Foundations of Inquiry

Full Answer Section

• • Delayed functional recovery: Reduced early mobility can hinder muscle strength recovery, balance, and overall functional independence, potentially impacting their ability to return to pre-operative activity levels.
  • Increased pain: Prolonged bed rest can exacerbate pain and stiffness.
  • Psychological impact: Patients experiencing delayed recovery may feel frustrated, anxious, or depressed.
  • Reduced quality of life: A slower recovery can negatively impact their overall quality of life and ability to participate in daily activities.

• Impact on the Organization:

  • Increased healthcare costs: Longer hospital stays translate to higher costs for bed occupancy, nursing care, medications, and resources.
  • Increased risk of hospital-acquired conditions (HACs): Higher rates of DVT, PE, pneumonia, and pressure ulcers can lead to financial penalties and reputational damage for the organization.
  • Decreased bed availability: Prolonged stays reduce the availability of beds for new surgical patients, potentially leading to scheduling backlogs and decreased revenue.
  • Increased nursing workload: Managing complications associated with delayed ambulation requires more nursing time and resources.
  • Lower patient satisfaction: Patients experiencing prolonged recovery and complications may report lower satisfaction with their care.

B1. PICO Components:

Based on the clinical practice problem of delayed ambulation in postoperative adult patients following elective hip replacement surgery:

• P (Patient, Population, or Problem): Adult patients (≥ 18 years old) who have undergone elective hip replacement surgery.
• I (Intervention): Implementation of a standardized early ambulation protocol (defined as mobilization out of bed within 24 hours post-surgery with progressive increases in activity).
• C (Comparison): Usual care (variable timing and approach to postoperative ambulation as determined by individual surgeon or nursing preference).
• O (Outcome): Reduced incidence of postoperative complications (DVT, PE, pneumonia, pressure ulcers), decreased length of hospital stay, and improved functional mobility at discharge.

B2. Evidence-Based Practice (EBP) Question:

For adult patients undergoing elective hip replacement surgery (P), does the implementation of a standardized early ambulation protocol (I), compared to usual care (C), lead to a reduced incidence of postoperative complications and decreased length of hospital stay (O)?

C. Evidence Appraisal of a Research-Based Article

(Note: As a large language model, I cannot access and select a specific article. For the purpose of this exercise, I will create a hypothetical scenario based on a likely research article addressing the EBP question.)

Let's assume the following hypothetical research-based article was selected:

Article Title: "The Impact of a Standardized Early Ambulation Protocol on Postoperative Outcomes Following Elective Hip Arthroplasty: A Randomized Controlled Trial"

Authors: Smith et al.

Journal: Journal of Arthroplasty, 2023

C1. Background or Introduction (Purpose):

The introduction of this hypothetical article likely begins by highlighting the established benefits of early ambulation following major surgery in general. It then focuses specifically on elective hip arthroplasty, acknowledging the potential for postoperative complications and prolonged recovery. The authors likely state that variability exists in postoperative ambulation practices and argue for the need to investigate the impact of a standardized early ambulation protocol on reducing complications and length of stay in this specific patient population. The purpose of the study, as stated in the introduction, would be to evaluate the effectiveness of a standardized early ambulation protocol, initiated within 24 hours post-surgery, compared to usual care, on the incidence of postoperative complications (DVT, PE, pneumonia, pressure ulcers) and length of hospital stay in adult patients undergoing elective hip arthroplasty.

C2. Research Methodology:

The hypothetical article states it used a randomized controlled trial (RCT) design. This methodology involves randomly assigning eligible adult patients undergoing elective hip arthroplasty to one of two groups:

• Intervention Group: Received care following a standardized early ambulation protocol, which likely details specific timelines and progressive activity levels initiated within 24 hours post-surgery, guided by nurses and physical therapists.
• Control Group: Received usual postoperative care, where the timing and extent of ambulation were determined by the surgeon's orders and nursing assessment, without a specific standardized protocol.

The study likely specified the inclusion and exclusion criteria for participants (e.g., age range, type of hip replacement, pre-existing conditions). Data would have been collected prospectively on the incidence of the defined postoperative complications and the length of hospital stay for both groups.

C3. Level of Evidence (JHNEBP Model):

Using the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, a well-conducted randomized controlled trial (RCT) is considered Level I evidence. This is the highest level of evidence as it involves random assignment to control for confounding variables and aims to establish a cause-and-effect relationship.  

C4. Data Analysis:

The researchers in this hypothetical article would have analyzed the collected data using statistical methods appropriate for comparing outcomes between the two groups. This would likely include:

• Descriptive statistics: Calculating means, standard deviations, and frequencies to describe the characteristics of the participants in each group and the incidence of outcomes.
• Inferential statistics: Using statistical tests such as chi-square tests or Fisher's exact tests to compare the incidence of postoperative complications between the intervention and control groups. T-tests or Mann-Whitney U tests would likely be used to compare the mean length of hospital stay between the groups.
• Analysis of variance (ANOVA) or regression analysis: These might be used to control for potential confounding variables if baseline characteristics differed significantly between the groups or to explore the influence of other factors on the outcomes.
• The researchers would have reported p-values and confidence intervals to determine the statistical significance and clinical relevance of their findings.

C5. Ethical Considerations:

A well-conducted RCT would have addressed several ethical considerations:

• Institutional Review Board (IRB) approval: The study would have received approval from the IRB to ensure the protection of human subjects.
• Informed consent: Participants would have been fully informed about the study's purpose, procedures, potential risks and benefits, and their right to withdraw at any time before providing written consent.  
• Confidentiality and anonymity: Participant data would have been kept confidential and, where possible, anonymous.
• Justice: The selection of participants would have been fair and equitable.
• Equipoise: The researchers would have a genuine uncertainty about which intervention was more beneficial at the start of the trial.

If no ethical considerations were explicitly mentioned, the critique would need to state this as a limitation and discuss the importance of these elements in research involving human subjects.

C6. Quality Rating (JHNEBP Model):

According to the JHNEBP model, the quality rating for a Level I (RCT) study is based on factors such as:

• Study design: Was the RCT rigorously conducted with appropriate randomization, blinding (if possible), and control for bias?
• Sample size: Was the sample size adequate to detect a clinically significant difference?
• Data analysis: Were appropriate statistical methods used?
• Control of confounding variables: Were potential confounding factors addressed in the design or analysis?
• Clarity of reporting: Were the methods and results clearly described?
• Attrition rate: Was the dropout rate acceptable, and were the reasons for attrition discussed?

Based on these criteria, the hypothetical RCT would be rated as High Quality (A) if it met most or all of these criteria with minimal limitations, Good Quality (B) if it had some limitations that did not seriously compromise the results, or Low Quality (C) if it had significant flaws that could invalidate the findings.

C7. Analysis of Results or Conclusions:

The results section of the hypothetical article would present the findings of the statistical analyses, comparing the incidence of postoperative complications and the length of hospital stay between the early ambulation protocol group and the usual care group.

C7a. How the Article Helps Answer the EBP Question:

If the results of this hypothetical RCT showed a statistically significant reduction in the incidence of postoperative complications (e.g., lower rates of DVT, PE, and pneumonia) and a statistically significant decrease in the mean length of hospital stay in the early ambulation protocol group compared to the usual care group, then the article would provide strong Level I evidence supporting the implementation of a standardized early ambulation protocol for adult patients undergoing elective hip replacement surgery. The findings would directly answer the EBP question by demonstrating the benefits of the intervention (early ambulation protocol) on the identified outcomes (reduced complications and length of stay) in the specified population (adult hip replacement patients) compared to the usual care control group.

D. Evidence Appraisal of a Non-Research-Based Article

(Note: Again, I will create a hypothetical scenario for a non-research-based article.)

Let's assume the following hypothetical non-research-based article was selected:

Article Title: "Implementing an Early Ambulation Program After Hip Arthroplasty: A Quality Improvement Initiative"

Authors: Jones and Brown

Journal: Orthopaedic Nursing, 2024

D1. Background or Introduction (Purpose):

The introduction of this hypothetical non-research-based article likely discusses the known benefits of early mobilization after surgery and highlights the challenges and variability in achieving consistent early ambulation in their institution following hip arthroplasty. The authors might mention anecdotal observations of prolonged hospital stays and postoperative complications. The purpose of this article would be to describe the implementation and outcomes of a quality improvement (QI) project aimed at standardizing and promoting early ambulation (within 24 hours) for adult patients after elective hip replacement surgery within a specific hospital setting.

D2. Type of Evidence:

The type of evidence used in this hypothetical article is a quality improvement (QI) project. QI projects involve systematic efforts to improve processes and outcomes within a specific healthcare setting. They often involve implementing changes and then measuring the impact of those changes over time.  

D3. Level of Evidence (JHNEBP Model):

According to the JHNEBP model, a quality improvement project is generally considered Level III: Non-experimental study. While it involves data collection and analysis, it typically lacks the rigorous control and randomization of experimental research designs like RCTs. The findings are often specific to the context in which the QI project was conducted.

D4. Quality Rating (JHNEBP Model):

The quality rating for a Level III (QI project) would be based on factors such as:

• Clarity of objectives: Were the goals of the QI project clearly defined?
• Description of the intervention: Was the early ambulation protocol clearly described?
• Data collection methods: Were appropriate methods used to collect data on relevant outcomes (e.g., time to first ambulation, length of stay, complications)?
• Data analysis: Were appropriate methods used to analyze the data and identify trends?
• Measurement of outcomes: Were the outcomes clearly defined and measured?
• Sustainability plan: Was there a plan for sustaining the improvements achieved?

Based on these criteria, the hypothetical QI project could be rated as High Quality (A) if it was well-designed and implemented with clear objectives, rigorous data collection and analysis, and a plan for sustainability, Good Quality (B) if it had some limitations in the design or implementation, or Low Quality (C) if it had significant flaws that limit the reliability of the findings.

D5. How the Author’s Recommendations Help Answer the EBP Question:

The authors' recommendations in this hypothetical QI project would likely be based on the observed outcomes following the implementation of their early ambulation protocol. If they found a decrease in the time to first ambulation, a trend towards reduced length of stay, or a lower incidence of certain complications after implementing the standardized protocol, their recommendations would likely support the adoption of similar standardized early ambulation protocols in other settings. They might discuss specific strategies that facilitated successful implementation, such as staff education, standardized documentation, interdisciplinary collaboration, and patient education. These practical insights from a real-world implementation can provide valuable guidance and support the findings from the research-based article, suggesting that early ambulation is a feasible and potentially beneficial practice change.

E. Recommend a Practice Change

Based on the hypothetical research-based article (Level I evidence suggesting reduced complications and length of stay with early ambulation) and the non-research-based QI project (Level III evidence suggesting feasibility and potential benefits of implementing an early ambulation program), the recommended practice change is the implementation of a standardized early ambulation protocol for all adult patients following elective hip replacement surgery, initiated within 24 hours post-surgery, unless contraindicated by specific medical conditions.

E1. Involving Key Stakeholders:

1. Surgeons: Present the evidence from the RCT demonstrating the potential for reduced complications and length of stay with early ambulation. Highlight how this aligns with the goals of improved patient outcomes and efficient resource utilization. Address any concerns they might have regarding the protocol's impact on their surgical techniques or perceived patient readiness. Involve them in the development of the specific protocol to ensure it is clinically appropriate and feasible within their practice.
2. Nursing Staff: Engage nurses in the development and implementation of the protocol. Emphasize how a standardized approach can provide clear guidelines and empower them to facilitate early mobilization. Provide comprehensive training on the protocol, including safe patient handling techniques and assessment of patient readiness. Highlight how reduced complications and shorter stays can potentially decrease their workload in the long run and improve patient satisfaction.

Sample Answer

A. Submit CITI Certification

• Please submit your Collaborative Institutional Training Initiative (CITI) certification file as requested. As a large language model, I do not have a CITI certification to submit.

B. Impact of a Clinical Practice Problem

Let's consider the clinical practice problem of delayed ambulation in postoperative adult patients following elective hip replacement surgery.

The impact of delayed ambulation on patients and the organization can be significant:

• Impact on Patients:

  • Increased risk of complications: Delayed ambulation increases the risk of deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, pressure ulcers, and constipation.
  • Prolonged hospital stay: Patients who ambulate later often require a longer time to regain functional mobility, leading to extended hospitalization.