NSG/455 Week 5: Evidence Synthesis and Proposed Practice Change, sample paper

From Evidence to Practice: A Synthesis and Proposal to Lock Implanted Ports With Saline at an Outpatient Infusion Center, With Measures

[Student Name]

University of Phoenix

NSG/455: Evidence-Based Practice and Statistics

Week 5 Assignment

[Instructor Name]

[Date]

The infusion center, staff and baseline figures are a composite written for a model paper; the synthesized sources are real publications.

The question that began this course was simple: why does the infusion center lock every implanted port with heparin? Over four weeks, it became a PICOT question, a documented search, an exercise in reading non-inferiority statistics and an appraisal of the key sources. This paper synthesizes that evidence and proposes a change in practice. The evidence does not prove that saline is better than heparin; it shows that heparin has not earned its place as the default, and that is enough to change what the center does routinely.

Synthesis of the Evidence

Occlusion. The evidence consistently shows no clear advantage of heparin over saline in preventing occlusion. The Cochrane review of randomized trials in adults with central venous catheters found low-certainty evidence and could not establish that heparin was superior (López-Briz et al., 2018). Two randomized trials conducted specifically in adults with implanted ports supported saline: one found saline non-inferior to heparin for functional problems such as difficulty withdrawing blood (Goossens et al., 2013), and a multicenter trial found no significant difference in occlusion (Dal Molin et al., 2015).

Infection. Across the review and the trials, catheter-related bloodstream infection was uncommon, and no source found a meaningful difference between the lock solutions. The evidence cannot prove that infection rates are equal, but it provides no signal that saline increases them.

Harms and practical considerations. Heparin carries risks that saline does not, including heparin-induced thrombocytopenia, contribution to bleeding in patients with low platelet counts and medication errors involving concentration mix-ups. Saline removes those risks and is less expensive.

Guidance. National infusion standards accept either heparin or preservative-free saline for locking central devices and direct clinicians to follow the device manufacturer's directions for use and organizational policy (Gorski et al., 2021).

Strength of the conclusion. Rated with the Johns Hopkins model in Week 4, the body of evidence is good in overall strength: consistent in direction, with adequately sized randomized trials in the target population, but limited by open-label designs and variable definitions of occlusion.

The Proposed Practice Change

Recommendation. For adults with implanted ports at the infusion center, change the default lock solution from 5 mL of heparin 100 units/mL to 10 mL of preservative-free 0.9% sodium chloride, flushed with a pulsatile technique and followed by positive-pressure clamping, when the port manufacturer's directions for use permit saline.

Exceptions. Continue heparin locking when the manufacturer's directions for a specific port model require it, for patients referred with a physician's order specifying heparin and for ports with a history of recurrent occlusion, pending individual review. Children are outside the scope of this change.

Rationale. The evidence shows saline is a reasonable alternative for occlusion and infection, and it removes heparin-related risks. The exceptions reflect the limits of the evidence and the authority of device instructions. Keeping the exceptions narrow and documented prevents them from quietly becoming the new default, while leaving room for individual judgment.

Implementation

Implementation follows five steps. First, pharmacy and the vascular access team review the directions for use of every port model placed at the hospital and list those that permit saline. Second, the infusion center's procedure and order set are revised, reviewed by the pharmacy and therapeutics committee and approved by oncology leadership. Third, nurses receive a short education session covering the evidence, the pulsatile flush and positive-pressure technique and the exceptions. Fourth, heparin lock syringes are removed from routine stock and kept only for documented exceptions, which also reduces concentration mix-up risk. Fifth, patients are informed of the change at their next visit, with a plain explanation that the new lock solution works as well without the risks of heparin.

Anticipated Concerns and Responses

Three concerns are likely to arise. Oncologists may worry that a rise in occlusions would delay chemotherapy. The response is that the evidence does not show a meaningful increase, that alteplase remains available to restore patency and that the evaluation will detect any change within months. Experienced nurses may feel that heparin has worked for years and that changing it implies they were wrong. The response is that heparin was a reasonable practice when adopted and that evidence-based practice means updating defaults as evidence accumulates, not judging past practice. Pharmacy may be concerned about managing two stocks during the transition. The response is to keep a small, separately stored supply of heparin for documented exceptions, which also addresses the concentration mix-up risk identified in Week 1. Naming these concerns in the proposal allows the change team to address them before they become resistance.

Evaluation Measures

Measures were chosen before the change so results can be compared with the baseline collected in Week 1.

Outcome measures: port occlusions requiring alteplase per 1,000 port-days, compared with the prior year's baseline; catheter-related bloodstream infections per 1,000 port-days, tracked with the infection prevention team; and ports removed for dysfunction.

Process measures: percentage of port locks using saline among eligible patients, from documentation audits, and percentage of nurses completing education.

Balancing measures: heparin-related adverse events and near misses, expected to decline, and nurse-reported difficulty with blood withdrawal, which could rise if technique is inconsistent.

Review. Results will be reviewed quarterly for one year on a run chart. If occlusion rates rise meaningfully above baseline, the team will review technique, device types and patient factors before deciding whether to modify the change.

Conclusion

A routine heparin lock, examined through a PICOT question, a documented search, careful reading of statistics and structured appraisal, turns out to rest on weaker evidence than its long use suggested. The synthesized evidence supports saline as a safe and effective default for locking implanted ports in adults, with exceptions where device instructions or clinical history call for heparin. Implemented with education and clear procedures, and evaluated with outcome, process and balancing measures, the change brings the center's practice into line with the evidence and gives it the data to confirm that decision in its own patients.

References

Dal Molin, A., Clerico, M., Baccini, M., Guerretta, L., Sartorello, B., & Rasero, L. (2015). Normal saline versus heparin solution to lock totally implanted venous access devices: Results from a multicenter randomized trial. European Journal of Oncology Nursing, 19(6), 638-643. https://doi.org/10.1016/j.ejon.2015.04.001

Goossens, G. A., Jerome, M., Janssens, C., Peetermans, W. E., Fieuws, S., Moons, P., Verschakelen, J., Peerlinck, K., Jacquemin, M., & Stas, M. (2013). Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: A randomised, non-inferiority, open trial. Annals of Oncology, 24(7), 1892-1899. https://doi.org/10.1093/annonc/mdt114

Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice, 8th edition. Journal of Infusion Nursing, 44(1S), S1-S224. https://doi.org/10.1097/NAN.0000000000000396

López-Briz, E., Ruiz Garcia, V., Cabello, J. B., Bort-Martí, S., Carbonell Sanchis, R., & Burls, A. (2018). Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults. Cochrane Database of Systematic Reviews, 2018(7), Article CD008462. https://doi.org/10.1002/14651858.CD008462.pub3