Abstract of thesis entitled

A Nurse-initiated Nasogastric Tube Replacement Protocol for

Adults Receiving Artificial Nutrition to Improve the Efficiency of

AED Services

Submitted by

Lam Wing Hang

for the degree of Master of Nursing

at The University of Hong Kong

in July 2013

Overcrowding in emergency departments is a worldwide problem. The non-

urgent utilization of the emergency service is considered a serious threat to the

quality of care delivered. Patients in stable condition admitted for nasogastric tube

dislodgement is one of the typical examples observed in Hong Kong. According to

the triage protocol, the waiting time for consultation is estimated to be at least 120

minutes for patients triaged into non-urgent categories, with the total length of stay

possibly prolonged in cases of resuscitation. Consequently, these patients are at risks

of feeding regime disturbance and altered nutrition.

Nasogastric tube insertion is a basic nursing procedure in most clinical

settings in Hong Kong. However, under current practice, nurses in the emergency

department are not allowed to initiate the procedure unless a medical consultation

has been performed, not even for patients in stable condition. In order to reduce the

length of stay of these patients and minimize possible complications resulted from

the delayed treatment, it is suggested to switch the practice from physician-led to

nurse-led. This translational nursing research project was i) to explore and evaluate

the effectiveness of nurse-led care for stable patients in various healthcare settings

through a systematic literature review, ii) to develop an evidence-based protocol of

nurse-initiated nasogastric tube replacement, iii) to assess its feasibility and

applicability in a local emergency department, as well as iv) to develop strategies for

the implementation and evaluation of the new practice.

A systematic literature review was undertaken using four electronic

databases, namely MEDLINE, CINAHL, Cochrane Library and British Nursing

Index. Search terms “nurse-led”, “nurse-initiated”, “training”, “effect$” were used.

A total of 1,994 relevant citations were retrieved. Ten randomized controlled trials

met the inclusion criteria and were finally selected. Extracted data and

methodological qualities of the included studies were assessed using a structured

appraisal instrument.

All studies generated high level of evidence on the effectiveness of nurse-

initiated interventions provided to stable patients in various healthcare settings,

which included the improvement of patients’ health outcomes, reduction of waiting

time for consultations, increased level of patient satisfaction. The quality of nurse-

led practice was of the same standard as the usual practice led by doctors. The nurse-

initiated intervention was further enhanced by the provision of training and

collaboration with medical staff.

Six evidence-based recommendations were devised for the nurse-initiated

nasogastric tube replacement protocol. It included i) provision of training, ii)

development of patient assessment form for the protocol, iii) initiation of baseline

assessment for eligible patients and iv) radiographic verification by nurses, v)

collaboration with medical staff, and vi) ongoing evaluation of the implementation.

The nurse-initiated nasogastric tube replacement for stable patients is an

effective solution to the problem of overcrowding in emergency department. Further

development of non-urgent treatments and services led by emergency nurses should

be considered.

A Nurse-initiated Nasogastric Tube Replacement Protocol for

Adults Receiving Artificial Nutrition to Improve the Efficiency of

AED Services

by

Lam Wing Hang

BNurs. H.K.U.

A thesis submitted in partial fulfillment of the requirements for

the Degree of Master of Nursing

at The University of Hong Kong.

July 2013

i

Declaration

I declare that this thesis represents my own work, except where due

acknowledgement is made, and that it has not been previously included in a thesis,

dissertation or report submitted to this University or to any other institution for a

degree, diploma or other qualifications.

Lam Wing Hang

ii

Acknowledgements

I had the great fortune to be supervised by Miss Fu Chui Yuk, Idy. She is a

wonderful and generous individual who has been consistently providing me with

direction, encouragement and love, bearing with my chaotic thoughts and challenging

my wild metaphors! I am forever grateful to this brilliant and broad-minded teacher.

I am very appreciative of my colleagues and friends who have made my soul

bloom throughout this journey. With their help and support, I experienced physical,

emotional and spiritual replenishments. They have brought me immense joy.

Above all, I would like to express the deepest gratitude to my family, for

their constant demonstrations of love. They have been supporting me in all my

wishes, hopes and dreams.

iii

Table of Contents

Declaration i

Acknowledgements ii

Table of Contents iii

Abbreviations v

CHAPTER 1: INTRODUCTION

1.1 Background 1

1.1.1 Accident & Emergency Departments in Hong Kong 1

1.1.2 Triage System 2

1.2 Affirming the Need 3

1.2.1 Overutilization of Accident & Emergency Department Services 3

1.2.2 Geriatric Patients in Accident & Emergency Department 3

1.2.3 Nasogastric Tube Dislodgment and Malnutrition among Elderly 4

1.3 Objectives and Significance 5

1.3.1 Research Questions 6

1.3.2 Objectives of the Dissertation 6

CHAPTER 2: CRITICAL APPRAISAL

2.1 Identification of Studies 7

2.1.1 Inclusion and Exclusion Criteria 7

2.1.2 Data Extraction 8

2.1.3 Appraisal Strategy 8

2.2 Results 8

2.2.1 Study Characteristics 9

2.2.1.1 Types of Participants (P) 9

2.2.1.2 Types of Interventions (I) 9

2.2.1.3 Types of Comparisons (C) 10

2.2.1.4 Types of Outcome Measures (O) 11

2.2.2 Summary of Methodological Issues 11

2.3 Summary and Synthesis of Data 15

2.3.1 Clinical Outcomes 15

2.3.2 Cost-effectiveness 15

2.3.3 Patient Satisfaction 16

2.3.4 Characteristics of Nurse Interventionists 17

2.3.5 Nature of Training 17

2.3.6 Evidence-based Recommendations 18

CHAPTER 3: TRANSLATION & APPLICATION

3.1 Implementation Potential 20

3.1.1 Target Population and Clinical Setting 20

3.1.2 Transferability of the Findings 21

3.1.3 Feasibility 22

3.1.3.1 Availability of Staff and Resources 22

3.1.3.2 Potential Barriers 23

3.1.4 Cost/Benefit Ratio of the Implementation 25

3.1.4.1 Patients Aspect 25

3.1.4.2 Staff Aspect 25

3.1.4.3 Organization Aspect 26

3.2 Evidence-based Protocol 27

iv

CHAPTER 4: IMPLEMENTATION PLAN

4.1 Communication Plan 31

4.1.1 Identification of the Stakeholders 31

4.1.2 Process of Communication 32

4.1.3 Implementation Strategies 33

4.2 Pilot Study Plan 34

4.3 Evaluation Plan 36

4.3.1 Nature and Number of Clients to be Involved 36

4.3.2 Data Collection and Outcomes Measurement 37

4.3.3 Statistical Analysis 38

4.3.4 Basis for the Effective Change of Practice 39

CHAPTER 5: CONCLUSION 40

APPENDICES

Appendix A: Search History 41

Appendix B: Table of Evidence 42

Appendix C: Appraisal Checklist for Randomized Controlled Trials (SIGN) 51

Appendix D: Nurse-initiated Nasogastric Tube Replacement Protocol in AED 61

Appendix E: Estimated Cost of the Nurse-initiated Intervention 68

Appendix F: Estimated Saving of the Nurse-initiated Intervention 70

Appendix G: Levels of Evidence & Grades of Recommendation 71

Appendix H: Timeline of the Implementation of the Nurse-initiated Nasogastric

Tube Replacement Protocol in AED

72

REFERENCES 73

v

Abbreviations

AED Accident & Emergency Department

AEIS Accident & Emergency Information System

APN Advanced Practice Nurse

ARCC Advancing Research and Clinical practice through close Collaboration

COS Chief of Service

COPD Chronic obstructive pulmonary disease

CPAP Continuous positive airway pressure

DOM Department Operations Manager

EBP Evidence-based practice

ENP Emergency Nurse Practitioner

ESS Epworth Sleepiness Scale

FEV1 Forced expiratory volume in 1 second

HA Hospital Authority

HO House Officer

IQR Interquartile range

LOS Length of stay

NG tube Nasogastric tube

OSA Obstructive sleep apnea

PFR Peak flow rate

RCT Randomized controlled trial

RN Registered Nurse

SEN Senior Emergency Nurse

SF-36 Short Form 36 Health Survey

SHO Senior House Officer

SIGN Scottish Intercollegiate Guidelines Network

SMO Senior Medical Officer

VAS Visual Analogue Scale

WM Ward Manager

1

CHAPTER 1

INTRODUCTION

1.1 Background

The Accident & Emergency Department (AED) is the main source of care

for patients in immediate life-threatening or critical condition. The arrival rates,

types and acuity levels of attenders cannot be anticipated. Even when the

department service is overloaded, no one is refused for care. Unfortunately, many

studies have found that an increasing number of people are using the emergency

service as the primary source of care (Lau et al., 1996; Lee et al., 2000; Larkin,

2001; Yim et al., 2009). Many of those patients are not in conditions resulted from

accidents or in any medical emergencies. Their conditions often require no

specific hospital treatments. The non-urgent utilization of AED services has

become one of the serious threats to the global healthcare system.

1.1.1 Accident & Emergency Departments in Hong Kong

Currently, there are 16 AEDs in Hong Kong serving an overall population

of more than 7 million and providing a high standard of emergency care to people

in the community who perceive the need for or are in need of acute care. The

workflow of AEDs in Hong Kong is developed with well-organized guidelines

and protocols for different cases such as cardiopulmonary resuscitation, disaster

and trauma management, intoxication, wound suturing, etc.

2

1.1.2 Triage System

The severity of AED attenders’ medical condition is categorized using the

triage system (Hospital Authority, 2012). It was first introduced in 1988 by the

Hospital Authority, HKSAR. The triage protocol is updated periodically by the

AED Nursing Development Committee every three to five years. A five-tier

system divides AED attenders into categories according to their medical

conditions, regardless of the patients’ economic statuses, social factors or personal

issues. The sorting of patients into priority categories is performed by trained

AED nurses who have at least one year of emergency clinical experience.

For category one (critical), the target response time is immediate without

delay. Those patients are suffering from life-threatening events with unstable vital

signs, thus requiring immediate resuscitation.

For category two (emergency), the target response time is within 15

minutes. Those patients are suffering from major life-threatening events, having

borderline vital signs and are at potential risks of rapid deterioration.

For category three (urgent), the target response time is within 30 minutes.

Those patients are suffering from a major condition, having stable vital signs but

are at risks of deterioration.

Categories four and five are classified as “semi-urgent” and “non-urgent”

respectively. Patients in these categories are suffering from acute yet minor

conditions with stable vital signs. They can afford to wait, have no suggested

complication, or they can even be treated by general practitioners. The target

response time is no less than 120 and 180 minutes respectively. When

resuscitation is being performed on other patients in more acute condition, the

3

consultations and treatments provided to non-critical attenders in AED will be

delayed. Thus, the response time will eventually be longer.

1.2 Affirming the Need

1.2.1 Overutilization of Accident & Emergency Department Services

AED is considered the main source of care to serve patients in immediate

life-threatening or critical condition. Nevertheless, a large proportion of AED

attendances were not true emergencies (Lee et al., 2000). According to the annual

report of a local AED from January 2011 to December 2011, the total number of

AED attenders was 124,065. Among them, 70.7% were triaged as “semi-urgent”

to “non-urgent” (AEIS, 2012).

There are several factors leading to the misuse of AED services, i)

perceived emergency status of own disease, ii) feeling sick when general

practitioners or out-patient clinics were not in service, iii) lack of improving signs

after general practitioner consultations, iv) proximity to hospital from home, etc.

(Lee et al., 2000). Meanwhile, the annual report also showed that geriatric

attenders made up more than 25% of the total number of non-critical cases.

1.2.2 Geriatric Patients in Accident & Emergency Department

The aging population is a global concern. Similar to western countries,

elderly people account for a large proportion of AED attenders (Lau et al., 1996,

Yim et al., 2009). In the local AED, 33% attenders were aged over 65 in 2011

(AEIS, 2012). Common geriatric cases are decreased general condition,

4

hypertension, chest pain, acute exacerbation of chronic obstructive pulmonary

disease (COPD), bone fracture related to fall, etc. These are regarded as

emergency events as geriatric attenders are at higher risks of deterioration in

general. They are often triaged into category three or above in order to receive

prompt medical treatments and pharmacological interventions in AED.

On the contrary, geriatric attenders will be triaged into category four or

below if their vital signs are stable. In general, their chief complaints are

musculoskeletal pain, bowel disturbance, enteral feeding problem, somatic

complaint for which no immediate treatment is required, etc. (Lau et al., 1996;

Chu & Pei, 1999). Consequently, the length of stay (LOS) of these patients in

AED would be much longer, especially for those who may have coexisting

complex and non-specific medical problems. More time and investigations are

needed in order to make an accurate diagnosis.

1.2.3 Nasogastric Tube Dislodgement and Malnutrition among Elderly

The placement of nasogastric (NG) tube provides long-term enteral

nutritional support for patients who are unable to hydrate or nourish themselves.

Dislodgement of NG tube is a typical example of non-critical geriatric cases in

AED. According to the triage guideline, patients who are admitted for NG tube

dislodgement will be triaged into category four if their vital signs are stable. In the

local AED, approximately 200 elderly patients are admitted for replacement of

NG tube every year, ranging from nine to twenty cases per month (AEIS, 2012).

The waiting time for medical consultations averages at 120 minutes. NG tube is

inserted by an AED nurse after the medical consultation. Radiographic imaging

will be ordered for these patients and subsequently reassessed by a medical officer

5

in order to verify a correct tube placement. This process of treatment takes another

60 minutes approximately. Thus, the total LOS in AED for these patients is

estimated to be two to four hours.

The possible delay in treatment and the prolonged LOS in AED for this

group of attenders lead to the disturbance of feeding regime and subsequently

altered nutrition. Prevalence of malnutrition among elderly is one of the most

alarming health concerns worldwide. Approximately 12% of the elderly people in

the community had malnutrition (Harris & Haboubi, 2005) whereas 50% of the

old age home residents were found to be malnourished (Volkert et al., 2011). The

adverse outcomes of malnutrition are dehydration, constipation, pressure sore,

infection, hospitalization, etc.

1.3 Objectives and Significance

The insertion of NG tube is a basic nursing procedure and qualified nurses

should have gained relevant knowledge and skills from preregistration training.

There is no exception to AED nurses, who have at least three years of clinical

experience before entering the department. If AED nurses are allowed to initiate

NG tube replacement for patients in stable condition prior to medical

consultations, it will certainly shorten the LOS in AED for these patients and

minimize consequential risks and complications of malnutrition.

The development of nurse-led care has escalated worldwide since 2000,

which helps modernize health services and reform healthcare roles and

professional boundaries (Richardson & Cunliffe, 2003). Many studies have proven

6

that nurse-initiated interventions targeting stable or minor injured patients were

safe and able to achieve the same level of effectiveness in comparison to doctor-

led care (Sharples et al., 2002; Cooper et al., 2002; Antic et al., 2009). Therefore,

the purpose of this systematic review was to explore and appraise nurse-initiated

care practiced in various healthcare settings.

1.3.1 Research Questions:

1. How effective are nurse-initiated interventions in improving patient

outcomes in various healthcare settings?

2. What is the relationship between the effectiveness of nurse-initiated

interventions and the levels (or year) of experience of nurse

interventionists?

1.3.2 Objectives of the Dissertation:

1. To review the current literature on the effectiveness of nurse-led

interventions in various healthcare settings

2. To develop an evidence-based protocol of nurse-initiated nasogastric tube

replacements for stable patients admitted to AED

3. To assess the transferability and feasibility of implementing a nurse-

initiated nasogastric tube replacement protocol in AED

4. To develop implementation strategies , and

5. To develop an evaluation plan of the effectiveness of the proposed nurse-

initiated intervention in AED

7

CHAPTER 2

CRITICAL APPRAISAL

2.1 Identification of Studies

A search strategy was designed to identify and collect as many relevant

publications as possible for the review. A systematic search was conducted in July

2012 with the use of four electronic databases, namely MEDLINE, CINAHL,

Cochrane Library and British Nursing Index. The following search terms “nurse-

led”, “nurse-initiated”, “training” and “effect$” were used in combination or

separately. Reference lists from all the eligible studies were scrutinized and

searched manually for additional clinical trials. Duplicated articles were removed.

2.1.1 Inclusion and Exclusion Criteria

Articles were included if they were randomized controlled trials (RCT)

published between January 2000 and July 2012. Eligible studies were limited to

English with full text available. Specialty qualification or relevant training for

nurse interventionists prior to trials had to be mentioned. Studies with

interventions targeting mental patients were excluded since mental patients are not

classified as in stable condition and they risk becoming violent and uncooperative.

Education and promotion-focused studies were also excluded as this integrated

review emphasized the effectiveness of nurse-led practices in various healthcare

settings, rather than patient education or health promotion.

8

2.1.2 Data Extraction

Data of the selected articles were extracted and organized in an evidence

table, which facilitated a more comprehensive and systematic analysis. The table

included bibliography, study design and level of evidence, number and

characteristics of patients, intervention, comparison between intervention group

and control group, length of follow-up, outcome measures and effect size. Studies

were listed according to the year of publication in an ascending order.

2.1.3 Appraisal Strategy

The quality of the selected studies was appraised with the use of a

methodology checklist for RCTs, which was developed by Scottish Intercollegiate

Guidelines Network (SIGN). The appraisal was divided into two sections. The

first section referred to the level of internal validity of the studies, whereas the

second section focused on the overall assessment of the studies.

2.2 Results

The initial search retrieved 1,994 abstracts. Fifty-three articles with full

text were identified, of which 19 duplicates were removed and 26 articles did not

met the selection criteria. Two articles were further identified from reference lists

of relevant studies. Ultimately, ten eligible articles were selected. The results of

the literature search and selection process were summarized in Appendix A.

9

2.2.1 Study Characteristics

Most of the eligible studies (n=9) were carried out in Western countries,

namely, the UK (n=5), the Netherlands (n=1), Sweden (n=1), the USA (n=1),

Australia (n=1). Only one study was carried out in Hong Kong. Six studies took

place in hospital settings. The remaining four studies took place in out-patient

clinics. Seven studies were single-centered whereas three were carried out in

multiple sites. Evidence of the each study was summarized using the evidence

table in Appendix B and analyzed with the PICO approach.

2.2.1.1 Types of Participants (P)

The demographic characteristics of participants were addressed in all

selected studies. Almost all participants were aged 18 or above, except in two

studies (Cooper et al, 2002; Baumann et al., 2008), where the participants were

aged 16 or above and 36 months or below respectively. All participants were

recruited in response to the aim of each study, whose medical conditions fulfilled

the requirements of the trials.

2.2.1.2 Types of Interventions (I)

Interventions were divided into two types, which were nurse-led follow-

ups (Blue et al., 2001; Sharples et al., 2002; Antic et al., 2009; Strand et al., 2011)

and nurse-initiated treatments (Shum et al., 2000; Cooper et al., 2002; Kinley et

al., 2002; Derksen et al., 2007; Baumann et al., 2008; Ho et al., 2012). The

durations of interventions ranged from five hours to two years.

10

Nurse-led follow-ups (n=4) included physical examinations, blood tests

ordering and radiographic investigations. Furthermore, nurses in general practice

were authorized to issue prescriptions and referrals to other clinics with doctor’s

approvals (Shum et al., 2000) and to adjust the setting of continuous positive

airway pressure (CPAP) for patients with obstructive sleep apnea (OSA) (Antic et

al., 2009).

As for the nurse-initiated treatments (n=6), not only did the nurses perform

physical assessments, order blood tests and radiographic investigations and issue

referrals, but they also diagnosed and treated eligible patients with minor injuries

(Cooper et al., 2002; Derksen et al., 2007). In Ho et al.’s study (2012), nurses

initiated the administrations of albuterol puffs for patients with COPD

exacerbations during triage assessments. Moreover, the nursing role extended to

preoperative assessments which included history taking, physical examinations

and tests ordering (Kinley et al., 2002). In Baumann et al.’s study (2008), nurses

initiated the use of volumetric ultrasound to measure the diameters of transverse

bladders before performing urinary catheterizations for eligible participants.

2.2.1.3 Types of Comparisons (C)

Comparisons between the intervention group and the control group were

made in each study. The intervention group referred to patients who were

allocated to nurse-led care, whereas the control group received usual practice or

doctor-led treatments. Three out of ten studies (Blue et al., 2001; Baumann et al.,

2008; Ho et al., 2012) compared nurse-led practice to usual practice. The other

seven studies (Shum et al., 2000; Cooper et al., 2002; Kinley et al., 2002; Sharples

11

et al., 2002; Derksen et al., 2007; Antic et al., 2009; Strand et al., 2010) performed

comparisons between nurse-led interventions and doctor-led practice.

2.2.1.4 Types of Outcome Measures (O)

All selected studies measured outcomes in three dimensions, i) clinical

outcomes (Shum et al., 2000; Baumann et al., 2008; Antic et al., 2009; Strand et

al., 2011; Ho et al., 2012) such as improved health status in patients, accuracy of

diagnosis made by nurse interventionists, decreased hospital admission rate, ii)

patient satisfaction (Shum et al., 2000; Cooper et al., 2002; Sharples et al., 2002;

Derksen et al., 2007; Antic et al., 2009; Strand et al., 2011) from reduced waiting

time and more information and advice given by nurses, and iii) cost effectiveness

(Sharples et al., 2002; Strand et al., 2010) relating to the labor cost of nurses and

cost of extra blood tests or radiographic investigations ordered by nurses.

2.2.2 Summary of Methodological Issues

The ten eligible studies were RCTs yet varied in methodological quality.

The results of quality assessment for each study were summarized in Appendix C.

A focused research question was addressed appropriately at the beginning

of each study, which was essential to identify its objectives. Randomization and

measurement were employed and performed by personnel involved in neither the

recruitment of participants nor the administration of interventions. The methods of

randomization were documented clearly in most studies and were achieved with

the use of computer (Blue et al., 2011) or block randomization (Shum et al., 2000;

Kinley et al., 2002; Sharples et al., 2002; Derksen et al., 2007; Baumann et al.,

2008; Antic et al., 2009; Strand et al., 2011; Ho et al., 2012). In Cooper et al.’s

12

study (2002), the method of randomization was not documented, yet the

concealment method was addressed. The risk of selection bias regarding the

sequence generation processes among studies was low.

Concealment was applied to all studies. The varying methods were clearly

documented in most of them. Seven studies used sealed envelopes with sequenced

numbering (Shum et al., 2000; Cooper et al., 2002; Kinley et al., 2002; Sharples et

al., 2002; Baumann et al., 2008; Strand et al., 2011; Ho et al., 2012). Two studies

employed the use of computers to achieve concealment (Blue et al., 2001; Derksen

et al., 2007). In Antic et al.’s study (2009), the concealment method was not

addressed, yet the author claimed that selection was done by personnel not

involved in the clinical area. The risk of selection bias related to the adequacy of

allocation concealment was low.

Blinding of interventions was infeasible in all studies as participants were

aware of or informed about the treatments they were receiving. Study results

might thus be strained by the Hawthorne effect. It refers to a risk of alteration in

the behavior of the interventionists or participants, eventually influencing the

outcome measures in studies (Polit & Beck, 2004, p. 180). Risks of performance

and detection bias were therefore higher.

The demographic characteristics of participants and sample sizes were

addressed in all studies, and no significant difference was found between the

intervention groups and control groups. In addition, authors in all studies clearly

stipulated the inclusion and exclusion criteria of the recruitment of participants.

Positive clinical outcomes in all studies were generated by using

standardized, validated and reliable measurements including the patients’ self-

rating scale (Shum et al., 2000), the Short Form 36 Health Survey (SF-36)

13

(Sharples et al., 2002; Antic et al., 2009), the Visual Analogue Scale (VAS)

(Strand et al., 2011) and the Epworth Sleepiness Scale (ESS) on health status

improvement (Antic et al., 2009), number of deaths and hospital readmissions

recorded by the hospital admission department (Blue et al., 2001), final clinical

judgment by senior consultants on the accuracy of diagnosis (Cooper et al., 2002;

Kinley et al., 2002; Derksen et al., 2007), improved clinical parameters in forced

expiratory volume in 1 second (FEV1) (Sharples et al., 2002), urine volume

(Baumann et al., 2008) and peak flow rate (PFR) (Ho et al., 2012).

Six studies addressed patient satisfaction (Shum et al., 2000; Cooper et al.,

2002; Sharples et al., 2002; Derksen et al., 2007; Antic et al., 2009; Strand et al.,

2011). The satisfaction rates were measured by the use of self-completed

questionnaires. The satisfaction questionnaire (Shum et al., 2000; Derksen et al.,

2007; Antic et al., 2009) measured the impression of professional care, depth of

relationship with health providers and quality of explanation or advice given. The

patient satisfaction questionnaire (Cooper et al., 2002) and SF-36 (Sharples et al.,

2002; Antic et al., 2009) focused on the physical and social functioning, mental

health, vitality, pain and general health status. VAS (Strand et al., 2011) assessed

the overall satisfaction with nurse-led follow-ups.

Cost-effectiveness was assessed in three studies (Sharples et al., 2002;

Antic et al., 2009; Strand et al., 2011). All expenses on resource utilization related

to care, which included labor cost, laboratory tests, radiographic investigations,

outpatient visits and hospital admissions, were recorded and summarized by the

hospital accounting departments.

The dropout rate of patients in each trial was well documented, ranging

from 0% to 20.6%. Some studies had a high dropout rate of more than 20% (Shum

14

et al., 2000; Cooper et al., 2002), in which mailed questionnaires were used to

measure patient satisfaction. It was obvious that questionnaires which required

return by post had higher dropout rates than those using other means of collection

(Cooper et al., 2002). In Sharples et al.’s study (2002), the dropout rate was only

0.5% since a research assistant was assigned to ensure the completion of the

questionnaires by participants on site. The risk of attrition bias was therefore

significantly higher in studies with high dropout rates.

Three studies were carried out at multiple sites (Shum et al. 2000; Antic et

al., 2009; Kinley et al., 2002). In Kinley et al.’s study (2002), the researchers

performed a separate analysis on the outcome measures collected from three

different hospitals. The results between sites varied due to the inconsistency

practiced by nurse interventionists in history taking, physical examinations, and

tests ordering, which consequently led to the risk of performance bias.

The overall quality of the each study was rated according to the coding

system established by SIGN. Five studies were ranked as 1++ (Cooper et al.,

2002; Kinley et al., 2002; Baumann et al., 2008; Antic et al., 2009; Ho et al.,

2012) indicating most of the criteria in the checklists were fulfilled, whereas the

remaining five studies were ranked as 1+ (Shum et al., 2000; Blue et al., 2001;

Sharples et al., 2002; Derksen et al., 2007; Strand et al., 2010), as some criteria

were not fulfilled or inadequately described. Nevertheless, the outcomes were not

thought to be significant enough to alter the positive conclusion of evidence-based

nurse-led practice.

15

2.3 Summary and Synthesis of Data

According to the Institute of Medicine, quality of care is defined as “the

degree to which health services for individuals and populations increase the

likelihood of desired health outcomes and are consistent with current professional

knowledge” (Lohr, 1990, p.4). The quality and effectiveness of nurse-led practice

were the main subjects of investigation in all selected studies. Such practice was

evaluated in terms of clinical outcomes, cost effectiveness and patient satisfaction.

2.3.1 Clinical Outcomes

Nurse-led practice was found to have improved patient outcomes

significantly in all studies, which were indicated by the positive changes in

patients’ self-rated health status (Shum et al., 2000), FEV1 parameters (Sharples et

al., 2002), ESS scores and improved CPAP adherence (Antic et al., 2009), reduced

attempts of urinary catheterization (Baumann et al., 2008), PFR, oxygen saturation

level and perception in dyspnea (Ho et al., 2012).

Hospital readmission rate and waiting time for consultation were

significantly lowered. The reduction in hospitalization (Blue et al., 2001; Sharples

et al., 2002) ranged from 13.1 % to 28.4% while the reduction in waiting time for

consultation (Cooper et al., 2002; Derksen et al., 2007; Ho et al., 2012) ranged

from 29.9% to 34.3%.

2.3.2 Cost-effectiveness

The unit cost of management and labor cost of nurse-led practice were

measured and suggested to be lowered in three studies (Sharples et al., 2002;

16

Antic et al., 2009; Strand et al., 2011). The overall cost of these trials was

significantly higher than usual care led by doctors. The additional cost included

the increased duration of time spent in follow-up visits, inpatient admissions and

medication prescriptions (Sharples et al., 2002), plus the cost of laboratory tests

and radiographic investigations ordered by nurses (Antic et al., 2009; Strand et al.,

2011). The cost saved from labor cost of nurses was thus offset. Nevertheless, the

extra utilization of resources was found to be necessary in maintaining medical

safety and ensuring accuracy of diagnosis. It was suggested that the extra cost was

compensated when consultants were eventually freed up to see new and clinically

demanding patients, and cost savings would likely accrue if nurse-led practice was

to be implemented more generally (Sharples et al., 2002; Antic et al., 2009).

2.3.3 Patient Satisfaction

The level of patient satisfaction was found to be significantly higher in

nurse-led intervention groups in all studies. Studied participants were satisfied

with the length of consultation (P<0.001) and professional care (P=0.018) and

found nurses’ advice and explanation being useful and adequate (P=0.001) (Shum

et al. 2000; Cooper et al., 2002; Derksen et al., 2007; Antic et al., 2009). Two

studies further pointed out that the courtesy and kindness of nurses encouraged

patients to express more personal opinions and discuss their health conditions

(Cooper et al. 2002; Strand et al. 2011). In other words, the nurse-patient

relationship was promoted, which subsequently enhanced patients’ well-being.

17

2.3.4 Characteristics of Nurse Interventionists

Nurse interventionists in the ten reviewed studies were either experienced

staff who had at least six years of working experience in the study settings (Shum

et al., 2000; Kinley et al., 2002; Derksen et al., 2007; Baumann et al., 2008; Strand

et al., 2011; Ho et al., 2012) or staff who had attained specialty qualifications in

the areas where they worked (Blue et al., 2001; Cooper et al., 2002; Sharples et

al., 2002; Antic et al., 2009). Hence, interventions initiated by nurses who have

either advanced knowledge or clinical experience were more likely to improve the

clinical outcomes.

2.3.5 Nature of Training

The provision of training prior to implementing the intervention was

proven to be essential in all selected trials. Apart from the advanced clinical

knowledge and experience, training provided for nurse interventionists prior to the

nurse-led practice was taken into account in the studies. Scopes of training

included consolidating the knowledge on anatomy and physiology (Kinley et al.,

2002; Derksen et al., 2007), physical examinations (Kinley et al., 2002; Sharples

et al., 2002; Strand et al., 2011), laboratory tests and radiographic interpretations

(Kinley et al., 2002; Sharples et al., 2002; Derksen et al., 2007; Baumann et al.,

2008; Strand et al., 2011), operations of medical equipment like CPAP setting

(Antic et al., 2002) and sonographic imaging & measurement (Baumann et al.,

2008), according to the nature of interventions of each trial. Nevertheless, in Antic

et al.’s study (2009), no additional training was offered to the nurse

interventionists who were considered experienced in the management of OSA and

CPAP. The mean number of years of clinical experience was 8.3. Positive clinical

18

outcomes, cost effectiveness and patient satisfaction were accomplished in the

intervention group of the study (Antic et al., 2009).

2.3.6 Evidence-based Recommendations

In Ndosi et al.’s study (2011), nurse-led intervention referred to “a model

of care where nurses practice at an extended role, assume their own patient case

loads and perform nursing interventions which include monitoring of patients’

condition, psychosocial support and referring appropriately”. This model of care

was applicable to the healthcare settings of selected studies. Given the high level

of evidence on the effectiveness of nurse-led interventions provided to patients in

stable condition, it is believed that NG tube replacement initiated by experienced

and well-trained nurses prior to medical consultation would be beneficial to AED

attenders with stable vital signs in the local setting.

Despite NG tube insertion being a basic nursing procedure, it still carries

certain risks for patients admitted to AED should they not be carefully assessed

prior to the initiation of the intervention. Differences in anatomical and

physiological structures, complex and non-specific underlying medical problems

among patients could affect the intervention. The existing guideline on NG tube

insertion focuses mainly on procedural information whereas its contraindications

and precautions are not sufficiently described. Thus, it is necessary to develop a

comprehensive nurse-initiated NG tube replacement protocol in AED, which

should include the selection criteria for patient recruitment, the new workflow, as

well as precautions and related risk management for the practice.

Advanced and appropriate training should be provided prior to the

implementation in order to ensure consistent and safe practice among AED nurses.

19

The content of training should include the introduction of the nurse-initiated NG

tube replacement protocol and workflow, consolidation of anatomic and

physiologic knowledge, physical assessment and the knowledge and skills of

radiographic interpretation on confirming tube placement.

The promotion of patient’s well-being is essential in nursing practice.

Holistic patient care is always the priority, ranked above economic concerns. Not

only does nurse-led practice allow nurses to provide timely treatments and care to

patients, but it also lightens the workload of doctors, allowing them to spend more

time treating patients in critical condition, particularly in AED setting. If

appropriate training is provided to nurses, they are capable of delivering care of

the same high quality as usual practice led by doctors to stable patients. The nurse-

initiated intervention for patients admitted for NG tube dislodgement is likely to

generate more value-added clinical outcomes and promote a better health service

system than the current practice for the society.

20

CHAPTER 3

TRANSLATION & APPLICATION

3.1 Implementation Potential

Nurse-initiated intervention is suggested to be as safe and effective as

doctor-led practice, for stable or minor injured patients. The integrated review in

the previous chapter has demonstrated the positive outcomes of nurse-initiated

practice in various healthcare settings in terms of clinical outcomes, cost

effectiveness and patient satisfaction. Coupled with the provision of training prior

to the practice, the nurse-initiated intervention is potentially applicable and

beneficial to patients in AED.

Initiating NG tube replacement by AED nurses is suggested to be valuable

to patient care in terms of minimizing their LOS and facilitating the workflow in

the department. Such intervention should be assessed for its transferability,

feasibility and cost/benefit ratio, before being put into practice in the local setting.

3.1.1 Target Population and Clinical Setting

Patients who are admitted to AED for NG tube dislodgment will first be

assessed their suitability for the intervention by nurses. Adult patients with stable

vital signs are eligible for the intervention. However, they will be excluded from

the intervention if they have underlying complications. Selection criteria regarding

patient recruitment were illustrated in the nurse-initiated NG tube replacement

protocol in Appendix D. Approximately 200 patients are admitted for NG tube

dislodgment in the local AED annually, with a quarter of them requiring overnight

21

hospital stay. The main reasons behind hospital admissions are prolonged waiting

time in AED and lack of transportation services for the frail group due to the

delayed treatment.

3.1.2 Transferability of the Findings

According to the findings from the ten selected studies, the mean age of

the targeted patients ranged from 36.8 to 76.4 in nine studies, with one study

focusing on pediatric patients. Most of the patients suffered from minor illnesses

or injuries (n=5) or chronic illnesses (n=4), with only one study targeting a

population undergoing pre-operative assessment. All of them had stable vital

signs. Nurse interventionists either had more than five years of clinical experience

(n=6) or had attained specialty qualifications in their own settings (n=4).

Designated trainings were provided for nurse interventionists prior to

implementations of the programs accordingly, which included the consolidation of

the knowledge on anatomy and physiology (Shum et al., 2000; Blue et al., 2001;

Kinley et al., 2002; Derksen et al., 2007), physical examinations (Kinley et al.,

2002; Sharples et al., 2002; Strand et al., 2010; Ho et al., 2012), laboratory tests

and radiographic interpretations (Cooper et al., 2002; Kinley et al., 2002; Sharples

et al., 2002; Derksen et al., 2007; Baumann et al., 2008; Strand et al., 2011).

NG tube dislodgement alone is not a life-threatening condition. When

these adult patients present no other medical complications, in other words, when

their vital conditions are stable, they share similar characteristics with participants

in the selected studies. In the local AED, all staff nurses had at least three years of

clinical experience and more than half of them had attained emergency nursing

specialty qualification. Therefore, they should be qualified to be the

22

interventionists once appropriate training is provided to them. Such training to

AED nurses should include the consolidation of initial physical assessment and

techniques of NG tube insertion, as well as the induction of radiographic

interpretation knowledge and skills.

3.1.3 Feasibility

There are various practical concerns about the potential of implementation,

including the availability of staff and resources, the support and assistance from

colleagues and the hospital plus the potential for clinical evaluation (Polit & Beck,

2004, p. 690). These are all essential components to assess the feasibility of

implementing the nurse-initiated practice in the department. Planning for clinical

evaluation will be specified in the next chapter.

3.1.3.1 Availability of Staff and Resources

The staffing pattern in each shift is evenly assigned on the basis of clinical

experience. During daytime, two Advanced Practice Nurses (APN) act as the

duty-in-charge with an addition of six to eight Registered Nurses (RN) are

assigned to specialized areas like triage, wound management, mental healthcare

and advanced life support. In the night shift, nursing intensity is lower with one

APN and four RNs providing clinical services. The staffing pattern provides

adequate nursing manpower to implement the nurse-initiated practice and ensures

the availability of support and guidance from senior nurses.

NG tube insertion is a basic nursing procedure, yet practice variation

among nurses is expected due to the differences in clinical background. For

example, those who have previously worked in pediatric wards are expected to be

23

less competent in NG tube insertion for adults. In order to standardize the

procedure, all nurses (n=56) are required to attend a one-hour basic training

workshop at the end of a morning shift by rotation and three identical sessions will

be held in AED. Such arrangement will not interfere with the clinical services in

the department. In addition, two identical sessions of three-hour advanced training

workshops will be given to all APNs and senior nurses with a minimum of ten

years of clinical experience (n=25). With their clinical expertise and the additional

training provided on radiological interpretation, they can be the assessors to ensure

correct tube placements.

3.1.3.2 Potential Barriers

Barriers should be identified at an early stage in order to facilitate the

implementation and ongoing evaluation for the new practice. The potential

barriers can be classified as nurse-related and organization-related.

Nurse-related barriers refer to their attitudes towards evidence-based

practice. The diversity of educational background, level of clinical experience and

personal characters among nurses are decisive for implementing the intervention.

In order to minimize practice variation and optimize clinical competency among

nurses, it is crucial to establish a standardized workflow of NG tube replacement

in AED and provide staff with training, as well as to organize regular staff

meetings which help to facilitate better communication. Participation in the

training session(s) will be made compulsory for all AED nurses, hence, time-off

compensation will be granted by the department at a time which causes minimal

interruption to the manpower allocation and clinical services provision.

24

The organization climate in the local setting is conducive for research

utilization. In order to optimize the quality of service delivery, medical

profession’s support is a significant impetus to the development (Lloyd Jones,

2005). Therefore, collaboration among multidisciplinary health professionals who

are stakeholders of the system is suggested. Nevertheless, inconsistent

expectations and a lack of role clarity among stakeholders are barriers to the

implementation (Titler, 2007). For this matter, well-defined roles and

responsibilities of stakeholders should be emphasized and regular meetings should

be held during the implementation. Details of the communication plan are

discussed in the next chapter.

For local AED services, a multidisciplinary approach has been well

established for providing efficient emergency care, like trauma team activation

and contingency management. Thus, once the proposed nurse-initiated NG tube

replacement program is approved, a multidisciplinary committee will be formed to

develop the new practice protocol. Core members will include the Chief of

Service (COS), the AED Consultant, the Consultant Radiologist, the Department

Operations Manager (DOM), the Ward Manager (WM) and the project

coordinator. The COS, DOM and WM are administrators of the department, they

will act as advisors for setting the inclusion and exclusion criteria for patient

recruitment. The AED Consultant and the Consultant Radiologist will provide

training to nurses. The project coordinator is responsible for the design, planning

and communication with stakeholders. All team members are readily available in

the setting and committed to provide high quality emergency services to patients,

hence willing to contribute towards the research utilization and the

implementation of this new practice.

25

3.1.4 Cost/Benefit Ratio of the Implementation

The assessment of cost and benefits of the practice is an essential part for

the planning of implementation. Cost analysis should be carried out to determine

whether the clinical benefits of the implementation outweigh the monetary cost in

patients, staff and the organization aspects (Polit & Beck, 2004, p. 228).

3.1.4.1 Patients Aspect

Timely nurse-initiated care for patients admitted for NG tube dislodgement

is valued in shortening the LOS in AED and preventing a delay of feeding regime.

Nevertheless, possible risks for the implementation have to be taken into account.

Tube placement performed with improper techniques can be traumatizing to

patients (Pancorbo-Hidalgo et al., 2001, Yardley et al., 2010). An evidence-based

guideline is therefore essential to provide clear instructions for nurses on how to

conduct a comprehensive baseline assessment for potential patients. To further

reduce the risks for patients, the number of NG replacements will be limited to no

more than two attempts (Bankhead et al., 2009). If it fails after two trials, patients

will be referred back to the Senior Medical Officers (SMO) for reassessment.

3.1.4.2 Staff Aspect

The prolonged LOS in AED for patients admitted for NG tube

dislodgement would definitely increase healthcare staff’s workload in terms of the

need of constant surveillance (Grant et al., 2012). Adult patients who require

enteral nutritional support are subjected to a certain degree of functional decline

and are highly dependent in their daily activities such as personal hygiene,

positioning and transportation. According to the local AED statistics from January

26

2011 to December 2011, most patients were fit for discharge after the NG tube

replacement, but more than 20% of them may need an overnight stay in the

department due to the unavailability of non-emergency ambulance transfer service

for discharge after 8pm (AEIS, 2012). This unnecessary hospital stay of the frail

attenders creates additional burden to AED staff and hence lowering their morale.

The proposed nurse-initiated practice can consolidate staff nurses’ clinical

knowledge, enhance problem-solving skills and minimize the practice variation

upon training. It can further increase nursing autonomy, promote staff satisfaction

and strengthen interdisciplinary relationships through the implementation and

evaluation processes.

3.1.4.3 Organization Aspect

To implement this new practice in AED, certain resources will be required

at the organizational level, in particular manpower cost for providing and

receiving training, time-off compensation for staff, and material cost for

developing the evidence-based protocol and teaching materials. Details of the

expenses were presented in Appendix E. Although initiating the new practice may

be costly in the short-term, it is believed to shorten the LOS of patients and hence

lower the hospital cost on patient surveillance, additional treatments and

unnecessary overnight stay. Resources can therefore be reallocated to patients in

unstable condition who are in greater need of care and treatment. In the long run,

it is a cost-saving practice for the department as well as for the healthcare system.

The estimated saving from this nurse-initiated intervention totals at more than

HKD118,800 annually, as analyzed in Appendix F.

27

Nurse-initiated NG tube replacement for patients in AED can promote

higher quality emergency nursing services in managing stable patients. Medical

staff can thus be freed up to treat patients in critical or life-threatening conditions.

Hence, it creates a positive workplace environment within the department.

3.2 Evidence-based Protocol

Six recommendations were derived from the literature review of the ten

eligible studies and graded accordingly using the grading system developed by

Scottish Intercollegiate Guidelines Network (SIGN) in Appendix G. The grade of

recommendation was determined by the strength of evidence of the reviewed

studies and the applicability to the procedures of the nurse-initiated NG tube

replacement for stable patients in AED. The selected studies provided high levels

of evidence in regard to the effectiveness of nurse-led care for stable patients and

the significance of providing prior training to nurse interventionists. Hence, all

recommendations were classified as grade A. The evidence-based

recommendations are the core of the nurse-initiated NG tube replacement

protocol, which comprise the i) provision of prior training to AED nurses, ii)

development of patient assessment form of the protocol, iii) initiation of baseline

physical assessment for eligible patients and iv) radiographic verification by

trained AED nurses, v) collaboration with senior medical staff and vi) ongoing

evaluation of the implementation by the project coordinator.

28

A. Preparation of nurses for implementing the new practice

Recommendation 1: To provide one-hour basic training workshop for all nurses

and three-hour advanced training workshop for all APNs and senior nurses.

(Grade A)

Evidence: Scopes of training in the selected studies included consolidating the

knowledge on anatomy and physiology (Kinley et al., 2002 [1++]; Derksen et al.,

2007 [1+]), physical examinations (Kinley et al., 2002 [1++]; Sharples et al., 2002

[1+]; Strand et al., 2011 [1+]), laboratory tests and radiographic interpretations

(Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+];

Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++]; Strand et al., 2011 [1+]),

operations of CPAP setting (Antic et al., 2009 [1++]) and sonographic imaging &

measurement (Baumann et al., 2008 [1++]) according to the nature of

interventions in each trial. The duration of such trainings ranged from 30 minutes

to 12 months.

Recommendation 2: To develop patient assessment form for standardized

documentation of the nurse-initiated NG tube replacement. (Grade A)

Evidence: Documentation methods used in the selected studies were nursing notes

which recorded patients’ vital signs (Blue et al., 2001 [1+]; Cooper et al., 2002

[1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+]; Derksen et al., 2007

[1+]; Baumann et al., 2008 [1++]; Strand et al., 2011 [1+]), laboratory tests and

radiographic findings (Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++];

Sharples et al., 2002 [1+]; Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++];

Strand et al., 2011 [1+]) and referrals (Shum et al., 2000; Cooper et al., 2002

[1++]; Antic et al., 2009 [1++]). The content of documentation in these studies

29

provided vital information of patient care, clinical service management, as well as

data necessary for the evaluation of the implementation of nurse-led care.

B. Baseline assessment for eligible patients

Recommendation 3: To perform baseline assessment to identify eligible patients

in stable condition according to the selection criteria. (Grade A)

Evidence: Baseline assessments included obtaining patients’ medical history and

vital signs in order to identify eligible participants in stable condition for related

care in each of the selected study (Shum et al., 2000 [1+]; Blue et al., 2001 [1+];

Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+];

Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++]; Antic et al., 2009 [1++];

Strand et al, 2011[1+]; Ho et al., 2012 [1++]).

C. Risk reduction strategies for NG tube placement

Recommendation 4: To initiate radiographic verification by AED nurses.

(Grade A)

Evidence: Two studies (Cooper et al., 2002 [1++]; Derksen et al., 2007[1+])

showed that there was no significant difference of the number of patients being

appropriately ordered for x-ray (56.6% vs. 47.5%, P = 0.2) and accuracy in

radiographic interpretations (91% vs. 97%, P = 0.29) by nurses or doctors upon

appropriate training.

30

Recommendation 5: To collaborate with senior medical staff for reassessing the

radiographic interpretations by AED nurses. (Grade A)

Evidence: Reassessments of radiographic interpretations (Cooper et al., 2002

[1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+]; Derksen et al., 2007

[1+]; Baumann et al., 2008 [1++]; Strand et al., 2011 [1+]) by senior medical staff

were required during the implementation of nurse-led practice.

D. Evaluation of nurse-initiated intervention

Recommendation 6: To organize ongoing evaluations of clinical outcomes every

three months. (Grade A)

Evidence: Clinical outcomes included the improvement of patients’ health status

(Sharples et al., 2002 [1+]; Antic et al., 2009 [1++]; Strand et al., 2011 [1+]; Ho et

al., 2012 [1++] ), reduced LOS in the clinical settings (Blue et al., 2001 [1+];

Derksen et al., 2007 [1+]; Antic et al., 2009 [1++]; Strand et al., 2011 [1+]; Ho et

al., 2012 [1++] ), accuracy of physical examinations (Shum et al., 2000 [1+]; Blue

et al., 2001 [1+]; Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++]; Sharples et

al., 2002 [1+]; Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++]; Antic et al.,

2009 [1++]; Strand et al, 2011[1+]; Ho et al., 2012 [1++]) and radiographic

interpretations by trained nurses (Cooper et al., 2002 [1++]; Derksen et al., 2007

[1+]), as well as increased job satisfaction (Sharples et al., 2002 [1+]; Cooper et

al., 2002 [1++]; Derksen et al., 2007 [1+]). Time intervals of evaluations ranged

from one month to one year among the selected studies.

31

CHAPTER 4

IMPLEMENTATION PLAN

Implementing evidence-based practice (EBP) requires conceptual models

to help organize strategies and clarify variables such as the beliefs and behaviors

of stakeholders, which may influence the adoption of the practice (Titler, 2007).

The diffusion of innovations theory (Rogers, 2003) and Advancing Research and

Clinical practice through close Collaboration (ARCC) model are therefore utilized

to guide the implementation of the new practice into clinical setting.

4.1 Communication Plan

In order to facilitate the implementation of the EBP, stakeholder analysis

should be conducted. According to Freeman (1984, p.46), stakeholders are defined

as “any group or individual who can affect or is affected by the achievement of the

organizational objectives.” It is crucial to identify all potential stakeholders and

balance their expectations for the new practice, as this reflects how they are

motivated to support the proposed changes (Peltokorpi, 2008).

4.1.1 Identification of the Stakeholders

The identification of stakeholders is the first step of the implementation

(Shirey, 2012). In the local AED, the stakeholders are administrators, the project

coordinator and all frontline clinical staff. Administrators are COS, DOM and

WM, who are prime decision makers in the department. The project coordinator is

32

in charge of the design, planning, coordination and communication throughout the

implementation period whereas frontline clinical staff refers to medical officers

and nurses of all levels who will carry out the intervention.

4.1.2 Process of Communication

In order to translate the evidence into clinical practice, the diffusion of

innovations theory (2003) is adopted as a guide to facilitate communication with

stakeholders. It stated that “individuals with strong leadership are highly

influential and committed to innovative changes in the organization” (Rogers,

2003, p. 137). They would therefore encourage others to adopt changes and hence

facilitate the development of new innovations.

Administrative support has been significantly linked to the diffusion of

EBP in an organization (Delamaire, M & Lafortune, G., 2010). Hence,

administrators in AED will first be approached through email and face-to-face

communication by the project coordinator in order to get preliminary support. If

administrators show interest in the implementation, the project coordinator will

proceed to organize a meeting with them. The negative impacts of prolonged LOS

on patients admitted for NG tube dislodgement and the evidence of effective

nurse-initiated interventions for stable patients, which includes improved clinical

outcomes, increased patient and staff satisfaction as well as cost-efficiency, will

be reported and discussed in the meeting. Accordingly, the proposed

implementation of the new practice will be presented in order to seek the

necessary approval. Once an approval is granted by administrators of the

department, they will be invited to serve as advisors for the continuous process of

development and the revision of the new practice. Training for AED nurses of all

33

levels and regular meetings with stakeholders will be organized in sequence. The

timeline of the implementation was illustrated in Appendix H.

Two-way communication is beneficial for facilitating the implementation

among all parties involved. During the 12-month implementation period, meetings

with advisors and APNs will be organized by the project coordinator every three

months, whereas meetings with RNs will be held every six months. Feedbacks

from all stakeholders will be discussed in the meetings and adopted as necessary

to refine the implementation. In the meantime, staff will be frequently updated on

any revisions made to the protocol through emails and change-of-shift reporting.

4.1.3 Implementation Strategies

The ARCC model (Melnyk & Fineout-Overholt, 2012) is adopted in

planning for the implementation strategies. It was originally conceptualized in

1999 as a framework for implementing and sustaining EBP in healthcare settings.

The key mechanism of the model is an EBP mentor. The EBP mentor refers to an

APN, who is competent and knowledgeable to make clinical judgments

effectively. The EBP mentor can therefore assist nursing staff and medical officers

in consolidating their EBP knowledge and skills as well as implementing EBP

projects (Lancaster-Bowie, 1998). In the local AED, APNs are educated at the

master’s level and have at least ten years of clinical experience in emergency

settings. Moreover, they are responsible for facilitating and evaluating clinical

staff development, which make them most suitable as EBP mentors.

To ensure the quality and efficiency of the new practice implementation, a

series of training programs will be provided to all nursing staff. Training materials

and content will be designed and prepared by the project coordinator in alliance

34

with the AED Consultant and Consultant Radiologist. Three identical one-hour

training workshops will be provided to nurses of all levels in the department. The

proposed evidence-based protocol, its workflow and the new emergent format of

documentation will be introduced. Two identical three-hour advanced training

workshops will be offered to APNs and senior RNs, in which mentoring and

radiographic interpretation knowledge and skills will be covered. Upon the

completion of the advanced training, APNs and senior RNs will be tested on

radiographic interpretation. The test contains 20 chest radiographs of post NG tube

insertions. Results will be reviewed by the Consultant Radiologist and a 100%

accuracy in interpreting all radiographic images is mandated. In order to ensure

clinical competency among APNs and senior RNs, additional tutorial session(s)

will be provided to those who fail to meet the requirement by the Consultant

Radiologist, until they meet the passing criterion before carrying out the task.

4.2 Pilot Study Plan

A six-week pilot run will be carried out prior to the full implementation of

the program, which targets at recruiting a maximum of 20 patients. Eligible

patients will be screened during the triage assessment by AED nurses. Once the

patient is recruited, the nurse will initiate NG tube replacement and order chest

radiograph. APNs or senior RNs are responsible for interpreting and documenting

the radiographic findings. Finally, all results will be reassessed by SMOs. This

pilot run provides an opportunity for conducting the proposed EBP on a smaller

35

scale in order to test and revise the logistics, as well as evaluating the

effectiveness of the training program.

The key objective of the nurse-initiated NG tube replacement intervention

is to minimize the LOS of eligible patients in AED. In order to evaluate its

effectiveness, it is necessary to test the logistics of the new workflow by

scrutinizing the appropriateness of the inclusion and exclusion criteria set for

patient recruitment, the total time required for the whole procedure of NG tube

replacement under the new practice, the potential difficulties in carrying out the

intervention, and/or the additional resources required for the change of practice.

The effectiveness of the training program will continuously be evaluated

during the pilot study period. The project coordinator monitors the applicability

and sustainability of the new knowledge and skills implemented by AED nurses,

particularly competency in radiographic interpretation and compliance in

documentation in the newly developed patient assessment form.

A formal meeting will be conducted by the project coordinator at the end

of the pilot testing. This aims at collecting feedbacks and understanding the

attitudes of stakeholders regarding the protocol implementation. Nurse and doctor

representatives of different ranks will be invited to participate in the meeting. The

logistics of the practice, potential difficulties of the clinical application and their

workload will be discussed and evaluated in order to determine the need of

providing additional training or supporting resources prior to the full

implementation. They are encouraged to share their own ideas and opinions at the

meeting for the refinement of the evidence-based protocol and logistics of the

implementation.

36

4.3 Evaluation Plan

The primary outcome of the proposed practice is a LOS reduction for

stable patients who are admitted for NG tube replacement in AED. The LOS is

defined as the total time patients spend in AED from initial registration until the

time of discharge from the department. Minutes will be used as the unit for time

measurement. The reduction of LOS enables the prevention of profound negative

impacts on these patients, such as altered nutrition, unnecessary hospitalization

and risk of nosocomial infection of patients who rely on artificial nutrition. Data

of LOS of these eligible patients will be retrieved from AED records. Secondary

outcome measures the level of accuracy in radiographic interpretations by APNs

and senior RNs. It is believed that the advancement of clinical skills and

knowledge empowers AED nurses to make professional judgments and promote

excellence in the care they provide. The level of accuracy in nurse-initiated

radiographic interpretation will be reassessed by SMOs. Other outcome measures

include stakeholder satisfaction levels and cost-effectiveness of the

implementation. Stakeholders’ satisfaction can be assessed during regular

meetings as their attitudes towards the implementation reflect the level of

acceptance of the practice. The operational cost and saving from the

implementation will be calculated and the data of all outcomes will be analyzed by

the project coordinator at the end of the 12-month implementation period.

4.3.1 Nature and Number of Clients to be Involved

The nurse-initiated NG tube replacement protocol targets adult patients in

stable condition requiring artificial nutrition. Exclusion criteria are recent history

37

of traumatic head injuries and neurological or gastrointestinal disorders. Details of

the selection criteria for patient recruitment can be referred to the nurse-initiated

NG replacement protocol in Appendix D.

The sample size calculation is based on the primary outcome from

measuring the LOS of stable patients admitted for NG tube replacement. Since

there is no previous study evaluating the outcomes of nurse-initiated NG tube

replacement in emergency departments, a nested cohort review from 1st July, 2011

to 1st July, 2012 in the local AED was performed. A total of 176 patients subjected

to NG tube dislodgements were identified. The median LOS [Interquartile range

(IQR)] was 162 minutes [95% CI: 104.5, 177.5] and 34% of patients were

discharged in 120 minutes or less. In order to achieve the targeted 16% increase to

bring the percentage of patients discharging in 120 minutes or less to 50%, a

statistical test for two proportions was used (Lenth, 2006). Assuming 80% power

and at a 5% level of significance, 127 patients will be required for the evaluation.

4.3.2 Data Collection and Outcomes Measurement

Patient’s demographic data, vital signs on arrival, LOS in AED can be

extracted from AED records.

Data of the radiographic interpretations of NG tube placement performed

by APNs or senior RNs and SMOs can be found in AED records and the newly

designed patient assessment forms. If the results from both parties are

inconsistent, the opinion of the Radiology Consultant, which has generally been

regarded as the “gold standard”, will be sought and taken as the final judgment

(Freji, Duffy, Hackett, Cunningham & Fothergill, 1996; Hardy & Barrett, 2003;

Free, Lee & Bystrzycki 2009).

38

Staff satisfaction levels towards the implementation will be continuously

evaluated during regular meetings held within the implementation period. The

sense of increased nursing autonomy, the consolidation of clinical knowledge and

skills related to NG tube insertion, as well as the enhancement of workflow

compared with the usual practice will be taken into account. The project

coordinator will encourage staff to give comments during the meetings.

Improving patient flow by reducing the LOS of patients in less acute

condition can bring substantial benefits in terms of cost, quality of care and staff

satisfaction (Johnson, 2012). Referring to the previous cost and benefit estimation

for implementing the new practice listed in Appendix E & F, more than

HKD118,800 can be saved. The reduction in hospital admission rate is suggested

to be the main source of saving. If the LOS of these eligible patients is shortened,

they are more likely to be discharged on the same day. Therefore, the

hospitalization rate will be lowered. Hospital admission data of the recruited

patients will be obtained from the hospital admission office and reviewed by the

project coordinator at the end of the 12-month implementation.

4.3.3 Statistical Analysis

Descriptive statistics will be used to examine patients’ demographic

characteristics and to generate mean and standard deviation for continuous

variables and number and percentage for categorical ones. The LOS will be

presented in terms of mean, median and interquartile ranges. The proportion of

patients being discharged in 120 minutes or less will be generated for comparison

with the previous cohort. The proportion of accuracy in radiographic

interpretations and the clinical experience among responsible APNs or senior RNs

39

will be analyzed by measuring the degree of association. Years of clinical

experience will be categorized into three groups, 10 to 15 years, 16 to 20 years

and 21 years or above. A chi-squared test will be used and a p-value ˂0.05 will

indicate statistical significance.

4.3.4 Basis for the Effective Change of Practice

The proposed new practice aims at reducing the overall LOS of patients

admitted for NG tube replacement in AED. If 50% or more of this population can

be discharged in 120 minutes or less, the implementation of the practice is

considered effective. Accuracy in radiographic interpretations by nurses in various

emergency settings had been found to vary markedly, ranging from 65% to 93%.

This discrepancy was suggested to be the result of a lack of standardization in

related training for health professionals (Free, Lee & Bystrzyckit, 2009). As for

the local AED, there is no related training on radiographic knowledge for nurses.

Therefore, the secondary objective which refers to the accuracy in radiographic

interpretations by nurses, will be achieved when 80% or more of patients have the

NG tube properly verified by APNs and senior RNs in AED.

40

CHAPTER 5

CONCLUSION

Emergency care strives for short term interventions in an attempt to halt

possible complications from illnesses or injuries (Considine et al., 2012). It also

ensures efficiency and high quality of critical care. Like other countries,

overutilization of AED services in Hong Kong has put a huge strain on the quality

of care and hospital facilities. In order to cope with the increasing healthcare

service demand, effective strategies should be identified to improve AED

workflow by reducing the LOS of patients with non-urgent complaints.

Nurse-initiated NG tube replacement is considered one of the measures in

shortening the LOS of stable patients in AED, as well as achieving a better

allocation of resources in the hospital by minimizing unnecessary admissions. It is

suggested that provided with specialty training and repetitive exposures, nurses’

radiographic interpretation skills and knowledge can be as competent as those of

medical officers (Swaby-Larsen, 2009; Hardy & Barrett, 2003; Free, Lee &

Bystrzycki, 2009). Consequently, nurse-initiated NG tube replacement for stable

patients can be implemented as common practice in AED. Medical officers are

thus allowed to focus on providing prompt and precise interventions for patients in

urgent and critical conditions. As a result, the extended scope of AED nursing

services will not only facilitate a higher quality of care, but also promote the

professional status of emergency nurses in the public.

41

Appendix A: Search History

Electronic Database

Keyword (s)

MEDLINE CINAHL Cochrane

Database

British nursing

index

1. (Nurse led OR Nurse initiated) 1721 687 57 1904

2. training 237289 237004 1507 6046

3. effect$ 4336138 12081 7620 11708

4. (1) AND (2) 1004 641 43 1788

5. (1) AND (3) 1467 796 55 1881

6. (4) AND (5) 723 479 36 756

Sub-total 1994

Search Items

Limited to “RCT” 9 45 4 76

Retrieve “full-text” records 3 23 1 26

After duplicates excluded 34

Full-texts articles reviewed for

eligibility (inclusion & exclusion

criteria)

12

Limited to publication year: 2000-2012 8

Hand search for relevant articles (+)2

Total 10

42

Appendix B: Table of Evidence

Bibliographic

citation

Study

type &

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Shum et al.,

2000)

RCT (1-) Eligible

patients

(n=2021),

206 patients

refused to

participate,

which in turn

1815 patients

in total.

Doctor group:

915

Nurse group:

900

No definite

inclusion criterion

is set, yet patients

were excluded if

they were <I year

old, pregnant;

having severe chest

pain/abdominal

pain/breathing

difficulties;

vomiting blood or

having

fits/blackouts.

Patients who were

temporary residents

and those with

literacy or language

difficulties were

also excluded.

Nurses managed the

patient’s care and

took the history,

performed a physical

exam, offered advice

and treatment, issued

prescriptions which

were approved by

doctors. Referrals to

doctors and routine

follow up were

offered by nurses

when appropriate.

The differences

of doctor group

and nurse group

in terms of

patients’

satisfaction and

clinical outcomes

4 months Patients’ satisfaction

(score from 0-100):

-General satisfaction

-Professional care

-Perceived time

Doctor Vs. Nurse

76.4 Vs. 78.6

(p=0.046)

76.7 Vs. 79.2

(p=0.049)

67.7 Vs. 73.3

(p<0.001)

Improved to cured:

(Doctor Vs. Nurse)

82.6%: 83%

General comment: Nurse led follow-up were well accepted by patients, and the positive clinical outcomes were significant. However, the longer time for consultation by

nurses might imply longer time for nurses to get along with the new service, and the content of patients’ satisfaction questionnaire was not illustrated.

43

Bibliographic

citation

Study

type &

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Blue et al.,

2001)

RCT (1+) Eligible

patient

(n=361),

177 (49%) had

left ventricular

systolic

dysfunction,

165 gave

consent and

were

randomized.

Intervention

Group (n=84)

Control group

(n=81)

-Patients who were

admitted as an

emergency to acute

medical admissions

unit, with heart

failure due to left

ventricular systolic

dysfunction

Planned home visit,

telephone contact,

and a pocket-sized

booklet of heart

failure information

were provided to

eligible patients.

Comparison of

death from all

causes or hospital

readmission

due to

worsening heart

failure between

the intervention

group and control

group

Comparison of

the % use of

angiotensin

converting

enzyme between

the intervention

group and the

control group

A mean of

12 months

-No. of death or

readmission from all

causes

-Readmission to

hospital for

worsening heart

failure

-No. of days in

hospital due to

worsening heart

failure

Control group Vs.

Intervention group

61: 52

HR: 0.72; p=0.075

(95% CI: 0.49 to

1.04)

26: 12

HR: 0.61; p=0.033

(95% CI: 0.38 to

0.96)

Median (days)

9: 8

General comments: The medication regimes were slightly different between control group and intervention group, i.e. Dosage use of beta blockers for heart failure. Yet

the main objective of this study is to examine the effectiveness of nursing intervention to facilitate treatments, therefore, the result was consistent.

44

Bibliographic

citation

Study

type &

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Cooper et al.,

2002)

RCT(1+) Eligible

patients

(n=214), with

10 declined to

participate

and 5 were

not seen by

the assigned

clinical

group.

-Total

patients

(n=199)

ENP led

group

(n=102)

SHO led

group

(n=102)

- aged > 16

- has sustained a

minor injury

which was within

the category of the

ENP protocol

Clinical assessment,

advice, X-ray

interpretation and

follow-up (if

indicated) were

provided to eligible

patients with minor

injury, by either

ENP or SHO

Patient

satisfaction,

quality of clinical

documentation,

unplanned

follow-up and

missed injuries

were compared

between ENP-led

care and the

predominant

SHO service

2 months

-Patient satisfaction

(response rate: 84%)

-Quality of clinical

documentation

(with 13 clinical

notes could not be

found, i.e. 93.5% is

assessed)

-Unplanned follow-

up

-missed injury

SHO-led Vs.

ENP-led

-87.8: 98.8(%)

-26.6/30: 28/30

(based on the

Documentation

Audit Tool)

-18.3% Vs. 21.5%

-1% Vs. 1%

General comments: The study population was sufficiently large to demonstrate higher levels of patient satisfaction and clinical documentation quality with ENP-led than

SHO-led care.

45

Bibliographic

citation

Study

type &

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Kinley et al.,

2002)

RCT(1+) Eligible

patients:

1907, of

whom 1874

completed the

study.

In the house

officer group

(control) arm:

926

In the nurse

group

(intervention)

arm: 948

All participants

attending for

assessment before

general anesthesia

for general,

vascular, urological

or breast surgery

Assessment by one

of three

appropriately trained

nurses or by one of

several

preregistration house

officers

-History taken

-physical

examination

-investigations

ordered

Measures were

evaluated and

graded in terms of:

“correct”,

“overassessment”,

“underassessment

not affecting

management” and

“underassessment

possibly affecting

management”

11 months

- No.(%) of cases

graded as

“underassessment

possibly affecting

management”

- No.(%) of

unnecessary tests

ordered

House officer arm

Vs. Nurse arm

14.9% Vs. 12.8%

24% Vs. 14%

General comments: The generality of clinical outcomes may questionable as the assessment of nurses’ performance was solely relied on the nurse interventionist, i.e. one

from each site. However, it was a good indicator for further training in the future.

46

Bibliographic

citation

Study type

&

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Sharples et

al., 2002)

RCT(1+) Eligible

patients

(n=109), 69

patients were

excluded due

to unsuitable,

not see and

refused.

The first 80

attenders

were

recruited.

Doctor-nurse

(n=41)

Nurse-doctor

(n=39)

- aged >18 with

bronchiectasis

confirmed by high

resolution CT scan

- Concurrently with

an established

treatment plan

(nurse practitioner

did not assess

newly referred

patients

independently)

In the nurse

practitioner led

clinic, patient

received routine

tests, clinical

assessment and

discussion of

management plan,

amendment of

treatment and further

investigations

ordered when

indicated.

Difference in

clinical measures

and cost

effectiveness

between nurse

practitioner led

and doctor led

care

Two year

(Two 1-

year

blocks of

crossover

care led

by either a

nurse

practitione

r or

medical

staff)

Primary measure

-FEV1 (%)

Secondary measure

-FVC (%)

-12minute walk (m)

-No. of readmissions

-Health related

quality of life (SF-36)

-Cost of care (mean

cost/patient)

Doctor-nurse Vs.

Nurse-doctor

70.3: 70.4

85.5: 87.0

758: 712

262: 238

23: 43

Overall cost:

£2711: £4208

Labor cost:

£217: £180

General comments: The authors addressed that nurse-led follow-up was effective to generate positive clinical outcome. However, the labor cost for nurses was lower; the

overall cost was exceedingly high for the group. No recommendation provided for the costly program. On the other hand, the return rate of questionnaire was reinforced

by researchers; the low dropout rate was maintained.

47

Bibliographic

citation

Study type

&

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Derksen et

al., 2007)

RCT (1+) Eligible

patients

(n=1348),

512 patients

were

included.

HO group

(n=249)

SEN group

(n=263)

- Aged 18-65

- Anke/foot injury

within 48 hours

- Mental/physical

condition which

complicated the

assessment of

injury, trauma that

required surgery

was excluded.

Nurse assessed the

participants

according to the set

algorithm, ordered

x-rays and provided

appropriated

treatment

accordingly, i.e. cast

or pressure bandage

Accuracy of

making diagnosis

and level of

patient satisfaction

between doctor-

led group and

nurse-led group.

8 months Primary Outcome:

-Diagnostic accuracy:

-Patient satisfaction:

-Waiting time:

HO Vs. SEN

Sensitivity:

0.78(0.57-0.91):

0.94 (0.78-0.99)

Nurses > Doctors

32 mins: 21 mins

General comments: The accuracy of making diagnosis was judged by trauma surgeon and the blinding in all kinds was not conducted throughout the study, however, all

these have no effect on the result of patient satisfaction.

(Baumann et

al., 2008)

RCT(1+) Total

patients: 93

The

conventional

are: 45

The

ultrasound

arm: 48

Children attended

to the ED who aged

≥36 months

requiring diagnostic

urine samples

(minimal amount

required for a

urinalysis and

culture was 2.5cm3

Urinary

catheterization with

the use of

conventional method

(non-imaged) or

ultrasound

The success rate

of first-attempt

conventional

catheterization

vs.

catheterizations

performed after

volumetric

ultrasound

11 months

-First-attempt success

rate

-Collection of

≥2.5cm3 urine

Conventional

group (%) vs.

ultrasound group

(%)

67% Vs. 92%

78% Vs. 100%

General comments: Lack of blinding in the study might affect the significance of the effects. However, it was confirmed that sonographic imaging was an effective means

to collect urine specimen successfully in the first attempt.

48

Bibliographic

citation

Study type

&

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Antic et al.,

2009)

RCT(1+) Eligible

patients

(n=195)

In Model A

(Nurse led),

n=100

In Model B

(Specialist

led), n=95

-Age 18-75 years

-Epworth

Sleepiness Scale

(ESS) score of 8 or

more

-history of snoring

“most nights” or

“every night”

-willing to trial

CPAP

Eligible patients in

Model A received

nursing intervention

according to the

“Nurse CPAP

Management

Protocol”. Routine

follow-up, phone

consultation and

extra reviews were

provided by the

trained nurse.

Comparison

between a

simplified

package of care

(nurse-led home

diagnosis and

CPAP therapy)

for patients with

moderate-severe

OSA and current

physician-led

best practice in

OSA

management.

3 months Primary outcome:

-Change in ESS score

-Patient satisfaction

with Model A was

greater than with

Model B in terms of:

-time waiting

-Information

provided

-Time spent with

health professionals

-Adequate

explanation

Model A Vs.

Model B

4.02 Vs. 4.15

(mean)

3.73 Vs. 3.759

p<0.05

3.73 Vs. 3.5

p=0.004

3.685 Vs. 3.468

p=0.011

3.82 Vs. 3.57

p=0.002

3.764 Vs. 3.544

p=0.008

General comments: The simplified and diagnostic and management model was proven to be effective in treating moderate-severe OSA patients and was not inferior to

current usual doctor-led practice. However, no comparison of nurses’ performance was made among the 3 chosen centers.

49

Bibliographic

citation

Study

type &

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Strand et al.,

2010)

RCT(1+) Eligible

patients

(n=113), with

3 refused to

participate

Surgeon

group (n=56)

Nurse group

(n=54)

- Curatively

operated for rectal

cancer

- aged >18

Follow-ups were

performed by trained

nurse or surgeon

according to the

same protocol,

including

assessment of bowel

function and

symptoms,

colorectal

examination and

blood samples

collection if

indicated.

- Patient

satisfaction

- Resource

utilization

- medical safety

Study

period:

57

months

Program

period:

Regular

visits

every six

months for

the first

three years

after

surgery

and

thereafter

once

yearly up

to five

years

1. Patient satisfaction

(VAS)

2. Resource

allocation

-Time for

consultation

-Extra blood samples

-Extra radiographic

investigation

3. Costs

-Costs for salary

including social costs

-Costs for laboratory

tests

-Costs for

radiography

Doctor Vs. Nurse

9.4: 9.5

(out of 10)

15: 23(mins)

p=0.001

4: 16(%)

p=0.003

2: 6(%)

p not available

46.4: 25.5

p<0.001

0.92: 4.08

p=0.014

7.22: 21.18

p=0.017

General comments: Patient satisfaction was higher in nurse-led group. However, the sample size was suggested to be too small to detect any rare clinical outcomes, i.e.

local recurrence or metastases.

50

Bibliographic

citation

Study

type &

evidence

level

Number of

patients

Patient

characteristics

Intervention(s) Comparison Length of

follow-up

Outcome measures Effect size

(Ho et al.,

2012)

RCT

(1++)

Eligible

patient

(n=122),

with 12

patient were

excluded

Albuterol

group

(n=55)

Control

group

(n=55)

-aged 18 or above

-Known COPD

Chinese patient

-previous use of

albuterol MDI

-competent to blow

the peak flow meter

-complaint od

dyspnea

For the eligible

patient in the

intervention group, 6

albuterol puffs via a

MDI were

administered by

nurse.

Comparison of

improvement in

signs and

symptoms of

acute

exacerbation of

COPD patients in

A&E department

with or without

nurse-initiated

albuterol meter

dose inhaler

between

intervention and

control groups.

6 weeks

Primary outcome:

-Change of PFR

(L/min) in the triage

station prior to

consultation,

measured by peak

flow meter with 3

attempts

Secondary outcome:

-Change of pulse

oximeter oxygen

saturation (SpO2, %)

-Respiratory rate

(breaths/minute)

-Heart rate

(beats/minute)

“During triage”

Vs. “Prior to

consultation”

88.6 Vs. 91

(mean)

p<0.001

93.6 Vs. 94.0

p<0.001

23.7 Vs. 23.3

p=0.067

97.7 Vs. 99.4

p=0.001

General comments: Hawthorne effect might induce due to no blinding upheld for the trial. However the results can apply to other AEDs in locally as the study site was

one of the acute hospitals in Hong Kong.

51

Appendix C: Appraisal Checklist for Randomized Controlled Trials,

SIGN

Study Identification:

Shum, C., Humphreys, A., Wheeler, D., Cochrane, M. A., Skoda, S., Clement, S. (2000).

Nurse management of patients with minor illnesses in general practice: multicentre,

randomized controlled trial. BMJ, 320:1038-1043

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered.

1.2 The assignment of subjects to treatment

groups in randomized

Well covered. Random permuted blocks

of four was adapted.

1.3 An adequate concealment method is used Well covered. Sequentially numbered,

non-resealed, opaque envelopes were used

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Not applicable.

1.5 The treatment and control groups are

similar at the start of the trial

Well covered. The recruitment and

exclusion criteria were clearly defined

1.6 The only difference between groups is the

treatment under investigation

Well covered. Patients were either seen by

practice nurse or doctor

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered. Tools for measuring

outcomes were identical

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

In the doctor group, 170 out of 915

patients dropped out before completion of

the study (withdrawn/ lost to follow-up),

i.e. 18.6%

In the nurse group, 184 out of 900 patients

dropped out before completion of the

study (withdrawn/ lost to follow-up), i.e.

20.4%

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered.

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Well covered. 5 general practices were

addressed in south east London and Kent.

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1+. No blinding in the studies, risks of

selection bias and performance bias

increased

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

52

Study Identification:

Blue, L., Lang, E., McMurray, J. J. V., Davie, A. P., McDonagh, T. A., Murdoch, D. R.,

Petrie, M. C., Connolly, E., Norrie, J., Round, C. E., Ford, I., Morrison, C. E. (2001).

Randomized controlled trial of specialist nurse intervention in heart failure. bmj323,715-718

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered.

1.2 The assignment of subjects to treatment

groups in randomized

Well covered.

1.3 An adequate concealment method is used Well covered.

Randomization was allocated by the

Robertson Centre for Biostatistics

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Not applicable.

1.5 The treatment and control groups are

similar at the start of the trial

Not applicable.

Although the eligible patients from the

two groups were having left ventricular

systolic dysfunction, their medication

regimes were not identical

1.6 The only difference between groups is the

treatment under investigation

Well covered.

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered.

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

8 patients died and 1 patient was transfer

out to convalescent setting out of 165

eligible patient, i.e. 5.5%

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered.

Patients who were assigned to usual care

would not be seen by specialist nurses

after hospital discharge.

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Not applicable.

The study is carried out in an acute

admissions unit of a teaching hospital in

UK, no comparison was made.

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1+

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

53

Study Identification:

Cooper, M. A., Linsay, G. M., Kinn, S., Swann, I. J. (2002) Evaluating emergency nurse

practitioner services: a randomized controlled trial. Journal of Advanced Nursing: 40(6),721-

730

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered.

1.2 The assignment of subjects to treatment

groups in randomized

Well covered.

Randomization assignment was done by

one of the authors who did not directly

involved in the clinical part of the trial

1.3 An adequate concealment method is used Well covered.

Opaque, sequentially numbered seal

envelopes were used

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Not applicable.

Patients were recruited to the trial only

when both the researcher and an ENP

were on duty

1.5 The treatment and control groups are

similar at the start of the trial

Well covered.

1.6 The only difference between groups is the

treatment under investigation

Well covered

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered.

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

In SHO-led group (n=102), 81 patients

completed and returned the questionnaire,

i.e. the dropout rate was 20.6%

In ENP-led group (n=102), 87 patients

completed and returned the questionnaire,

i.e. the dropout rate was 14.7%

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis)

Well covered. No participants requested

to change the clinical group

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Not applicable. The study is carried out in

the A&E department in UK.

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1++

2.2 Taking into account clinical

considerations, your evaluation of the

methodology used, and the statistical

power of the study, are you certain that the

overall effect is due to the study

intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

54

Study Identification:

Kinley, H., Czoski-Murray, C., George, S., McCabe, C., Primrose, J., Reilly, Wood, R.,

Nicolson, P., Healy, C., Read, S., Norman, J., Janke, E., Alhameed, H., Fernandes, N.,

Thomas, E. (2002). Effectiveness of appropriately trained nurses in preoperative assessment:

randomized controlled equivalence/ non-inferiority trial. BMJ;325: 7 December, 2002

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered

1.2 The assignment of subjects to treatment

groups in randomized

Well covered.

Block randomization was used

1.3 An adequate concealment method is used Well covered. Opaque sealed envelopes

were used

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Not applicable.

1.5 The treatment and control groups are

similar at the start of the trial

Well covered.

1.6 The only difference between groups is the

treatment under investigation

Well covered.

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered. Evaluation was done by

specialist registrar in anesthetics graded as

“correct”, “overassessement”,

“underassessment not affecting

management” and “underassessment

possibly affecting management”

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

In house officer (control) arm, 27 out of

953 patients dropped out, i.e. 2.8%;

In nurse (intervention) arm, 6 out of 954

patients dropped out, i.e. 0.6%

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered. If any cases which was

graded as “underassessment possibly

affecting management”, it would be

corrected by consultant panels without

bias in judgments.

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Well addressed. Baseline characteristics

of patients among the 4 NHS hospitals

were similar, comparison of nurses’

performance was examined

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1++

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

55

Study Identification:

Sharples, L. D., Edmunds, J., Bilton, D., Hollingworth, W., Caine, N., Keogan, M., Exley, A.

(2002). A randomized controlled crossover trial of nurse practitioner versus doctor led

outpatient care in a bronchiectasis clinic. Thorax, 57:661-666

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered.

1.2 The assignment of subjects to treatment

groups in randomized

Well covered. Blocks of length 4 and 6

were used.

1.3 An adequate concealment method is used Well covered. Numbered opaque

envelopes were used

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Not applicable

1.5 The treatment and control groups are

similar at the start of the trial

Well covered

1.6 The only difference between groups is the

treatment under investigation

Well covered.

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered. Clinical measures were

recorder by technicians independent of the

study.

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

In doctor-nurse group, 1 patient was died

before the completion of study, i.e. the

dropout rate was 0.2%.

In the nurse-doctor group, 1 patient died

and 1 patient was unable to complete the

test, i.e. the dropout rate was 0.5%

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered. 6 patients who received

doctor led care in the first block required

revised management plan, which unable

to proceed to nurse practitioner led care in

the second block

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Not applicable. The study is carried out in

the Lung Clinic in UK

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1+

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

56

Study Identification: Derksen, R. J., Bakker, F. C., Lange-de Klerk, E. S. M., Spaans, I. M., Heilbron, E. A., Veenings, B., Haarman, H. J. T. M. (2007). Specialized emergency nurses treating ankle and foot injuries: a randomized controlled trial. American journal of Emergency Medicine, 25: 144-151

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered

1.2 The assignment of subjects to treatment

groups in randomized

Well covered.

Randomization was conducted by

computer

1.3 An adequate concealment method is used Well covered.

Blocks of 20

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

No applicable

1.5 The treatment and control groups are

similar at the start of the trial

Well covered in the “Selection of

patients” session

1.6 The only difference between groups is the

treatment under investigation

Well covered

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered. A set algorithm was used.

Injuries were confirmed by X-rays.

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

In HO group, 21 patients lost to follow-

up, i.e. dropout rate is 8.0 %.

In SEN group, 16 patients lost to follow-

up, i.e. dropout rate is 6.4 %.

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered.

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Not applicable.

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1+

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

57

Study Identification:

Baumann, B.M., McCans, K., Stahmer, S. A., Leonard, M.B., Shults, J., Holmes, W. C.

(2008). Volumetric bladder ultrasound performed by trained nurses increases catheterization

success in pediatric patients. American Journal of Emergency Medicine; 26:18-23

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered

1.2 The assignment of subjects to treatment

groups in randomized

Well covered. Block randomization was

used

1.3 An adequate concealment method is used Well covered. Sequentially numbered

sealed packets were used

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Not application. Both the subjects and

investigators recognized each other at the

start of urine collection

1.5 The treatment and control groups are

similar at the start of the trial

Well covered. The subject characteristics

were clearly descripted in the article

1.6 The only difference between groups is the

treatment under investigation

Well covered.

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered. Measurement tools were

well-defined in the study

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

Well covered.

No participant dropped out at the first

attempt of urine catheterization. The

reattempt issue was not address as it was

out of the scope of study

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered.

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Not applicable. The study was carried out

in one emergency department

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1++

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

58

Study Identification:

Antic, N. A., Buchan, C., Esterman, A., Hensley, M., Naughton, M. T., Rowland, S.,

Williamson, B., Windler, S., Eckermann, S., McEvoy, R. D. (2009). A randomized controlled

trial of nurse-led care for symptomatic moderate-severe obstructive sleep apnoea. American

Journal of Respiratory and Critical Care Medicine, 179:501-508

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered.

1.2 The assignment of subjects to treatment

groups in randomized

Well covered. The randomization

sequence was undertaken by a third party

who did not involve in the trial.

1.3 An adequate concealment method is used Block randomization with block size of

20 was used within each center.

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Well covered.

All the questionnaires and measurements

were administered by research assistants

who had no involvement in the clinical

trial and were blinded to the patient

allocation

1.5 The treatment and control groups are

similar at the start of the trial

Well covered in “Participants” section

1.6 The only difference between groups is the

treatment under investigation

Well covered.

The nurse CPAP management protocols

were well descripted.

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered in “Outcome measures”

section

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

In Model A, 10 out of 100 patients

dropped out, i.e. 10%

In Model B, 11 out of 95 patients dropped

out, i.e. 12%

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered.

Data were analyzed using intention to

treat principles, given patients’

assignment and observed compliance

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

The clinical trial was carried out in three

centers in Australia. Results are

comparable among the three sites

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1++

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

59

Study Identification:

Strand, E., Nygren, L., Bergkvist, L., Smedh, K. (2010). Nurse or sugeon follow-up after rectal

cancer: a randomized trial. Colorectal disease;13:999-1003

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered

1.2 The assignment of subjects to treatment

groups in randomized

Well covered.

“Blocks of four” is used by stoma

therapist.

1.3 An adequate concealment method is used Well covered.

Closed envelope is used

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Well covered.

1.5 The treatment and control groups are

similar at the start of the trial

Well covered.

The demographic and clinical

characteristics of participants were

addressed in a table

1.6 The only difference between groups is the

treatment under investigation

Well covered.

Both groups were treated with the same

protocol

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered.

Outcomes are measured according to the

questionnaire done by patients after the

program

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

3 out of 113 patients refused to participate

the study, i.e. 2.7%

21 out of 110 patients died before the

completion of the study, i.e. 19%

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered.

No participants requested to change group

during the study period.

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Not applicable.

The study was carried out in the colorectal

unit of a hospital in Sweden

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1+

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

60

Study Identification:

Ho, J. K. M., Yau, W. H. (2012). Nurse-initiated albuterol metered-dose inhaler for acute

exacerbations of chronic obstructive pulmonary disease in an emergency department: a

randomized controlled trial. Hong Kong Journal of Emergency Medicine, 19(3):162-170

Study Design: Randomized controlled trial

INTERNAL VALIDITY

1.1 The study addresses an appropriate and

clearly focused question

Well covered.

1.2 The assignment of subjects to treatment

groups in randomized

Well covered. “Block of four”

randomization is used by the investigator.

1.3 An adequate concealment method is used Well covered. The allocation was

concealed in sequentially numbered

opaque envelopes

1.4 Subjects and investigators are kept ‘blind’

about treatment allocation

Not applicable. No blinding was used in

the study

1.5 The treatment and control groups are

similar at the start of the trial

Well covered

1.6 The only difference between groups is the

treatment under investigation

Well covered

1.7 All relevant outcomes are measured in a

standard, valid and reliable way

Well covered

1.8 What percentage of the individuals or

clusters recruited into each treatment arm

of the study dropped out before the study

was completed

Well covered.

No participant dropped out before the

completion of study

1.9 All the subjects are analyzed in the groups

to which they were randomly allocated

(often referred to as intention to treat

analysis

Well covered. The principle of intention-

to-treat was used to maintain the effect of

randomization

1.10 Where the study is carried out at more than

one site, result are comparable for all sites

Not applicable. The study was a single-

center RCT

OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimize

bias? Code ++, +, or -

1++

2.2 Taking into account clinical considerations,

your evaluation of the methodology used,

and the statistical power of the study, are

you certain that the overall effect is due to

the study intervention?

Yes

2.3 Are the results of this study directly

applicable to the patient group targeted by

this guideline?

Yes

61

Appendix D: Nurse-initiated Nasogastric Tube Replacement Protocol

in AED

I. Background

Emergency nursing care ranges from disease and injury prevention to life-

saving. The practice is unique for its high degree of coordination, swiftness,

individual competence and integration of independent roles in an interdependent

team effort. Meanwhile, AED nurses should be a generalist whose expertise

includes almost every basic specialty of nursing (Hospital Authority, 2010).

AED is the main source of care for patients in immediate life-threatening

or critical condition. However, it is estimated that over 70% of the attenders are

triaged into non-critical categories annually (AEIS, 2012). Such overutilization of

AED services results in prolonged AED stays for patients and overcrowded

working environment for staff. Among these 70% of AED attenders,

approximately 200 of them are admitted for NG tube replacement.

Despite NG tube insertion being a basic nursing procedure, tube

replacements cannot be initiated by AED nurses until medical consultations have

been performed. This may further prolong the LOS in AED and lead to subsequent

complications for these patients. In order to optimize clinical services, AED

nurses should play an active role in providing timely treatments for patients

admitted with minor illnesses or injuries based on evidence-based protocols.

Nurse-initiated interventions for patients in stable condition have been

proven to improve health outcomes in many studies worldwide. In order to shorten

62

patients’ LOS and promote AED efficiency, an evidence-based protocol of nurse-

initiated NG tube replacement is established.

II. Objectives

To standardize selection criteria for identifying eligible patients

To provide quick reference for risk management during NG tube insertion

To facilitate the workflow of NG tube insertion for AED attenders

III. Selection Criteria for Patient Recruitment

A. Inclusion Criteria

Aged over 18

Stable vital signs on AED arrival

Admitted for NG tube dislodgement

B. Exclusion Criteria

Recent history of head injury and/or signs of base of skull fracture

Respiratory symptoms, e.g. shortness of breath

Ear, nose and throat (ENT) disorder

Gastro-intestinal (GI) disorder

Abdominal pain/distention

Repeated vomiting and/or with presence of coffee ground vomitus

Bleeding tendency, e.g. anemia, thrombocytopenia

Decrease in level of consciousness

63

IV. Recommendations

A. Preparation of nurses for implementing the new practice

Recommendation 1: To provide one-hour basic training workshop for all nurses

and three-hour advanced training workshop for all APNs and senior nurses.

(Grade A)

Evidence: Scopes of training in the selected studies included consolidating the

knowledge on anatomy and physiology (Kinley et al., 2002 [1++]; Derksen et al.,

2007 [1+]), physical examinations (Kinley et al., 2002 [1++]; Sharples et al., 2002

[1+]; Strand et al., 2011 [1+]), laboratory tests and radiographic interpretations

(Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+];

Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++]; Strand et al., 2011 [1+]),

operations of CPAP setting (Antic et al., 2009 [1++]) and sonographic imaging &

measurement (Baumann et al., 2008 [1++]) according to the nature of

interventions in each trial. The duration of such trainings ranged from 30 minutes

to 12 months.

Recommendation 2: To develop patient assessment form for standardized

documentation of the nurse-initiated NG tube replacement. (Grade A)

Evidence: Documentation methods used in the selected studies were nursing notes

which recorded patients’ vital signs (Blue et al., 2001 [1+]; Cooper et al., 2002

[1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+]; Derksen et al., 2007

[1+]; Baumann et al., 2008 [1++]; Strand et al., 2011 [1+]), laboratory tests and

radiographic findings (Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++];

Sharples et al., 2002 [1+]; Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++];

64

Strand et al., 2011 [1+]) and referrals (Shum et al., 2000; Cooper et al., 2002

[1++]; Antic et al., 2009 [1++]). The content of documentation in these studies

provided vital information of patient care, clinical service management, as well as

data necessary for the evaluation of the implementation of nurse-led care.

B. Baseline assessment for eligible patients

Recommendation 3: To perform baseline assessment to identify eligible patients

in stable condition according to the selection criteria. (Grade A)

Evidence: Baseline assessments included obtaining patients’ medical history and

vital signs in order to identify eligible participants in stable condition for related

care in each of the selected study (Shum et al., 2000 [1+]; Blue et al., 2001 [1+];

Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+];

Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++]; Antic et al., 2009 [1++];

Strand et al, 2011[1+]; Ho et al., 2012 [1++]).

C. Risk reduction strategies for NG tube placement

Recommendation 4: To initiate radiographic verification by AED nurses.

(Grade A)

Evidence: Two studies (Cooper et al., 2002 [1++]; Derksen et al., 2007[1+])

showed that there was no significant difference of the number of patients being

appropriately ordered for x-ray (56.6% vs. 47.5%, P = 0.2) and accuracy in

radiographic interpretations (91% vs. 97%, P = 0.29) by nurses or doctors upon

appropriate training.

65

Recommendation 5: To collaborate with senior medical staff for reassessing the

radiographic interpretations by AED nurses. (Grade A)

Evidence: Reassessments of radiographic interpretations (Cooper et al., 2002

[1++]; Kinley et al., 2002 [1++]; Sharples et al., 2002 [1+]; Derksen et al., 2007

[1+]; Baumann et al., 2008 [1++]; Strand et al., 2011 [1+]) by senior medical staff

were required during the implementation of nurse-led practice.

D. Evaluation of nurse-initiated intervention

Recommendation 6: To organize ongoing evaluations of clinical outcomes every

three months. (Grade A)

Evidence: Clinical outcomes included the improvement of patients’ health status

(Sharples et al., 2002 [1+]; Antic et al., 2009 [1++]; Strand et al., 2011 [1+]; Ho et

al., 2012 [1++] ), reduced LOS in the clinical settings (Blue et al., 2001 [1+];

Derksen et al., 2007 [1+]; Antic et al., 2009 [1++]; Strand et al., 2011 [1+]; Ho et

al., 2012 [1++] ), accuracy of physical examinations (Shum et al., 2000 [1+]; Blue

et al., 2001 [1+]; Cooper et al., 2002 [1++]; Kinley et al., 2002 [1++]; Sharples et

al., 2002 [1+]; Derksen et al., 2007 [1+]; Baumann et al., 2008 [1++]; Antic et al.,

2009 [1++]; Strand et al, 2011[1+]; Ho et al., 2012 [1++]) and radiographic

interpretations by trained nurses (Cooper et al., 2002 [1++]; Derksen et al., 2007

[1+]), as well as increased job satisfaction (Sharples et al., 2002 [1+]; Cooper et

al., 2002 [1++]; Derksen et al., 2007 [1+]). Time intervals of evaluations ranged

from one month to one year among the selected studies.

66

V. Assessment for Nurse-initiated NG Tube Replacement in AED (Recommendation 2)

*Please put a “√” in the appropriate box

Name & signature of primary nurse Name & signature of supporting nurse

Remarks (if any):

Patient’s label 1. Capture the triage time:

2. Screen for eligibility for NG tube reinsertion

BP: P: SpO2:

Stable vital signs (Recommendation 3)

Unstable vital signs

Recent history of:

Head injury

Respiratory symptoms, e.g. SOB

Nasopharyngeal disorders

Gastrointestinal disorders

Abdominal pain/distention

Repeated vomiting (?coffee ground)

Bleeding disorder

Decrease in level of consciousness

Others:

________________________

**Refer patient to Senior Medical Officer if any

“√” in the above boxes

3. Capture end-waiting time:

4. Insert NG tube according to standard protocol

5. Document the procedure

No. of attempts: (max. 2)

Size of NG tube: Fr

Marking: cm

6. Confirm tube placement with pH value ≤5.5

Yes No (reason: _____________ )

7. Verify tube placement with x-ray by

APN/senior RN (Recommendation 4)

X-ray finding:

8. Reassessment by SMO (Recommendation 5)

X-ray finding:

67

VI. Risk Management Strategy for Verifying NG tube Placement

Check position of tube after insertion

Obtain aspirate 1-2ml

Yes No

pH ≤5.5 pH >5.5

If possible, turn patient onto side

Wait for 15-30 minutes and repeat aspiration

Check if patient on H2-blockers or proton-pump inhibitor

Repeatedly >5.5

Repeatedly no aspirate

Reinsert NG tube

X-ray verification by APN/senior RN

Reassess by SMO

Yes No

*Modified from National Health Services (NHS), 2005 & Hospital Authority, 2012

68

Appendix E: Estimated Cost of the Nurse-initiated Intervention

I. Estimated Man-Hours for the training of Nurse-initiated NG Tube Replacement Program

Nurses in AED Activity Time spent

(hour)

RN (<10 years clinical experience)

(n=26) Attend one-hour basic training workshop (3 identical sessions)

26

Sub-total 26

Senior RN (≥10 years of clinical

experience) (n=14) Attend one-hour basic training workshop

Attend three-hour advanced training workshop (2 identical sessions)

56

APN (n=10) 40

Sub-total 96

Project Coordinator (n=1) Presentation in basic training workshop (30 minutes/session)

Presentation in advanced training workshop (1 hour/session)

1.5

2

Sub-total 3.5

AED Consultant(n=1) Trainer of basic training workshop (30 minutes/session) 1.5

Consultant Radiologist (n=1) Trainer of advanced training workshop (1 hour/session) 2

Sub-total 3.5

Total 129

69

II. Estimated Operational Cost of Nurse-initiated NG Tube Replacement in AED

Staff Time Spent (hour) Cost (HKD)

RN (<10 years of clinical experience)* 26 5,018

Senior RN (≥10 years of clinical experience) ** 56 13,328

APN*** 40 12,000

Consultant (AED)**** 1.5 1,375.5

Consultant (Radiology)**** 2 1,834

Project Coordinator (RN) 3.5 675.5

Sub-total

Fixed cost

Medical equipment for NG tube insertion AED

provision

Other cost

Stationary AED

provision

Photocopying & printing:

Handout for training (3 pages): 60 sets

Checklist for the program (2 pages): 110 sets

90

110

Sub-total 200

Hidden cost

Venue & AV systems for training sessions Hospital

premises

Computers & software for data analysis Hospital

premises

Total 34,431

*Mean monthly salary of RN (HGPS Point 15-25): HKD33, 969

Monthly working hour: 176

Hourly salary: 33, 969/176 = HKD193

**Monthly salary of senior RN (HGPS Point 25): HKD41, 898

Monthly working hour: 176

Hourly salary: 41, 898/176 = HKD238

***Mean monthly salary of APN (HGPS Point 26-33A): HKD52, 861

Monthly working hour: 176

Hourly salary: 52, 861/176 = HKD300

****Mean monthly salary of Consultant in AED and Department of Radiology

(HGPS Point 50-53A): HKD146, 650

Monthly working hour: 160

Hourly salary: 146, 650/160 = HKD917

(Accounting Circular No. 14/2012, Hospital Authority)

70

Appendix F: Estimated Saving of the Nurse-initiated Intervention

Items Item Description Saving in Monetary Terms (HKD)

Reduction in Hospitalization Total no. of patients admitted with NG tube dislodgement

in AED: 176*

Total no. of hospitalization due to NEATS unavailable:

36**

In-patient charge: HKD3,300/day***

118,800

Reduction in time spent for

medical consultation

__ Cannot be estimated

Reduction in LOS**** in AED Mean LOS in usual practice: 3 hours

Estimated LOS in pilot scheme: 2 hours or less

Percentage reduction: 33.3% or more

Cannot be estimated

Total 118,800+

*Calculation is based on the number of AED patients admitted for NG tube dislodgment patients from July 2011 to July 2012.

**In-hospital statistics from July 2011 to July 2012

***In-patient charges for general wards, Hospital Authority Ordinance (Chapter 113), section 18 (1-2)

****Accident & Emergency Information System (AEIS) Statistic from July 2011 to July 2012

71

Appendix G: Levels of Evidence & Grades of Recommendation

LEVELS OF EVIDENCE

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort studies

High quality case control or cohort studies with a very low risk of confounding or bias and a high

probability that the relationship is casual

2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate

probability that the relationship is casual

2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the

relationship is not casual

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

GRADES OF RECOMMENDATION

A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly

applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the

target population, and demonstrating overall consistency of results

B A body of evidence including studies rated as 2++, directly applicable to the target

population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the target

population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

72

Appendix H: Timeline of the Implementation of Nurse-initiated Nasogastric Tube Replacement Protocol in AED

Task/Month Sept

2013

Oct

2013

Nov

2013

Dec

2013

Jan

2014

Feb

2014

Mar

2014

Apr

2014

May

2014

Jun

2014

Jul

2014

Aug

2014

Sept

2014

Oct

2014

Nov

2014

Dec

2014

Jan

2015

Feb

2015

Seek approval and support from administrators

Identify advisors and EBP mentors

Prepare training materials

Basic & advanced training workshops for nurses

Six-week pilot test

Two-week pilot test evaluation

12-month implementation

Regular meetings with advisors and EBP

mentors

Regular meetings with RNs

Data collection and entry

Data analysis

Formulate the final report

73

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