Monday, April 19, 2010

Evidence Based Practice in Home Health: Why is it nearly Impossible to Implement?

Evidence based practice (EBP) is when a nurse utilizes knowledge and experience and integrates it with current evidence based research. This integration creates wisdom and when applied to nursing practice enables quality nursing care and improvement in patient outcomes.

So why is it nearly impossible to implement EBP in home health? The organizational infrastructure of home healthcare does not support this type of nursing practice because it requires a shift from skilled nursing interventions "the act of doing" to skilled nursing assessment, planning and evaluation "the act of thought and judgment."  Supporting evidence based nursing practice means that home health organizations need to provide the following to support discovery of fact and evidence:

• Time
• Resources
• Know-how

Home health nurses need time to think and research. Currently home health organizations set daily visit productivity and visit weights to ensure the nurse is spending time in the patient home "doing" patient care. However this current staffing model does not allow the nurse the ability to step back and formulate the questions to address the patient needs and advance nursing practice. EBP requires time to formulate the questions, time to research, time to move theory to application and then time to re-evaluate.

Resources are another key element to evidence based practice. Many home health organizations are independent entities with no affiliations to medical libraries and have limited technology. Home health nurses need access to articles, periodicals, studies and other evidenced based materials. Whether the resources are retrieved from an academic medical library or subscription to an online database, home health organizations need to provide both the affiliation and technology for access to evidence based materials.

Knowing how to implement evidence based practice is the other key element. If EBP is a priority to home health organizations then continuing nurse education activities are essential. Home health nurses need support in learning how to search and retrieve information, how to assess its validity and how to re-evaluate once the evidence has been put into practice. Sharing the knowledge through publication is important because it builds the evidence to support the practice. Home health nurses need continuing education activities which help the practitioner become a scholarly writer so that others can read what practice changes are effective for a given problem and the measurable outcomes associated to the change.

While I have only identified three elements to evidence based practice, I am sure there are other factors. I look forward to learning about them during the VNAA 28th Annual Meeting pre-conference with faculty Dr. Marcia Rachel and Rebecca Askew, both published authors of the recent Home Healthcare Nurse journal article Keeping It Real: Evidence Based Practice in Home HealthCare. Stay tuned for an updated blog, hopefully with additional strategies to help home health organizations successfully implement evidence based practice. In the mean time I am including additional resources to reference.

Evidence Based Practice Resources
Web Tutorials

Yale University
Nursing Library and Information Resources
Cushing/Whitney Medical Library

Information Services Department of the Library of the Health Sciences-Chicago, University of Illinois at Chicago.
Evidence-Based Practice in the Health Sciences: Evidence-Based Nursing Tutorial

Penn State University, University Park
Evidence Based Practice Tutorial for Nurses

University of Minnesota
Welcome to Evidence-Based Practice: An Interprofessional Tutorial

Web Resources
Virginia Commonwealth University
Evidence-Based Nursing Resource Guide

Agency for Healthcare Research and Quality

National Guideline Clearinghouse™ (NGC)

University of Iowa's 17th National Evidence-Based Practice Conference


Sunday, April 18, 2010

Battling Influenza: Doing My Part

I had the pleasure of attending the National Influenza Vaccine Summit (NIVS) in Dallas, June 29 – July 1, 2009, representing the VNAA. In addition, I also had the honor of moderating one of the summit breakout session panels: 2009 - 2010 Service Delivery, Late Season Vaccination and & Retrospective Coverage Data. This was an important session to participate in as VNAs are community immunizers providing 1.5 million vaccine doses annually. VNAs understand the importance of partnering with organizations like Center for Disease Control and Prevention (CDC), The Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) and collaborating in forums such as NIVS to expand the immunization coverage within the community.

Many do not realize the importance of vaccination for the prevention of influenza because many do not know the morbidity and mortality associated to the influenza disease. According to the CDC, approximately 5-20% of the U.S. population becomes ill with the influenza virus annually. Further, this highly contagious disease causes an estimated 36,000 deaths each year. Although 36,000 deaths annually may not sound like a lot, it is important to recognize that influenza and pneumonia were the eighth leading causes of death in the United States in 2006 (U.S. Department of Health and Human Services, 2009), just behind alzheimer’s, diabetes, accidents, chronic lower respiratory diseases, stroke, cancer, and heart disease. Yet many in the community continue to view influenza with an attitude of “it’s just the flu” with no life threatening consequences.

Having a family, I have personally experienced the consequences of young children contracting respiratory viruses. One of my children contracted a respiratory illness during the 2003 – 2004 year at the age of 4 months and we have been battling respiratory issues ever since. Diagnostic testing was not performed and therefore we never had a definitive diagnosis as to whether my child had contracted Respiratory Syncytial Virus (RSV) or influenza. Both illnesses are airborne diseases caused by a virus and both have similar signs and symptoms which I later read about in an article Influenza A In Young Children with Suspected Respiratory Syncytial virus Infection (Friedman, 2003). Friedman recommended that children presenting with fever and respiratory illness symptoms should be tested for both RSV and Influenza. I also learned at the NIVS that particular Influenza year 2003 – 2004 there was widespread activity that caused severe illness and deaths in children. Regardless of the cause of the respiratory illness my child experienced in 2004, he has remained highly susceptible to respiratory infections including croup and bronchitis since that time. In addition I have another child that has been recently diagnosed with asthma and therefore is also at risk for experiencing complications from influenza like bronchitis and pneumonia. And if that was not enough, at the NIVS, I learned that I too am highly susceptible to complications from influenza since I am in the high risk category – pregnancy during flu season.

Yes, I am entering my second trimester and I am due during the first week of January 2010. I must admit that as a nurse I had significant knowledge deficits related to influenza, vaccines and pregnancy. I was relieved to learn that I can get the vaccination while I am pregnant. This is noteworthy news since children under the age of 6 months are not recommended for vaccination against the influenza virus. However it has been found that vaccination during pregnancy does provide newborns with immunity against the influenza virus. I wish I would have known this during my pregnancy of 2003, as a study published in the October 2008 issue of the New England Journal of Medicine found that influenza vaccination in pregnancy "reduced proven influenza illness by 63% in infants up to 6 months of age and averted approximately a third of all febrile respiratory illnesses in mothers and young infants" (Zaman,2008). This would have helped reduce the likelihood of my 4 month old son in 2003 from contracting a respiratory illness. This pregnancy will be different and by following a few vaccine recommendations by (CDC) and the American College of Obstetrics and Gynecology (ACOG) to ensure my health and safety and protect my unborn child’s well being, I will get vaccinated. These guidelines can be found on the National Women’s Health Resource Center (NWHRC) at the Flu-Free and a Mom-to-Be pages a joint campaign initiative between the National Women’s Health Resource Center and the Association of Women’s Health Obstetric and Neonatal Nurses (AWHONN).

So it should become no surprise that I have professional and personal concerns related to the recent pandemic H1N1 Flu virus outbreak. This will be an added challenge as we enter the 2009 – 2010 seasonal Influenza year. However I am not panicking and will continue to follow the Advisory Committee on Immunization Practices (ACIP) recommendations. It will be interesting to learn about the results of the highly anticipated special ACIP meeting on Novel Influenza A (H1N1) scheduled Wednesday, July 29, 2009. There are many questions that need to be answered related to the vaccine that is under current development by the pharmaceutical manufacturers including when it will be released for distribution to the general public, how will the government release it, how many doses will be needed, will commercial insurers pay for the vaccine and what is the vaccine’s potential efficacy against the current H1N1 virus. In addition I will be following the World Health Organization (WHO) tracking of the pandemic and to see if there are changes in the H1N1 Flu virus virulence.

I intend to do all that I can to keep my family healthy and plan to have everyone vaccinated in September 2009 to not only protect me and my children but also to keep from spreading this highly contagious illness to others in my community that are at risk in developing complications from influenza including seniors over the age of 65. In addition practicing general health etiquette will ensure prevention and protection against current and future influenza strains. Although these techniques are simple in nature and everyone knows about them, it is amazing to me how forgetful individuals become regarding health etiquette in public environments. I was quickly reminded of others disregard to public health as I was traveling back home from the NIVS and was trapped in an airplane for three hours in front of a young couple that apparently had active respiratory illnesses. I knew this because the young women had a deep chest cough that would occur every 15 – 30 minutes during the flight and had intervals of sneezing and nose blowing. After the first coughing spell she took a cough drop but it was troubling to learn that she never covered her mouth when she coughed and the airline stewardess had to give her tissues. Her husband was not as ill and only would cough about every hour but still it was a deep chest cough that was beyond a “smoker’s cough.” Realizing that I may be just a tad over zealous since I just spent three days at the vaccine summit, I tried to tread lightly but did voice my concerns to the flight attendant. Apparently I was not the only one to complain, however the flight attendant stated there was not much she could do and only hoped that whatever they had was not contagious.

In closing, I am asking that everyone one do their part to stay healthy and get immunized against influenza. You can go as early as September or as late as March. Many do not realize that you can get the influenza virus as late as May, so it is never to late to get vaccinated. And as the H1N1 virus has shown it can be contracted during the summer months as well. But if you are still not convinced about the seriousness of the influenza illness and/or the safety and efficacy of vaccines, I would ask that you practice the following health habits to not only keep yourself healthy but also out of respect for public health.

1. Wash your hands, wash your hands, wash your hands. 20 – 30 seconds to the tune of Happy Birthday twice is all that it takes. If soap and water is unavailable please use alcohol based hand sanitizer.

2. Cover your mouth and nose when you sneeze or cough with a tissue and throw the tissue away after use. Try and keep a travel pack readily available instead of reusing the same old tissue. If a tissue is unavailable then use the inside of your elbow to cough into rather than into your hands.

3. Social distancing- stay home from work/school/church/mall or other public places when you are sick and seek treatment from a healthcare professional as soon as possible. The flu usually includes a high temperature fever with chills, with aches, pains, dry cough and extreme tiredness. There are medications that can help treat the flu called Anti-virals. Can’t tell if it is the cold or flu then use this resource to help tell the difference Cold or Flu.

4. Avoid close contact with others that are sick. If you cannot avoid contact due to caretaking please ensure hands are washed after every encounter and do your part to stay healthy.

5. Avoid touching your eyes, nose or mouth during the influenza season as this is how the virus is transmitted.

6. Practice health habits – get plenty of sleep, eat nutritious meals, exercise and reduce stress. Take vitamins, minerals and supplements as needed but ensure that you advise your healthcare professional that you are taking them in addition to any other prescription medication you may be on.


U.S. Department of Health and Human Services (2009). Center for Disease Control and Prevention. National Vital Statistics Reports: Deaths Final Data for 2006. (Volume 57, Number 14) Retrieved July 7, 2009 from

Friedman MJ and Attia MW. Influenza A in Young Children with Suspected Respiratory Syncytial Virus Infection. Acad Emerg Med 2003 Dec; 10:1400-3.

Zaman, K., Roy, Eliza, Arifeen, Shams E., Rahman, Mahbubur, Raqib, Rubhana, Wilson, Emily, Omer, Saad B., Shahid, Nigar S., Breiman, Robert F., Steinhoff, Mark C. Effectiveness of Maternal Influenza Immunization in Mothers and Infants N Engl J Med 2008 359: 1555-1564.