Nurses have a responsibility to ensure the care they provide is evidence based. A nurse led audit established best standards of practice and changed care delivery
Alison Griffiths, MSc, BSc, DipHE, RGN, EN(G), is Macmillan gynaecology clinical nurse specialist and deputy head of nursing/matron - cancer, Medway Foundation Trust, Kent.
Griffiths A (2010) Challenging accepted practice standards to ensure care is evidence based and up to date. Nursing Times; 106: 14, 19-20.
A vital part of nursing involves evaluating and challenging practices to ensure they are up to date and evidence based. This article describes how a literature review and an audit led to changes in an outpatient clinic.
Keywords Audit, Best practice, Patient satisfaction, Evidence based care
- This article has been double blind peer reviewed
- Ensuring patients receive the highest quality evidence based care requires nurses and other healthcare professionals to keep up to date with changes in the evidence base.
- Colleagues in other settings can offer useful insights that can support practice developments to reflect changes in the evidence base.
Evidence based practice is well established in healthcare, and nurses in all settings are generally accustomed to changing their practice to reflect the latest evidence.
The evidence base is constantly evolving, so what is considered best practice now may be superseded by new recommendations at any time. This means it is vital to review the evidence base regularly and change anything no longer considered to be best practice.
This article reports on an audit prompted by some advice that indicated our previous practice in the outpatient diagnostic hysteroscopy clinic was outdated.
Hysteroscopy is considered the gold standard investigation for evaluating the uterine cavity, as it allows a direct view of the endometrium and directed biopsy of suspicious lesions. Because the uterine cavity is a virtual space, the procedure requires its distension with gaseous (carbon dioxide) or low viscosity fluids. Normal saline is viewed as the medium that provides the most superior views (Clark and Gupta, 2005).
Outpatient diagnostic hysteroscopy is used extensively to evaluate common gynaecological problems, such as menorrhagia and postmenopausal bleeding (Clark et al, 2002). Adequate intrauterine cavity distension is fundamental to obtain a panoramic view for diagnostic hysteroscopic procedures (Clark and Gupta, 2005).
At Medway Foundation Trust, the Olympus flexible hysteroscope (3.5mm), with normal saline (0.9%) as the distension medium, has been used for more than 10 years. Practice for delivering distension fluids previously involved a clinical support worker standing at the patient’s side applying manual (hand squeezed) pressure to a 500ml bag of normal saline, while the nurse or doctor performed the hysteroscopic procedure.
The regional representative for the Olympus hysteroscope advised our department that the method by which we administered the distension fluid was considered to be “outdated practice”.
In addition, our previous practice was deficient in monitoring:
- A predefined flow rate of fluid delivery;
- Accuracy of fluid input/documentation;
- Maintenance of constant pressure;
- Evidence of patient satisfaction;
- Outpatient diagnostic protocols/guidance.
Team members were concerned about the lack of recent evidence to support practices in the outpatient clinics, which led to this audit.
While training to become a nurse hysteroscopist, I used opportunities to observe the practices of practitioners at other hospitals in the region. The aim was to compare practice so we could make improvements and enhance care delivery.
I observed differences in the way in which the distension fluid was administered, in that the nurse hysteroscopists used a pressure cuff and manometer method. The advantages of this are that it allows for a continuous flow of fluid into the uterine cavity, maintaining a constant intrauterine pressure, avoiding the risk of over distension of the uterine muscle fibres thereby reducing the risk of pain and discomfort (Kremer et al, 1998).
This practice also ensures the clinical support worker is free to support the patient, and to assist the hysteroscopist/practitioner when necessary.
An extensive literature search (Cochrane, MEDLINE, Ovid, Royal College of Obstetricians and Gynaecologists and other clinical databases) yielded no data on the manual (hand squeezed) method of administering intrauterine cavity distension fluids for diagnostic hysteroscopy. Conversely, the same search criterion revealed a wealth of literature on outpatient diagnostic hysteroscopic procedures.
Four randomised controlled trials advocated the use of a fluid monitoring device, namely the pressure cuff and manometer method (Campo et al, 2005; Sharma et al, 2005; Unfried et al, 2001; Nagele et al, 1999), while Bettocchi et al (2003) used an electronic infusion device. Clark et al (2002) recommended fluid delivery techniques, such as syringe and inject, gravity feed, pressure bag or automated pump methods, as adequate for outpatient diagnostic procedures.
Each RCT cited above recommended fluid infusion pressures should be kept between 50mmHg and 100mmHg in order not to exceed the mean arterial pressure. Higher inflow pressures of 150-250mmHg can be safely used but this is only recommended for short periods to increase uterine distension if required (Campo et al, 2005; Sharma et al, 2005; Bettocchi et al, 2003). Lower starting pressures should be considered in nulliparous and postmenopausal women who are more likely to experience pelvic discomfort from uterine stimulation (Kremer et al, 1998).
The audit aimed to collate and analyse data from trainee and qualified nurse hysteroscopists in the UK to compare practice against the standards in the literature.
Its objectives were to:
- Develop an evidence based standard for best practice;
- Benchmark clinical practice with that of other hospitals;
- Explore alternatives to practice;
- Improve patient satisfaction;
- Develop guidelines/protocols for the outpatient clinic.
Sources for standards
The standards were developed from the following sources:
- Review of the literature;
- Auditing the practice of trainee and qualified nurse hysteroscopists.
The following references were selected based on grade 1a and 1b evidence (NICE, 2001) as being useful and relevant (Yossry et al, 2007; Campo et al, 2005; Sharma et al, 2005; Bettocchi et al, 2003; Unfried et al, 2001; Nagele et al, 1999).
Data was collected retrospectively via a questionnaire consisting of 11 items on clinical practice when undertaking outpatient hysteroscopy, over three months in 2007. Questionnaires were emailed to all trainee and qualified nurse hysteroscopists around the country (totalling around 60).
Each nurse would have undertaken advanced nurse hysteroscopy training (level 3 or master’s) at the University of Bradford under the auspices of the British Society for Gynaecological Endoscopy.
The questionnaire was chosen as Parahoo (1997) argued questionnaires are efficient in providing data on the attributes of clients and staff and are used to evaluate practice and policy.
Thirty out of 60 (50%) questionnaires were returned electronically or by post. I carried out the data analysis in January 2008.
Results showed that 25 out of 30 respondents used a controlled method of fluid delivery for intrauterine cavity distension, either via the pressure cuff and manometer method (21/30) or the syringe and inject method (4/30) (5/30 used CO2) (see Fig 1).
Twenty nurse hysteroscopists kept the pressures low at 50-100mmHg for patient comfort. Pressure depended on parity, menopausal status, degree of cervical stenosis, anxiety levels.
The evidence from the questionnaire supports the standards described in the literature.
Agreed best practice from each of the sources for standards advocated the use of a device in which to deliver a more precise and controlled method of distension fluid. Pressure rates are recommended at between 50mmHg and 100mmHg.
The audit of nurse hysteroscopy practice led to the following recommendations:
l Outpatient clinical activity for selected procedures will be audited regularly to assess the impact of a “see and treat” outpatient hysteroscopy clinic;
- To undertake regular surveys to ascertain the views and experiences of those attending the outpatient hysteroscopy service;
- Offer further education and support to the nursing team, to raise awareness of evidence based practice.
- A consensus to change practice at Medway has been reached:
- Two pressure cuff and manometer sets are now in use in the outpatient setting;
- An outpatient diagnostic hysteroscopy guideline has been written and is available on the trust wide intranet.
Changing practice locally using the results from this audit will enable us to use a more precise mode of delivering intrauterine cavity distension fluids with regulated pressure (50-100mmHg), and allow the operators greater autonomy. It will also reduce the risk of discomfort for patients and make more effective use of clinical support worker time and skills. The audit will enable us to develop and implement protocols/guidelines for evidence based best practice, ensuring we adhere to the trust’s clinical governance policy.
Changes to expand day case diagnostic and treatment services are under way, driven by many factors including advances in medicine, patient choice, political influences and economic pressures. The changes involve transferring more traditionally inpatient procedures to day surgery.
The outpatient hysteroscopic service is an ideal environment to deliver a “see and treat” service. This places major emphasis on governance, clinical risk management and continuous clinical audit by nurses and medical staff, along with the implementation of evidence based care and management.
This audit demonstrates the importance of checking practice against the evidence base, and the value of sharing practice across multiple sites, particularly within specialist services, to ensure standards of care are consistent and reflect best practice.
Bettocchi S et al (2003) What does ‘diagnostic hysteroscopy’ mean today? The role of the new techniques. Current Opinion in Obstetrics and Gynecology; 15: 4, 303-308.
Campo R et al (2005) Prospective multicentre randomised controlled trial to evaluate factors influencing success rate of diagnostic hysteroscopy. Human Reproduction; 20: 1, 258-263.
Clark T et al (2002) Accuracy of hysteroscopy in the diagnosis of endometrial cancer and disease. A systematic review. Journal of the American Medical Association; 288: 1610-1621.
Clark T, Gupta J (2005) Handbook of Outpatient Hysteroscopy: A Complete Guide to Diagnosis and Therapy. London: Hodder Arnold.
Kremer C et al (1998) Flexible outpatient hysteroscopy without anaesthesia: A safe, successful and well tolerated procedure. British Journal of Obstetrics and Gynaecology; 105: 672-676.
Nagele et al (1999) Endometrial cell dissemination at diagnostic hysteroscopy: A prospective randomized cross-over comparison of normal saline and carbon dioxide uterine distension. Human Reproduction; 14: 11, 2739-2742.
NICE (2001) Item 9, Appendix C - The Guideline Development Process, Information for National Collaborating Centres and Guideline Development Groups. London: NICE.
Parahoo K (1997) Nursing Research - Principles, Process and Issues. Basingstoke: Palgrave Macmillan.
Sharma M et al (2005) Prospective randomized controlled study: outpatient hysteroscopy: traditional versus ‘No touch’ technique. BJOG: An International Journal of Obstetrics and Gynaecology; 112: 963-967.
Unfried G et al (2001) Flexible versus rigid endoscopes for outpatient hysteroscopy: a prospective randomized clinical trial. Human Reproduction; 16: 1, 168-171.
Yossry M et al (2007) Uterine distension media for outpatient hysteroscopy (protocol). Cochrane Database of Systematic Reviews; Issue 3, Art.No: CD006604.