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Introduction to Evidence-Based Practice : Practice Case #3

Practice Case 3: Nursing and the case for dry heat

This is a self-correcting exercise. Click on the letter (A, B, or C) or "Quiz Yourself" for a pop-up box with the response.

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ASSESS the Problem
Start with the problem -- a clinical problem or question arises from the care of the patients

Peripheral IV catheter insertion is a common nursing procedure often required for the administration of chemotherapy, antibiotics, blood products, fluids, and other medical therapies in hematologic patients with cancer. Although necessary and usually brief, IV insertion often is a source of patient anxiety and discomfort and can be extremely difficult to achieve, particularly in individuals receiving repeated courses of chemotherapy. Unfortunately, not all IV insertions are successful on the first attempt; multiple attempts may occur, which may cause patient distress and anxiety and increase costs as a result of additional supplies and nursing time. Nurses currently use various techniques, including heat, to improve the success rates of IV insertion; however, few are based on evidence. (Fink RM, 2009)  In an effort to improve the patient experience you are asked by the Nursing Council to look at the evidence for using dry versus moist heat for IV catheterization.

 
ASK the question

Choose the BEST clinical question:

 Is dry or moist heat more effective at reducing pain and anxiety?

 Does heat help improve the time to insertion of an IV catheter?

 Is dry or moist heat helpful in reducing pain and time of IV catheter insertion in patients undergoing chemotherapy?


ACQUIRE the evidence

Choose the best PubMed search strategy to address the clinical question.

Search: heat AND chemotherapy   Limited to randomized controlled trial

Search: hyperthermia AND catheterization  Limited to randomized controlled trial

Search: heat AND IV catheter  Limited to Human and English and last 5 years


APPRAISE the evidence

Fink RM. The impact of dry versus moist heat on peripheral IV catheter insertion in a hematology-oncology outpatient 
population. Oncol Nurs Forum. 2009 Jul;36(4):E198-204. doi: 10.1188/09.ONF.E198-E204. PubMed PMID: 19581223.

Abstract

PURPOSE/OBJECTIVES: To determine whether dry versus moist heat application to the upper extremity improves IV 
insertion rates. DESIGN: Two-group, randomized, controlled clinical design. SETTING: An academic cancer infusion center in the western United States. Sample: 136 hematologic outpatients with cancer or other malignancies. METHODS:
Participants were randomly assigned to dry or moist heat with warmed towels wrapped around each patient's arm for
seven minutes prior to IV insertion. Skin and room temperatures were monitored pre- and postwarming. Two experienced
chemotherapy infusion nurses performed the venipunctures according to protocol. Outcomes were examined using varianceanalysis, with 34 patients for each combination of nurse and heat type. MAIN RESEARCH VARIABLES: Number of IV
insertion attempts, time to achieve IV insertion postheating, patient anxiety levels pre- and postheating, and patient
comfort.Findings: Dry heat was 2.7 times more likely than moist heat to result in successful IV insertion on the first
attempt, had significantly lower insertion times, and was more comfortable. Heat type had no effect on patient anxiety.
CONCLUSIONS: Dry heat application decreases the likelihood of multiple IV insertion attempts and procedure time and is
comfortable, safe, and economical to use in an outpatient oncology setting.

You will need to read the full article to address the validity questions. Click on the link above to get a free copy of the article. Evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question.

Randomization: Were patients randomized?

Concealed allocation: Was group allocation concealed?

Baseline characteristics: Were patients in the study groups similar with respect to known prognostic variables?

Blinding: To what extent was the study blinded?

Follow-up: Was follow-up complete?

Intention to Treat: Were patients analyzed in the groups to which they were first allocated?

Equal treatment: Aside from the experimental intervention, were the groups treated equally?


What are the results & how can I apply them to patient care?

Results: Controlling for prewarming vein status, dry heat was 2.7 times more likely to result in successful IV insertion. After controlling for preinsertion anxiety, vein status, and the participants’ number of venipunctures in the prior year, dry heat resulted in significantly lower insertion times than moist heat. No significant difference was found between the heat modalities or between nurses on postinsertion patient reported anxiety scores.  Dry heat was associated with significantly higher participant self-reported comfort after controlling for preinsertion anxiety and vein status and the participants’ numbers of venipunctures in the prior year.

The results are reported as a continuous variable (change in scores).  This does not allow for calculations of Absolute and relative differences or number -needed-to-treat.

Questions to consider before applying the results of a study to your patient:

  • Were the study patients similar to my population of interest?
  • Does your patient match the study inclusion criteria? If not, are there compelling reasons why the results should not apply to your patient?
  • Were all clinically important outcomes considered?
  • Are the likely treatment benefits worth the potential harm and costs?

 

APPLY: talk with the patient

Return to the Nursing Council -- integrate that evidence with clinical expertise, patient preferences and apply it to practice

 

You bring this article to the Nursing Council and any other studies that you found to address this issue.  The Nursing Council needs to consider the results of thess studies, the benefits, the adverse effects, the cost and the training involved in changing clinical procedures. All of these factors need to be factored into a decision.