Essay, Research Paper
Critique of Immediate Versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries using the Stetler Model David Johnson Scientific Inquiry in Nursing IntroductionThe purpose of this paper is to utilize the Stetler model of research utilization to critique a research article pertinent to my area of specialization. The Stetler (1994) model is based on an earlier model (Stetler & Marram, 1976) for critiquing and evaluating research for its use and application of findings at the practitioner level of practice. The latest model has been expanded and refined to facilitate its use in both the practitioner and organizational level of practice. The current model is divided into six stages which are designed to assist the researcher in examining critically the applications of the research findings and deciding if the findings could be utilized in their clinical practice.Phase One: PreparationThe care of the trauma patient is one area of prehospital care that can be shown to have a clear and undeniable impact on the survivability of the patient. Managed care providers are now looking at outcomes of these patients to justify the expense and resources spent on this area of medical care. This study demonstrates a positive outcome for one group of trauma patients by withholding intravenous fluids in the field. The findings of this study are important as they go against common practice in the prehospital setting. For the past twenty years, treatment for the traumatic hypotensive patient has included rapid infusion of intravenous fluids to control blood pressure and sustain tissue perfusion. This study suggests that until bleeding is controlled in these patients with penetrating torso wounds, rapid and aggressive fluid replacement can increase bleeding, decrease clot formation and ultimately decrease survival. Phase Two: ValidationResearch Critique This is a prospective trial conducted over a three year period with 598 adult patients. The trial took place in one city (Houston, Texas) where there is one trauma center (Ben Taub General Hospital). This is an important aspect to consider as treatment protocols can vary greatly from location to location. All patients enrolled in the study were assigned to one of two groups: the immediate resuscitation group (control) in which intravascular fluids were given prior to surgery in the hospital and the delayed resuscitation group (experimental) in which intravenous fluids were delayed until the patient arrived in the operating room. Enrollment in a group was randomly assigned based on alternating even and odd days. I would choose to accept this study based on the well founded hypotheses and the relationship to previous research with at least seven cited references that support the findings. The setting is appropriate to my clinical setting and includes a large convenience sample. Although I would be cautious in inferring causality based upon this one study, there is enough evidence to warrant further investigation. The design is quasi-experimental with some attempt to control confounding variables. The two study groups were matched in terms of demographics and certain clinical characteristics to minimize the effect of these variables.Phase Three: Comparative EvaluationFit of SettingWhile the population described in this study may differ from the population found in Orange County, Houston is an urban setting similar to Los Angeles, the patients injuries are very similar to those seen in the trauma centers here. However, the number of penetrating trauma patients vary greatly from this county to the one from the study. It would take several years to obtain the same sample size in order to replicate this study as the type of patients described are not as numerous in this area. FeasibilityThe risk factors include both ethical and legal as with any studies that include human subjects. The researchers used an institutional review board of a local college of medicine to obtain approval to evaluate the impact of conducting the study on human subjects. This could be done at a local trauma center which is affiliated with a local college of medicine. Another aspect of feasibility is the need for resources. This was a three year study which involved a great deal of time, money, and personnel to conduct. It would difficult to conduct a similar study without a similar commitment from each of the three trauma centers. The last aspect of feasibility is readiness of others to participate. All three trauma centers in Orange County are already conducting studies to evaluate current trauma related care practices. The feasibility of obtaining involvement of these trauma center coordinators and medical directors are very high. The medical director in charge of prehospital practices has just completed a three study in conjunction with Los Angeles county and is very motivated to conduct prehospital studies looking at improving field protocols and field research is critical in this process.
Current PracticeAs is noted in the research article, there is a traditional practice of aggressive fluid administration in the trauma patient. Trauma protocols tend to be generic in nature. The treatment plans basically have been the same, regardless of mechanism of injury, anatomy involved, or severity of injury. This study suggests the need to look at specific injuries and specific treatments in the prehospital setting. Another issue is the long standing debate in prehospital medicine of scooping the patient and taking to them to a hospital with little scene treatment versus spending time at the scene to stabilize the trauma victim and then transporting them. While this particular study did look at the response time, the time on scene and time to transport the patient to the hospital, there was no data provided or reported on.Substantiating EvidenceAs mentioned earlier, there were several studies cited in the reference that support the hypotheses of this study. Experimental and clinical data suggests that internal hemorrhage due to laceration or penetration of the torso should not be treated with intravenous fluids or blood pressure elevation until the site of the bleeding can be controlled. Several animal studies support the hypotheses and several other studies by different researchers support the idea that delaying fluid treatment will improve outcomes in this type of patient.Phase Four: Decision MakingIn this phase of the model a decision is made that is based on all information obtained up to this point. I would consider using the findings from this study to implement changes in prehospital treatment protocols for the penetrating wound trauma patient. In order to conduct a similar study, there is a need to obtain approval. It may also be beneficial and more feasible to conduct a trial study or retrospective chart review of patients already in the system that meet similar criteria. Phase Five: Translation/ApplicationThe development of regionalized trauma care has been driven by the desire to decrease preventable deaths. In this sense, it is not the prevention of the injury itself but the intervention of appropriate prehospital care in preventing death. In studying interventions and their effectiveness, several factors must be taken into account. Some of these factors have already been discussed. Feasibility or can it be demonstrated that the treatment be used safely and properly in the prehospital setting by paramedics. The other factor is effectiveness or can it be demonstrated that the treatment improves outcome. In order to address these issues a quality assurance board has been designed. This committee monitors the quality of prehospital care and its impact on the patient in the field and in the hospital. The committee would evaluate the merits of a proposed study and offer feedback on its feasibility and effectiveness. Since this study involves trauma patients, the trauma committee would also evaluate the study for its appropriateness and feasibility to conduct. Once a study was designed and a proposal written, submitted and approved, the next step would be the implementation. The purpose and specific interventions of the study would need to be communicated to all paramedics through the prehospital care coordinators and base hospital medical directors as well as the paramedic coordinators employed at the various fire agencies. A system for giving follow up on the patients enrolled in the study would be necessary in order to provide information back to the paramedics. This would ensure compliance on their part as well as assure them that the treatment they are providing is not detrimental to the patients. Phase Six: EvaluationAs with any new treatment protocol, continuous quality improvement is necessary to monitor the effectiveness and impact on patient outcomes. Informally, peer case reviews would allow discussion of issues and provide appropriate follow up with individual paramedics. This would answer specific questions that can arise when dealing with complicated trauma cases or trauma patients that do not fit a particular protocol. Audits would need to be done on a formal basis to monitor the applications of new treatments. A review by the base hospital physician committee, quality assurance board, trauma coordinator group would be necessary to monitor outcomes of these patients and determine if the protocols are appropriate or in need of further evaluation. ReferencesBickell, W., Wall, Jr., M., Pepe, P., Martin, R., Ginger, V., Allen, M., & Mattox, K. (1994). Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. The New England Journal of Medicine, 331(17), 1105-1109.Stetler, C. (1994). Refinement of the Stetler/Marram model for application of research findings to practice. Nursing Outlook, 42(1), 15-25.Stetler, C., & Marram, G. (1976). Evaluating research findings for applicability in practice. Nursing Outlook, 24(9), 559-563.