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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