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Background Patient Morbidity with Chest Drains:
Tissue Erosion at Drain Site
• Patient/family concerns - tissue erosion at drain site
• “Sacred-cow practices”
• Knowledge deficits or gaps
• Variability in nursing practice for drain stabilization,
manipulation, and maintenance (Charnock, 2001; Wallen et al., 2002)
• Surgeon RCT comparing drain types (chest tube vs.
Blake drain)
Objectives • Demonstrate positive impact of implementing an
evidence - based practice guideline on patient
outcomes in patients with pediatric chest drains
• Align practice with research findings, clinical
expertise, and patient values
• Standardize interim care of chest drains, eliminating
unnecessary nursing practice variability as the reason
for drain failure and the morbidity of tissue erosion at
the drain site regardless of drain type
Sample • Pre-guideline group of 80 patients
• 21 Neonates (26% of sample)
• 100 % with conventional chest tubes
• 5 of 21 patients with Grade IV assessments(23%)
• Post-guideline group of 61 patients
• 25 Neonates (40% of sample)
• 60% with conventional chest tubes
• 40% with Blake drains
• 2 of 25 patients with Grade IV assessments (8%)
Project Results
• Presence of stabilization device (guideline component)
and drain size were statistically significant factors in
skin grade outcome (p <0.001)
• Presence of stabilization device and drain duration
were found to be predictors of skin outcome
• Presence of Blake drain found to have some protective
effect with a larger sample size likely to yield a more
definitive conformation
Evaluation • “Sacred-cow” practices not easily abandoned despite
the evidence
• Complexity of healthcare environment/competing
agendas
• Nurse work-arounds
• Difficulty in applying guideline to neonates with an
open sternum
• Incorporation of Rogers’ (2003) Theory of Diffusion of
Innovations to help drive project with PhD laggard
Conclusion • Evidence-based practice is a journey, not a destination
(IOM, 2011)
• Nurse led (DNP project), physician championed,
patient/family driven project promoted care
standardization and improved skin integrity at drain site
• Guideline revision to address neonates with an open
sternum
Evidence Translation: Implementation of An Evidence Based Practice Guideline
For Interim Care of Pediatric Chest Drains Kathy Drescher, MSN, APRN, CNS-CC, CPNP
Kenneth Lowrance, DNP, APRN, FNP-BC, NEA-BC
Dennis Cheek, PhD, RN
Zach Mueller, DNP, RN, NEA-BC
Eric N. Mendeloff, MD
Purpose
The purpose of this project was to implement an evidence-based practice guideline for interim care of pediatric
chest drains to standardize care and improve outcomes related to patency, manipulation, and maintenance.
Findings
Methods
• Iowa Model of Evidence-Based Practice and
Implementation Research Model served as
guiding frame work for project (Titler & Moore, 2010)
• Literature review and evidence classification
according to Melnyk and Fineout-Overholt’s
(2005) Level of Evidence Hierarchy
• Project merged with surgeon’s study
comparing drain types, Project approval from
IRBs (TCU and North Texas IRB at Medical
City) and Guideline approval by facility’s
Practice Council
• Team (physician partners, nursing colleagues,
patients/families) educated on the guideline
• Retrospective chart audits - 3-month sample
(pre-guideline) compared with 3-month
sample post-guideline group
• Guideline measured by utilization of a Bard
StatLock stabilization device on the outcome
variable of tissue erosion at drain entry site
Effect Odds Ratio 95% CI p Value
Group
(SD+/-)
0.023 [<0.001, 0.588]
0.023
Drain type
(Blake vs.
CT)
3.931
[0. 115, 133.965]
0.447
Age per
day
increase Age per 10 day
increase
0.999
0.990
[0.965, 1.034]
0.953
Drain per
day
increase Drain per 10 day
increase
1.018
1.20
[1.002, 1.035]
0.029
Size (Fr.) 0.960 [0.539, 1.717] 0.890
Effect Odds Ratio 95% CI p Value
Group
(SD+/-)
0.244 [0.058, 1.025]
0.0541
Drain type
(Blake vs.
CT)
0.295
[0. 029, 2,214]
0.2350
Age per
day
increase Age per 10 day
increase
0.999
0.99
[0.998, 1.000]
0.0303
Drain per
day
increase Drain per 10 day
increase
1.028
1.32
[1.016, 1.039]
<0.0001
Size (Fr.) 0.876 [0.542, 1.417] 0.5905
Logistic Regression Analysis: Effect of Predictor Variables
on Skin Outcome (Irritated vs. Good for Total Sample)
Logistic Regression Analysis: Effect of Predictor Variables
on Skin Outcome (Irritated vs. Good for 0-90 Day Group)
Special thanks to Morley A Herbert, PhD for help with
statistical analysis and interpretation of findings
References
• Briggs, D. (2010). Nursing care and management of patients with intrapleural drains. Nursing Standard,
24(1), 47.55.
• Charnock, Y. (2001). The nursing management of chest drains: A systematic review. The Joanna Briggs
Institute for Evidenced Based Nursing and Midwifery, 16, 1-93.
• Institute of Medicine (IOM). (2011). Clinical practice guidelines we can trust. Washington, DC: National
Academies Press.
• Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide
to best practice. Philadelphia: Lippincott Williams & Wilkins.
• Rogers, E. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.
• Titler, M., & Moore, J. (2010). Evidenced-based practice: A civilian perspective. Nursing Research,
59(1S), S2-S6. doi: 10.1097/NNR.0b013e3181c94ec0
• Wallen MA, Morrison AL, Gillies D, O'Riordan E, Bridge C, Stoddart F. Mediastinal chest drain clearance
for cardiac surgery (2002). Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.:
CD003042. DOI: 10.1002/14651858.CD003042.pub2
Blake Drain
Conventional
Chest Tube
Tissue Erosion at
Drain Site
Bard StatLock Device