Critical Appraisal Assignment for Arterial Line Transducer Placement for Accuracy in Frequent Patient Positioning

Jennifer Haselkamp and Joseph Mills

College of Central Florida

Evidence-Based Clinical Judgment

NUR4776

 

February 29, 2016

 

Critical Appraisal Assignment for Arterial Line Transducer Placement for Accuracy in Frequent Patient Positioning

 

                                                            PICO(T) Question
          How is arterial blood pressure affected by the placement of the transducer in early mobility and frequent re-positioning of Intensive Care Unit (ICU) patients (P) with patient mounted transducer (I), compared to the use of a stationary pole mounted transducer (C), on the precision of blood pressure measurements compared to a standard blood pressure cuff (O).

            The precision of invasive arterial blood pressure monitoring is considered the gold standard (Thiele & Durieux, 2011). Arterial blood pressure monitoring is dependent on positioning of the transducer for accuracy, relative to the patients position (Hoover, 2000). The level of the transducer must be parallel to the right atrium (He et al., 2015). The use of a stationary pole mounted transducer has been utilized for years as the standard placement (Thiele & Durieux, 2011). With the evidence of benefit for early mobility and frequent re-positioning of critical patients (Adler & Malone, 2012), the accuracy of the invasive arterial blood pressure measurements through various body positions is called into question (He et al., 2015).  The previously accepted method of a fixed position for the transducer does not adapt well to increased activity of the patient. Recent observations of a local 30 bed, Medical/Surgical ICU, in Ocala, Florida, has revealed bedside nurses have adapted a process of taping the transducer to the patients’ upper arm in alignment with the anterior axillary line and the fifth intercostal space, approximating alignment with the right atrium (Thiele & Durieux, 2011).  This method has permitted greater freedom of movement for the patients while in ICU. However, best practice and standards of care were questioned by the nursing staff there.  Subsequently, the Florida Board of Nursing (FBON) and the American Association of Critical Care Nurses (AACN) were consulted for their input and direction. The response from these authorities was, “both methods of transducer placement are acceptable because, no literature favoring one method over the other can be found, as long as proper leveling and zeroing was done to assure accuracy”.

                                                        Purpose

The purpose of this evidence-based practice study is to evaluate and implement a best practice process for the placement of the arterial catheter transducer (pole mounted or patient mounted) to accomplish both accuracy of reading (within plus or minus 10 millimeters of mercury, to a standard cuff blood pressure measurement) throughout frequent positioning of the patient. This evaluation will attempt to determine if there is a difference in mounted or stationary transducers, during patient mobility. The program will be designed to be sustainable in a 30 bed ICU at a local medical/surgical hospital. The findings will be implemented in the ICU to facilitate trending of arterial blood pressures during mobility of the ICU patients. Patients will be selected from the ICU at Munroe Regional Medical Center, Ocala. Florida. Post surgical and medical patients whose physicians deem an arterial line necessary for close monitoring of blood pressure, will be included in the study. Patients will be randomly placed into one of two groups. The first group will have the arterial blood pressure transducer mounted on a bedside holder and leveled, to the anterior axillary line, fifth intercostal space which is the customary alignment with the right atrium (Thiele & Durieux, 2011). The second group will have the transducer taped to the upper right arm at the level of the anterior axillary line, fifth intercostals space over the blood pressure cuff.  Patients’ position will be recorded when changed to include head of bed elevated or lowered, up out of bed to a chair and when returned to bed. Blood pressures will be recorded and a comparison by standard blood pressure cuff will be taken on the same arm as the radial artery catheter, after the change in position. A collection of data will be trended to include; patient position, standard blood pressure readings, and arterial line pressure readings. These will be collected to ascertain the variations in measurements from the pole mounted and patient mounted transducers compared to the standard cuff pressures. The study will continue for six months or data from 25 patients from each group are collected for review. A table of results will be generated from the raw data for evaluation. The findings will be discussed amongst the involved nurses and physicians at a meeting set up for this review. This will be to evaluate the data and determine if there is any cause for change in current practice. The findings for the best practice will be adapted (or kept), for use within the medical/surgical ICU. Educational details will be disseminated to the staff based on the findings and best evidence-based practice will be implemented. There are no anticipated additional costs expected during this study as the nursing hours will remain the same. Standard cuff pressure use is the current practice in the unit to verify arterial line pressures, so that additional equipment will not be necessary when utilizing the two methods of obtaining the blood pressure readings throughout the study.  Funding through nursing administration will be allocated to compile statistical analysis of the data utilizing computer algorithms and any ancillary personnel necessary for data compilation.                                                      

                                                       Background

Early mobility of the ICU patient population has been shown to reduce functional decline, mortality, morbidity, cost of care and length of stay (Perme & Chandrashekar, 2009).  With the large volume of evidence to support early mobility and the adaptation of the latest evidence in practice, it becomes essential to change vital sign monitoring to accommodate mobility and possible variations in blood pressure readings.  In specific, invasive arterial blood pressure monitoring is essential for accurate and timely adjustments necessary for medication and treatment options. The accuracy of monitoring is dependent on the position of the arterial transducer, as well as, the patients’ anatomical position relative to it (He et al., 2015). There has been correlation of consistency between cuff blood pressures and arterial line pressures to trend readings (Hoover, 2000). The precision of invasive arterial lines is considered the gold standard (Thiele & Durieux, 2011). The purpose of this evaluation is to establish the best practice to facilitate both the use of arterial blood pressure monitoring as well as frequent repositioning and mobility of the patient, without losing precision of blood pressure measurement.  We propose, by positioning the arterial line transducer where it will move with the patient, relative to the anterior axillary line and the fifth intercostal space, we will preserve the integrity and precision of the blood pressure measurement throughout changes in the patients position (Romagnoli et al., 2014).

The staff nurse will identify patients with an invasive arterial line in place as necessitated by their physician. The project director will record the location of the arterial line and alternately assign the patient to either the control group, utilizing the practice of placing the transducer on a pole mounted holder or the test group, placing the transducer on the patients’ upper arm above the arterial line, taped to the blood pressure cuff. Both will be aligned with the anterior axillary line and the fifth intercostal space as per current best practice (He et al., 2015). The staff nurse will record the hourly blood pressure of both the arterial line and the non-invasive blood pressure cuff and make a notation of the patients’ position. Standardized forms will be used to collect the data and facilitate recording of patient position. The length of time that the arterial line is used will be recorded, (date and time discontinued). Data will be collected until 50 patients with arterial lines have been recorded. The process will follow the Iowa Model of Evidence-Based Practice (Melnyk & Fineout-Overholt, 2015). The data will be collected, assessed and evaluated for purposeful use and findings discussed amongst the participants in a meeting convened for that purpose. The members of the meeting will consist of end point users of the blood pressure data and staff members. After an evaluation by the members, the findings as to the merit and continued use of the transducer mounting method will be disseminated to the facility.         

                                                            Proposed Change

    This evidence-based practice project is to evaluate how early mobility and changing a patient’s position will affect the accuracy of blood pressure measurements in patients with arterial line transducers mounted on a stationary pole as opposed to being attached to the patients arm.  The project will have two groups of patients, one being a stationary mounted transducer group, and the other will include the arm mounted transducer group. Patients will have been identified by the ICU supervisor as patients for this study. This data collection study will be introduced by the clinical nurse educator. Patients that have been flagged by the ICU team leader as having a transducer will then be followed and placed into the evidence based practice study. Patients are then followed for four days to record data or until the transducer is discontinued and removed.

                                                            EBP Model

     The Agency for Healthcare Research and Quality (AHRQ) model of evidenced-based practice will be utilized. This is a multi-model synthesis used for the rapid dissemination of healthcare information across many stakeholders and systems (Melnyk & Fineout-Overholt, 2015).  

Clinical Involvement

A project team that will include a staff nurse and an ICU supervisor will be formed. The project leader will provide education on the evidence to support the practice change. Teamwork will be enhanced by clinician input to enrich the project. Additional members of the team will include the clinical nurse manager, ARNPs, and Nurse Scientist with extensive EBP knowledge and expertise. The team will focus on how to identify the type of patients for the study, who will do the assessments, and how to log and input the recorded data. This group will also determine the tools to use to capture both process and outcome measures. Nursing student support will be enlisted to help provide patient education and encouragement.

                                                            Outcomes

The following outcomes will be used to evaluate the effectiveness of our EBP study regarding transducer patient position and mobility.

1. Changes to the current hospital policy regarding placement of the patients’ arterial line transducer to facilitate positioning and mobility, which will be recommended for patients once the EBP study is completed.
2. Monitor nursing staff satisfaction and ability to incorporate policy changes into everyday care. This can be done by having staff complete a new satisfaction survey a month post incorporation of the new policy changes.
3. Create a post six month follow up survey for all staff to complete to examine the efficiency of the EBP study.
4. Create a report of the study and evaluate as to the value of publishing it in a journal or on an online website. If published, other hospitals can assess the study for use in their institution and or repeat the study for further evaluation. By having other hospitals repeat this study and compare results this data can then be supported as a reliable EBP study.

Analysis of the outcomes data will be performed by the nurse researcher at our medical center in collaboration with the team and our Center for Clinical Excellence.

 

                                                            Timeline

Activity	Month 1-3			Month 4-6			Month 7-9
Complete literature review – identify/refine strategies	xx
Multidisciplinary data collection	x	xx	xx	xx	xx	xx
Intervention (changes to policy)							xx	xx	xx
Staff satisfaction survey (post intervention)								x	x
Data analysis (pre: historical data/6-month post intervention data)								x	xx
Create final report/poster									xx

 

Over the next six months (or 50 patients), information will be gathered to see if the patients’ blood pressure measurements show any difference between patient mounted transducers versus stationary transducers. The team will assemble the information into easily understood data that will be presented to ICU staff. At the end of the six months, the current hospital policy will be reviewed for change, if the data shows significant evidence that in doing so it would improve patient outcomes. If it is determined that a change in policy will be instituted, the staff will be informed of the change at least one month before with explanation of why the policy is changing, including data from the study through; flyers, personalized hospital email, and any in-services to be determined as needed. If an in-service is necessary, it will be done through a computer based system, in order that the staff can complete at their own pace. All in-services must be completed before policy changes will occur. Follow-up electronic surveys will be sent to ICU staff, one month after the new policy has been implemented, to determine if the policy change is being followed and documentation is complete. The survey will also address any problems that may have developed and assist staff in finding new ways to implement changes within the clinical setting.

                                                            Budget

Funds are to be made available for direct expenses only. Institutional overhead may not be included. Provide budget using the following chart, and describe/provide justification for how you will use the grant funding to support your project.

Item	Cost unit	Quantity	Amount
Computer Program	$100	1	$100
Printing	0.01/per page	250	$2.50
TOTAL			$102.50

 

(Note – this example was based on a QI project conducted at the University of Washington Medical Center – Sweeny SJ, Bridges EJ, Sayre C, Wild L. Care of the patient with delirium. Am J Nurs, 2008, 108(5), 72CC-72GG).

 

                                                            Equipment/Supplies

A printer, along with excel will be used to create flow charts to help keep track of patient’s data as it is complied. Once all data has been gathered and complied a presentation on the data will be shared. New policy changes can be made from the information collected.

                                                            Conclusion

            Patients’ blood pressure measurements are tracked using both the patient mounted and stationary arterial line transducers in the medical/surgical ICU. Patients body position and arterial line blood pressures are recorded and a standard cuff pressure also recorded for comparison. The data will be compiled and presented at a later date in time, upon EBP study completion. As there are currently no guidelines to follow regarding the best placement of the arterial transducer when frequently positioning patients in the ICU, this data looks to create new EBP guidelines for arterial transducer utilization and patient mobility related to blood pressure monitoring.

 

 

 

 

 

References

Adler J, Malone D. Early Mobilization in the Intensive Care Unit: A Systematic                 Review.  Cardiopulmonary Physical Therapy Journal. 2012;23(1):5-13.

He, H., Liu, D., Long, Y., Wang, X., Zhao, M., & Lai, X. (2015, August 23, 2015). The effect of variable arterial transducer level on the accuracy of pulse contour waveform-derived measurements in critically ill patients [Journal Article]. Journal of Clinical Monitoring and Computing. http://dx.doi.org/10.1007/s10877-015-9756-x

Hoover, L. (2000). Comparison of blood pressure readings between cuff pressures and radial arterial catheters with changes in transducer level and patient position [Journal Article (abstract)]. American Journal of Critical Care, 9, 220-221.

Melnyk, B. M., & Fineout-Overhol, E. (2015). Models to Guide Implementation and Sustainability of Evidence-Based Practice. In Evidence-Based Practice in Nursing & Healthcare (3 ed., pp. 283-284). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Perme, C., & Chandrashekar, R. (2009, February 20, 2009). Early Mobility and Walking Program for Patients in Intensive care Units: Creating a Standard of Care [Journal Article]. American Journal of Critical Care. http://dx.doi.org/10.4037/ajcc2009598

Romagnoli, S., Ricci, Z., Quattrone, D., Tofani, L., Tujjar, O., Villa, G. & DeGaudio, A. (2014). Accuracy of invasive arterial pressure monitoring in cardiovascular patients: an observational study [Journal Article]. Critical Care, 18, 1-11. Retrieved from http://ccforum.com/content/18/6/644

Thiele, R. H., & Durieux, M. E. (2011, May 16, 2011). Arterial Waveform Analysis for the Anesthesiologist: Past, Present and Future Concepts [Review Article]. International