The handful of oral surgery patients on Weinberg’s intensive care unit depend on nurses like Nancy Gruber to keep them from going back to the operating room. Their procedures—whether to remove cancerous muscle or repair an injury—involve replacing damaged muscle with a “free flap” of healthy muscle from elsewhere in the body.

Gruber’s careful positioning of the patient’s head or monitoring of the blood flow through the newly attached vasculature could mean the difference between flap success and failure. Yet unlike the standardized nursing protocols that accompany other post-surgical cases, there isn’t yet an established pathway for free-flap patients.

So Gruber and three fellow WICU nurses resolved to identify the best practices for improving flap perfusion using Hopkins Nursing’s new evidence-based practice model.

Evidence-based practice produces better patient outcomes because decisions are based on the best scientific evidence, says nurse researcher Robin Newhouse, one of the model’s developers. “Our model is designed to give staff nurses the tools to answer clinical questions, critique evidence and make recommendations for improvements in care.”

Over five sessions, with Newhouse as their mentor, the WICU nurses and an anesthesiologist examined 45 sources of evidence to nail down which practices delivered the best outcomes for free-flap patients. Using the studies, they determined that advancing patient age and tobacco use increase complications. They established benchmarks for how often patients should be assessed and analyzed which assessment techniques—ultrasound, venous monitoring—yielded the highest flap survival rates. Leech therapy, they found, was especially effective in treating venous congestion.

The group will meet once more to finalize their practice recommendations with the surgical team. “Putting a proven pathway in writing will ensure that the physicians and nurses are on the same page,” says Gruber. “That can only enhance our communication as a team.”

Across the hospital, nurses on the surgical intensive care unit are conducting their own project using the evidence-based practice model, this one investigating the use of a delirium screening tool. And a PACU project that examined whether ambulatory surgery patients should be discharged before voiding has led to a new protocol involving the use of bladder scanners.

-From Hopkins Nurse, Spring 2005

PHOTO: Nurse practitioner Cathy Barenski, left, and WICU nurses Nancy Gruber, Sharon Schromsky and Jennifer Helzer (not pictured) are using Hopkins Nursing’s evidence-based practice model to answer the question: What are the best practices to improve free-flap perfusion?