman, 2013). Hospitals should also attempt to raise awareness throughout the entire healthcare community about patient safety issues that are specific locally within their community of practice.
There are no specific requirements regarding the content or frequency of reports, but rather a general expectation that hospitals will educate the staff about their process for reporting and encourage them to utilize it. While most hospital policies regarding bedside reporting rely on face-to-face communication, some do not specify any particular method of communication. The Joint Commission does not have a specific policy for bedside reporting.
The Joint Commission requires hospitals to have a process in place for identifying, reviewing, and responding to patient safety concerns (The Joint Commission, 2021). This process should include an education program on reporting, encouraging staff to report problems and concerns as well as raising awareness about issues in the community. However, no specific mention of bedside reporting is made. The Joint Commission encourages hospitals to have a process for encouraging staff to report problems and concerns, including strategies for facilitating reporting (The Joint Commission, 2021). A recent policy statement by the American Nurses Association recommends that hospitals have a process in place for reporting concerns and problems, including strategies for facilitating reporting.
The Institute for Healthcare Improvement (IHI) is an independent, not-for-profit organization that promotes the improvement of healthcare systems, processes and outcomes. No mention of bedside reporting is made in their recommendations regarding patient safety (Sand-Jecklin & Sherman, 2013). For each patient safety goal, the Institute for Healthcare Improvement suggests hospitals develop and maintain a process for encouraging staff to report problems and concerns. This process should include strategies for facilitating reporting with categories such as "teaching reports" or "intervention reports". They do not specifically mention bedside reporting.
Many of the studies that have examined the effect of in-hospital bedside reporting have used retrospective designs, and therefore, the findings from these studies are difficult to extrapolate. These studies provide some information to determine if there is an effect of bedside reports on patient outcomes, but it is unclear as to what extent or how it works.
The first recommendation is that bedside reporting is an important component of patient safety policy, and should be implemented in hospitals with patient safety programs. Bedside reporting allows for the presence of a knowledge expert at the point of care, and is a direct way to engage clinicians in quality improvement. The Joint Commission has made recommendations on how hospitals should improve patient safety across their entire system, and having a process in place that encourages staff to report problems and concerns is one area they stress (Sand-Jecklin & Sherman, 2013). Bedside reporting allows for better communication between staff members, especially since they are present during potentially dangerous situations. In addition, it also allows staff members to promote better patient care by sharing information they acquire through bedside reporting. Bedside reporting by nurses may also provide a means for intervention and prevention of medical errors, harm, or injury to patients or staff.
The second recommendation is that organizations should develop a process for encouraging staff to report problems and concerns but should rely on traditional communication methods such as face-to-face conversations (i.e.; verbal) rather than forms developed specifically for bedside reporting. The use of forms for each incident may lead to decreased productivity at the point of care and increased error rates, because the barrier of filling out a form may prevent the time required to communicate effectively with patients and colleagues. Formats developed specifically for bedside reporting may be impractical and unenforceable, since they do not require the use of face-to-face communication and may serve as a barrier to communication. In addition, completion rates on forms may vary widely based on the type of incident reported (Sand-Jecklin & Sherman, 2013). However, some hospitals use both traditional methods, such as verbal communication, as well as electronic systems that report events that are typically associated with patient safety policy.
The third recommendation is that many healthcare organizations should increase their attention to patient safety initiatives and expand their participation in these programs. High quality patient safety initiatives are a goal for many healthcare organizations. Bedside reporting may be one such strategy because of its ability to empower staff members during difficult situations. Patient safety initiatives that use bedside reporting should be used along with other strategies, such as increasing nurse staffing levels and improving the healthcare workers’ capacity for continuous learning (McAllen et al., 2018).
The fourth recommendation is that more research is needed regarding bedside reporting for patient safety. More research is necessary to determine whether these incidents are reported, how they are reported, and the effects of reports on patient outcomes (McAllen et al., 2018). The lack of communication barriers between staff members in a hospital setting relies on face-to-face communication, and therefore, there may also be a need for more research in this area as well.
Bedside reporting has the potential to be costly, especially if time is spent developing forms and procedures specific to bedside reporting. However, many hospitals have found that it requires minimal time away from patient care (McAllen et al., 2018). In addition, if implementation of bedside reporting leads to a reduction in the occurrence of medical errors or other adverse events, hospital costs may decrease due to a decrease in the need for expensive lawsuits and patient care. Furthermore, there may be less need for new information systems to capture individual episodes of care.
Need for Future Study
This is a topic that has been studied in a variety of settings, but there are many gaps in our knowledge. First, there are several emerging areas of bedside reporting that have not yet been studied. More specifically, there is still limited research on the potential impact of bedside reporting on medication errors and patient outcomes. Further study should explore these new areas as well as determine more specific ways to improve the quality of care at the point of care (Williams, 2018). Finally, the effect of bedside reporting may vary depending on the unit level.
Although there is evidence suggesting that it may be a good practice to implement at all levels within an organization, this information is not available in the literature. Further research is needed to determine if bedside reporting could be implemented differently in different units within organizations.
In keeping with the philosophy of evidence-based practice, a review of the literature on bedside reporting in terms of assessing quality and performance is needed. Bedside reporting has the potential to lead to reductions in medical errors and adverse events, which should result in reduced costs. The need for further evaluations to identify the potential benefits of bedside reporting is relevant, given increasing concerns over healthcare costs. Accurate surveillance systems depend on reliable data and this may present a challenge when bedside reporting relies solely on self-reporting. This can be overcome through adding bedside assessment tools as well as ensuring that staff are trained in their use.
Bedside reporting is an important component of effective quality improvement programs at all levels. This policy ensures that clinician concerns are communicated and acted upon, and promotes a culture of safety with primary emphasis on patient safety. Some recommendations for those interested in implementing bedside reporting are to evaluate existing quality improvement programs to determine how bedside reporting fits into the overall goal of a patient safety culture. In addition, it is important to ensure that adequate staffing is available in order for adequate information sharing. Other recommendations include developing a process for encouraging staff to report problems and concerns but rely more heavily on traditional communication methods (such as verbal communication) rather than forms designed specifically for bedside reporting.
In conclusion, bedside reporting is an important component of patient safety policy, and should be implemented in hospitals with patient safety programs. Furnishing a means for staff to report concerns allows for more effective communication between clinicians and family members during potentially dangerous situations. Bedside reporting should use traditional communication methods (i.e., verbal), not forms, in order to prevent decrease in productivity and increase in errors that may be linked with form completion. Finally, the implementation of bedside reporting may lead to reduction in medical errors and other adverse events, thus reducing costs for hospitals.
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Groves, P. S., Manges, K. A., & Scott-Cawiezell, J. (2016). Handing Off Safety at the Bedside. Clinical Nursing Research, 25(5), 473–493. https://doi.org/10.1177/1054773816630535
Maxson, P. M., Derby, K. M., Wrobleski, D. M., & Foss, D. M. (2012). Bedside nurse-to-nurse handoff promotes patient safety. Medsurg Nursing: Official Journal of the Academy of Medical-Surgical Nurses, 21(3), 140–144; quiz 145. https://pubmed.ncbi.nlm.nih.gov/22866433/
McAllen, E., Stephens, K., Swanson-Biearman, B., Kerr, K., & Whiteman, K. (2018). Moving Shift Report to the Bedside: An Evidence-Based Quality Improvement Project. OJIN: The Online Journal of Issues in Nursing, 23(2). https://doi.org/10.3912/ojin.vol23no02ppt22
Sand-Jecklin, K., & Sherman, J. (2013). Incorporating Bedside Report Into Nursing Handoff. Journal of Nursing Care Quality, 28(2), 186–194. https://doi.org/10.1097/ncq.0b013e31827a4795
The Joint Commission. (2021). Hospital: 2021 National patient safety goals. Www.jointcommission.org. https://www.jointcommission.org/standards/national-patient-safety-goals/hospital-national-patient-safety-goals/
Williams, C. L. (2018). A Comparison of the Risks and Benefits of Nursing Bedside Shift Report vs. Traditional Shift Report: A Systematic Review of the Literature. International Journal of Studies in Nursing, 3(2), 40. https://doi.org/10.20849/ijsn.v3i2.382
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