Ask the Experts

Q The American Association of Critical-Care Nurses (AACN) publishes several evidence-based documents, including Practice Alerts, Procedure Manuals, and Protocols for Practice. What are the differences among these 3 publications and when should each one be used?A Marianne Chulay, RN, DNSc, and Joyce Hall, RN, MSN, reply:Each of the 3 publications serves a unique role in disseminating research-based information about critical care practice. The AACN Practice Alerts are designed to provide strong research-based direction to clinicians about a particular aspect of their practice that has a significant gap between the research and actual practice. The procedures published in the AACN Procedure Manuals provide a complete listing of everything to be done when providing a discrete nursing action for the patient, whether there is a research basis for each of the steps or not. The AACN Protocols for Practice are designed to provide a succinct summary of the key, research-based, nursing actions for a patient with selected conditions or technologies.Practice Alerts are succinct, evidence-based directives from AACN about important practices that must be performed by nurses to ensure optimal patient care and outcomes. Practice Alerts address 2 main areas of concerns: (1) the literature is clear about the expected practice but there is evidence that a majority of clinicians are not performing the action (a large research-practice gap exists) and (2) new, definitive research requires an immediate change in clinical practice.Topics in Practice Alerts address both nursing and multidisciplinary activities of importance to critically ill patients or environments.Practice Alerts are structured in the following format:Practice Alerts start with 2 to 4 bold statements that tell clinicians what the expected practice is that should be performed for optimal care. These statements represent actions that have been shown by research to be important aspects of patient care. The level of evidence that supports the practice statement is also listed, with most statements being at a level V (clinical studies in more than 1 or 2 patient populations and situations) or VI (clinical studies in a variety of patient populations and situations). The Practice Alert statements are followed by the scope and impact of the problem that substantiates the need for a change in practice.A summary of the evidence that supports the statements is included in the Supporting Evidence section, along with the most critical references of research studies, national guidelines, and/or expert opinion. The supporting evidence is followed by the actions that need to be implemented in nursing practice to ensure optimal patient care and the outcomes that can be expected if the nursing actions are implemented. The last section of the Practice Alert contains resources that will assist clinicians in implementing the change in practice.The AACN Procedure Manual is a detailed, step-by-step description of all the actions that nurses should take when performing a nursing intervention. The research studies that support the steps in the procedure are included in the rationale column for the procedure step. In addition, when strong levels of evidence exist to support an individual step, the level of evidence is also listed at the end of the procedure step.Many of the steps of procedures cannot be based on anything stronger than manufacturers’ recommendations or expert opinion because of lack of research at the time of publication. The Procedure Manuals are a comprehensive source for all procedures that are inherent in the care of critically ill patients.The Protocols for Practice are designed to provide a summary of the latest research findings about broad topics in critical care (eg, hemodynamic monitoring, care of patients receiving mechanical ventilation, noninvasive monitoring) in a format that is easy to understand and to integrate into clinical practice. Protocols for Practice usually include a general description of the protocol device or practice, a table of key nursing actions or recommendations and supporting rationale/references, an annotated bibliography of select references, and a reference list. The key nursing recommendation table only includes recommendations that are based on strong research and/or expert opinions on the importance of that recommendation. The protocol does not include all the steps of a procedure, only those that have strong, supporting evidence.The Protocols for Practice were designed to identify key research-based recommendations that clinicians should follow when providing care to critically ill patients without having to look up several different procedures on individual aspects of care. For example, the AACN Protocols for Practice: Care of Mechanically Ventilated Patients includes key, research-based recommendations on how to secure an endotracheal tube, how to inflate the cuff of an endotracheal tube, how to measure pressure in the cuff, how to suction an airway, how to humidify an artificial airway, and how to prevent complications of artificial airways. To find this information in the AACN Procedure Manual, at least 6 individual procedures would have to be reviewed before the clinician would be able to know the critical steps in maintaining an artificial airway.