EBP Implementation Plan Guide
PICOT Question
Topic 1
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Preliminary
Checkpoint
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Topic 2
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Checkpoint 1
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Topic 3
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Checkpoint 2
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Topic 4
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Checkpoint 3
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Identify a health care issue you
want to see change.
Understand the culture of the
organization in its readiness for
EBP implementation.
Develop PICOT question.
Build EBP knowledge and skills.
Define project purpose.
Who are the stakeholders for your
project?
Identify active (on the
implementation team) and
supportive (not on the team, but
essential to success) roles.
Identify project team roles and
leadership.
Begin acquisition of any necessary
approvals for project
implementation and dissemination
(e.g., system leadership, unit
leadership, ethics board [IRB]).
Feasibility: Briefly integrate the
evidence with stakeholder
influence to inform evidencebased recommendations.
Hone PICOT question.
Conduct literature search and
retain studies that meet criteria for
inclusion.
Connect with librarian.
Critically appraise literature.
Summarize evidence with focus
on implications for practice.
Begin formulating a detailed plan
for implementation of evidence.
Include who must know about the
project, when they will know, how
they will know.
Connect the evidence and the
Notes:
Notes:
Notes:
Notes:
© 2014. Grand Canyon University. All Rights Reserved.
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Topic 5
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Checkpoint 4
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Topic 6
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Checkpoint 5
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Topic 7
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Checkpoint 6
Topic 8
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Checkpoint 7
project.
Identify and address known
barriers and facilitators of project.
Define post-project outcome
indicators of a successful project.
Define baseline data collection
Notes:
source(s) (e.g., existing data set,
electronic health record), methods,
and measures.
Identify resources (human, fiscal,
and other) necessary to complete
project.
Gather outcome measures.
Write data collection protocol.
Write the project protocol (data
collection fits in this document).
Finalize any necessary approvals
for project implementation and
dissemination (e.g., system
leadership, unit leadership, IRB).
Finalize protocol for
Notes:
implementation of evidence.
Complete final data collection for
project evaluation.
Include specific plan for how the
evaluation will take place: who,
what, when, where and how, and
communication mechanisms to
stakeholders.
Complete proposal.
Notes:
Develop proposal presentation.
Present proposal.
Review proposals, addressing new
questions generated from process
of the peer review.
Notes:
Adapted from Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2010). Evidence-based practice in
nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams
& Wilkins.
Course Code
NUR-699
Class Code
NUR-699-O501
Criteria
Content
Percentage
55.0%
Abstract
Presents a complete, concise
overview of all phases of the proposed project.
10.0%
Project / Content Comprehension
25.0%
Sections A-G Synthesis
20.0%
Organization and Effectiveness
30.0%
Appendices
15.0%
Mechanics of Writing (includes spelling,
punctuation, grammar, language use)
15.0%
Format
15.0%
Research Citations (In-text citations for
paraphrasing and direct quotes, and reference
page listing and formatting, as appropriate to
assignment and style)
15.0%
Total Weightage
100%
Benchmark - Evidence-Based Practice Proposal Final Paper
No Submissions (71.00%)
None
None
None
None
None
None
250.0
Unsatisfactory (75.00%)
No abstract
Content is incomplete or omits most of the requirements
stated in the assignment criteria. Does not demonstrate an
understanding of the basic principles. Does not demonstrate
critical thinking and analysis of the overall program subject.
The main sections are not easily identified; some of the
subconcepts do not successfully integrate to form a cohesive
whole. Within section revisions methods and strategies are
described poorly. Basic descriptions, connections, and
alignment are not clearly presented. Logic flow is random,
not easily understood.
Several of the appendices are missing. Designs are
not
neat or organized, and do not include all required elements.
Unprofessionally developed.
Surface errors are pervasive enough that they impede
communication of meaning. Inappropriate word choice
and/or sentence construction are used.
No reference page is included. No citations are used.
Less Than Satisfactory
(83.00%)
Abstract minimally written, clearly not sufficient to provide
the reader with an understanding of the project.
Content is incomplete or omits some requirements stated in
the assignment criteria. Demonstrates shallow understanding
of the basic principles. Within section revisions components
may be missing details, only a surface level of evaluation is
offered, methods are described but flawed or unrealistic and
strategies are discussed, but incomplete.
The main sections are somewhat identified; some of the
subconcepts branch appropriately from the main sections.
Basic descriptions, connections, and alignment as well as a
clear logic flow are somewhat fragmented, not easily
understood.
Several of the appendices are missing. Design detracts from
purpose. The work is not neat and includes minor flaws or
omissions of required elements. Limited understanding of the
topic is present as evidenced by the design.
Frequent and repetitive mechanical errors distract the
reader. Inconsistencies in language choice (register), sentence
structure, and/or word choice are present.
Reference page is present. Citations are inconsistently used.
Satisfactory
(88.00%)
Abstract provides overview of part of the project, but does
not cover each section.
Content is complete, but somewhat inaccurate and/or
irrelevant.
Demonstrates adequate understanding of
the basic principles. The major sections have had revisions
but some components may be missing details. Reasonable
but limited inferences and conclusions are drawn but lack
development. Supporting research is inadequate in relevance,
All of the main sections are easily identified, and subconcepts
branch appropriately from the main sections. Recognizes links
among sections; however, some connections may be
ambiguous. Basic descriptions, connections and alignment as
well as basic logic flow are understandable, but are
somewhat lacking in a clear progression.
All of the appendices have been provided. Design is fairly
clean, with a few exceptions. Appearance is general, and
major elements are missing. Provides minimal details.
Appropriate for the audience and the content but some of
the development of the material is inadequate. Basic
understanding of the topic is present as evidenced by the
Some mechanical errors or typos are present, but are not
overly distracting to the reader. Correct sentence structure
and audience-appropriate language are used.
Reference page is included and lists sources used in the
paper. Sources are appropriately documented, although
some errors may be present.
Good
(92.00%)
Abstract provides a quick or too brief overview of all phases
of the proposed project. Contains project title, project
director's name, and affiliation.
Content is comprehensive and accurate, and definitions are
clearly stated. Sections form a cohesive logical and justified
whole. All of the major sections have been revised based
upon logical feedback, conclusions, and sound research.
Shows careful planning and attention to details and
illuminates relationships. Research is adequate, current, and
All of the main sections are easily identified, and subconcepts
branch appropriately from the main sections. Descriptions,
connections, and alignments are provided. Logic flow is
smooth and easily understood, facilitating a thorough
understanding of the various sections as they interrelate.
All of the appendices have been provided. Designs are
appropriate and present quality products. Appearance is
neat, with a few minor flaws or missing elements. Provides
details with accuracy. Reveals a solid understanding of the
topic as evidenced by design.
Prose is largely free of mechanical errors, although a few may
be present. A variety of sentence structures and effective
figures of speech are used.
Reference page is present and fully inclusive of all cited
sources. Documentation is appropriate and citation style is
usually correct.
Excellent
(100.00%)
Abstract provides a complete concise overview of all phases
of the proposed project and flows well with the rest of the
paper. Contains project title, project director's name,
and affiliation.
Content is comprehensive. Presents ideas and information
beyond that presented throughout the course, and
substantiates their validity through solid, academic research
where appropriate. Research is thorough, current, and
relevant, and addresses all of the issues stated in assignment
criteria. Final paper exhibits process of creative thinking and
All main sections are easily identified, and sub concepts
branch appropriately from main sections. Descriptions,
connections, and alignments are obvious and well supported.
Logic flow is smooth and easily understood, facilitating a
thorough understanding of various sections as they
interrelate. Connection to extraneous materials are well
All of the appendices have been provided. They are effective
and functional. The work is well presented and includes all
required elements. The overall appearance is neat and
professional. Gives sufficient detail with precision and
specificity. Reveals a solid understanding of the topic as
evidenced by the design.
Writer is clearly in command of standard, written, academic
English.
In-text citations and a reference page are complete and
correct. The documentation of cited sources is free of error.
Comments
Points Earned
Evidence-Based Practice Proposal Final Paper Overview
1. Throughout this course you will be developing a formal, evidence-based practice
proposal.
2. The proposal is the plan for an evidence-based practice project designed to address a
problem, issue, or concern in the professional work setting. Although several types of
evidence can be used to support a proposed solution, a sufficient and compelling base
of support from valid research studies is required as the major component of that
evidence. Proposals are submitted in a format suitable for obtaining formal approval
in the work setting. Proposals will vary in length depending upon the problem or
issue addressed; they can be between 3,500 and 5,000 words. The cover sheet,
abstract, references page, and appendices are not included in the word limit.
3. Section headings and letters for each section component are required. Responses are
addressed in narrative form in relation to that number. Evaluation of the proposal in
all sections is based upon the extent to which the depth of content reflects graduatelevel critical-thinking skills.
4. This project contains six formal sections:
a) Section A: Organizational Culture and Readiness Assessment
b) Section B: Problem Description
c) Section C: Literature Support
d) Section D: Solution Description
e) Section E: Change Model
f) Section F: Implementation Plan
g) Section G: Evaluation of Process
5. Each section (A – G) will be submitted as separate assignments so your instructor can
provide feedback (refer to each Module and the Course Assignment Matrix).
6. The final paper will consist of the completed project (with revisions to all sections), title
page, abstract, reference list, and appendices. Appendices will include a conceptual
model for the project, handouts, data and evaluation collection tools, a budget, a
timeline, resource lists, and approval forms.
7. Use the EBP Implementation Plan Guide and the Evidence-Based Practice Project
Student Example to assist you.
© 2014. Grand Canyon University. All Rights Reserved.
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Evidence-Based Practice Project Student
Example
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Table of Contents
Generating Evidence for Evidence-based Practice
Part 1: Introduction
I. The problem statement ………………………………….……………………....……….3
II. The evidence-based question ………………………………………..……….……….…4
Part 2: Assemble relevant evidence & related literature
III. Locating credible evidence………………………………………………….…...………3
IV. Appraise the evidence……………………………………………………….……...……4
Part 3: Implementation of the intervention
I. Planning of change………………………………………………………………..…....8-9
II. Clinical protocol and pilot project………………………………………………9-14 & 23
III. Integration and Maintenance …………………………………………………….…..14-15
IV. Barriers and strategies………………………………………………….……………15-18
Part 4: Conclusion ………………………………………………..…………………………….18
Part 5: References……………………………………………………………………………20-22
Part 6: Appendices …………………………………………………………..…………….……23
I. Management of Mechanically Ventilated Patients: Pilot Project ……………………23-24
II. Questions for Patient Ventilator Rounds ………………………………………………..25
III. Methodological matrix ………………………………………………………………26-28
IV. Prevention In- Service Flyer ……………………………………………………………27
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Problem Statement
The development of pneumonia caused by mechanical ventilation is a significant problem
in the intensive care units of hospital facilities. Ventilator-associated pneumonia (VAP) is the
“most commonly reported healthcare-acquired infection” in patients requiring mechanical
ventilation support (Garcia et al., 2009, p. 524). One of the most common reasons for an ICU
admission is related to respiratory distress or failure. VAP is described as a form of nosocomial
infection which occurs after the first 48 hours of receiving mechanical ventilation (Augustyn,
2007). The length of stay (LOS) for patients developing VAP is higher than those never
requiring mechanical ventilation by an increase of approximately six days (Garcia et al. 2009).
In intensive care units (ICUs) across the United States (US), ventilator-acquired pneumonia also
results in prolonged periods of actual mechanical ventilation, the excess use of antimicrobial
products, increased utilization of healthcare resources and costs, and significant increase in
morbidity and mortality (Coffin et al., 2008). Garcia et al. (2009) found on average, estimated
costs of an additional $11, 897 to $150,841 per individual case were spent. VAP has a
significant economic impact on our society, costing hospitals money which potentially could
have been saved.
Numerous risks factors contribute to the development of ventilator-acquired pneumonia
as mechanical ventilation presents a unique set of challenges for the patient requiring intubation
and ventilator support. Rigorous clinical studies show oral secretions pose an increased risk for
developing VAP (Augustyn, 2007). Treatments, strategies and evidence-based interventions
have been developed to decrease the risks and reduce the prevalence of VAP. There is evidence
indicating the use of oral chlorhexidine and the removal of oral secretions before position
changes may diminish the risks of developing ventilator-acquired pneumonia. By reducing the
levels of bacteria in the oropharynx there would theoretically be a decrease in the prevalence of
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nosocomial pneumonia (Houston et al., 2002). Research demonstrates the use of 0.12%
chlorhexidine gluconate oral rinse (CHX) pre and postoperatively reduces the incidence of VAP
in patients who are intubated greater than 24 hours.
Foreground Question
In adults supported with mechanical ventilation, what is the effect of oral chlorhexidine
use and removal of oral secretions prior to position changing on the development of ventilatoracquired pneumonia?
Review of Evidence and Synthesis of Literature
This is a literature analysis of research reports and literature reviews which studied the
effects of removal of oral secretions prior to position change on the occurrence of VAP. A
summary of the articles can be found in Appendix C. The studies varied in design; from
randomized to non-randomized, placebo, to longitudinal and a pilot study. Strength for each
study is noted at Level II on the hierarchy as each one is a randomized or nonrandomized clinical
study. The research supports our clinical question and was utilized with the development of
additions to be incorporated into the already existing ICU VAP protocol.
The studies focused on in this review consisted of evidence evaluating oral secretion
removal and the use of chlorhexidine gluconate oral rinse to prevent VAP. The cost
effectiveness of these interventions was found to be significant. Studies showed oral secretions
as being the medium to carry pathogens within the oropharyngeal site down into the respiratory
track. The literature hypothesized removing oral secretions prior to the position change of a
patient can prevent or minimize the movement of organisms into the respiratory tract which lead
to VAP development. Some researchers also concluded the significance of chlorhexidine use for
reducing nosocomial infections. The combination of both interventions creates a profound effect
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on reducing VAP occurrences its research importance, which this practice change aims to
strongly support.
The review of literature consists of evidence dating from 1996 to 2008, indicating the
need for continued research and close monitoring of clinical practice changes based on the best
evidence at the moment. This problem was identified long ago and yet still needs further
evidence for best practice. Three articles discuss removing oral secretions prior to position
changes of patients which are one of the two independent variables of interest for this review.
In one of those studies, VAP was diagnosed in 24 of 159 patients in the control group, but only
in five of 102 patients in the study group within the study group receiving oral suctioning prior to
all position changes (Chao, Chen, Wang, Lee, & Tsai, 2008). A similar study showed VAP
occurrence at 2.6% in the study group and 11% in the control group with probability of < 0.001
(Tsai, Lin, Chang, 2008).
Studies by DeRiso et al. (1996) and Houston et al. (2002) each sought to evaluate the
efficacy of oropharyngeal decontamination on nosocomial infections in patients undergoing heart
surgery using CHX before and after surgery. Both DeRiso et al. and Houston et al. discovered
an overall reduced rate of VAP (52% and 69% respectively for each study). The significance
level for both studies was less than .01 (use the higher of the two) with the use of CHX with oral
suctioning of subjects for these studies.
Another related intervention assessed in a similar randomized clinical study was the use
of subglottal suctioning by Smulders et al. (2002) and its effect on VAP incidence. This
intervention was appropriate for this review of literature; four percent of patients who underwent
continuous suctioning developed VAP as compared to 16% in the control group. A common
finding in the studies reviewed was the savings in spite of the costs of using CHX and equipment
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for oral and subglottal secretion removal. The majority of these studies revealed a significantly
reduced duration of mechanical ventilation and LOS in the ICU.
All research studies in this literature review, with the exception of Tsai et al.’s study,
consisted of study groups homogenous in patient samples, which suggest effective
randomization. Tsai et al.’s study has patient heterogeneity (of both medical and surgical ICU
patients) which may have confounded the results. Also, the results of Chao et al.’s study did
yield a significant difference with the distribution of patients having a history of COPD, DM, use
of antacids, and surgery. These variables were then evaluated with logistic regression for their
relationship in VAP development, and the results of the logistic regression showed no significant
impact on the direct development. Overall the reviews are well organized, use appropriate
language, and use mostly all paraphrasing. This review summarizes key finding of evidence for
clinical practice, and provides similar conclusions like our study regarding interventions to
implement in practice.
This literature review consisted of all but one study which were experimental in nature
and hold “a high degree of internal validity because of the use of manipulation and
randomization” (Polit & Beck, 2008, p. 295). Tsai et al.’s study was a time-sequenced, nonrandomized quasi-experimental study most vulnerable to threats to internal validity out of all the
literature reviewed. But the remaining study participants in the rest of these experimental
designs were all randomized after meeting inclusion criteria. Only two studies (by Houston et al.
and Tsai et al.) may have had questionable internal validity. Houston et al.’s study group was
large but possibly too broad with subjects intubated for too short of a period to have the
intervention be significant. This provides evidence for the need to implement such an
intervention and continue research. This may have led to potential Type I and II errors. Tsai et
al.’s weakness was the limitation of a non-randomized control study and patient heterogeneity as
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previously mentioned. In addition, Chao et al. used a staff nurse of the ICU to conduct data
collection; because it is her ICU she may want “her unit” to do well with compliance with the
study, creating bias. Also, in both this and Smulders et al.’s studies suctioning pressure was
discussed. Internal consistency was not documented and this lack of information affects the
reliability of the measurement tools. Selection bias does not appear to be a concern in these
studies, and there appears to be no threat of history and the groups were mainly homogenous.
Overall the internal validity of the research in this literature review is rather strong taking into
consideration these few discussed weaknesses.
Regarding external validity, the research findings in these studies can easily be generalized
to similar mechanically-ventilated ICU adult populations. The patient populations were
representative of the typical ICU population and because of this, external validity is strong.
Steps were taken to control characteristics which could impact the groups being compared, and
any requirements for participants were taken into consideration when developing the sample.
The study by DeRiso et al. was double-blinded and placebo-controlled in design
techniques, and Smulders et al.’s study reported blinding with the radiologists in regards to
reading all X-ray reports. These techniques enhanced the internal validity. The studies were
each performed in only one setting, but could very easily be replicated in another ICU
environment. Tsai et al. and Chao et al.’s studies had a period during their research which was
dedicated to educating staff on the protocol to be implemented to the experimental group. This
enhanced intervention fidelity in both studies. Also, the individual collecting the data from Chao
et al.’s study group was a trained staff member of the ICU floor, and such actions facilitated a
strong reaction with the intervention and validated construct. No incentives were provided to
staff members for compliance with Chao et al.’s study, but staff was aware of the fact that the
clinical setting was being monitored and data collected based upon their performance. However,
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normally nurses are not monitored closely and corrected for actions. Education for new changes
to protocols is usually brief, and like any change, will take some time for the staff to acclimate
to.
There appears to be no apparent threat to construct validity with the discussed literature.
However one could argue the researcher’s expectancies for desired outcomes playing an effect.
For example, Tsai et al. and Chao et al.’s studies involved the staff received a thorough
education and period of time to learn the protocol for the study’s intervention. Knowing the
researcher’s expectations, this could “become part of the treatment construct that is being tested”
(Polit and Beck, 2008, p. 301). Researchers appropriately balanced all concerns for validity in
their study.
Planning a Change
After critically analyzing the evidence, the nurse develops a plan to apply the findings to a
clinical practice. Developing a plan for change includes identifying strategies to gain
cooperation and evaluating outcomes. Once it is decided that evidence supports a practice
change, the change agent or facilitators must develop and test the improvement. This step
requires some preliminary planning and research. Is the innovation practical, the evidence
transferable, is the organization ready for change, are outcomes measurable and will is it possible
to implement the EBP within the organization (Newhouse, Dearholt, Poe, Pugh & White, 2007)?
If the answers are agreeable, the innovation must be authorized through the appropriate
organizational channels. The implementation of an evidence-based practice is considered a
quality improvement initiative and does not require the hospital Institutional Review Board
approval. The Quality Care Committee, which oversees process improvement, protocol, and
policy changes, will review and approve this proposed implementation of evidence-based
practice, as part of the initial planning. The planning phase includes assessing the feasibility of
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change, defining the change, identifying resources, and defining the desired outcomes (Reavy &
Tavernier, 2008).
The proposed EBP innovation is to complement the policy for oral care and suctioning of
mechanically ventilated patients with a 10% chlorhexidine gluconate oral rinse and increase
suctioning to every two hours prior to repositioning. These interventions can also be increased
according to the patients’ needs. The expected outcomes of the change are improved patient
care, reduced costs related to VAP infection and increased lengths of stay, and the reduction of
the incidence of VAP in patients mechanically ventilated for more than 24 hours. The project
feasibility is very good, due to the small scale of the intervention, the ease of implementation
into protocol already in place, it’s compatibility with the practice environment, and it is simple to
test in a small sample (Newhouse, Dearholt, Poe, Pugh & White, 2007). Other aspects
contributing to the project’s potential for success is the availability of ample resources including
the Quality Care Committee, Clinical Nurse Specialist, ICU Nurse Educator, Unit Preceptors,
Clinical Managers, and Infection Control Nurse.
Implementation and Evaluation of Change
Proposed Project
The authors plan to implement changes in current policy of management of ventilated
patients as a pilot project at Scottsdale Healthcare Shea ICU. The change will be to add
chlorhexidine rinse for oral care every two hours and suctioning of oral secretions prior to
repositioning the patient. The data will be collected on all ventilated patients during daily
multidisciplinary team vent rounds by the infection control nurse. See Appendix A for pilot
project with current changes in policy. We plan to implement the change at Scottsdale
Healthcare Shea medical surgical ICU from June 1, 2010 to April 1, 2011.
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Implementation Plan
To enhance the patient outcome during hospitalization, an evidence-based pilot project
will be implemented. As mentioned earlier, the problem of VAP pertains to all ventilated
patients in different ICUs, but it is easier to start the pilot project in one unit and expand it to the
other ICUs of the Scottsdale Healthcare hospitals after assessing the effectiveness of the plan and
making any necessary changes after the evaluation process. The authors propose to implement
the pilot project initially in the ICU of Scottsdale Healthcare at Shea campus. The plan will be
presented to the ICU nurse manager, supervisors, infection control nurse, and the clinical
educator of the ICU to obtain permission and approval in order to implement the plan. The plan
will also be presented to Quality Care Committee May 2010 meeting for their permission for the
change. After obtaining permission for the plot project, evidence base education material
containing prevalence of VAP rate, its complications, cost, recommended change with use of
chlorhexidine gluconate in oral care, and oral secretion suctioning prior to position change will
be presented to the staff during ICU Unit Base Committee (UBC). Four more teaching sessions
will be provided, two in each day and night shift, so that staff can attend a session which is more
convenient to them. All the registered nurses working in ICU will be required to attend one of
the teaching sessions. The teaching session or in-service will be on May 20, 2010 from 8 a.m. to
9 a.m. and from 8 p.m. to 9 p.m. These times are chosen to make it convenient for nurses to
attend the in-service before going home at the end of their shift. Two more teaching sessions
will be provided on May 23, 2010 from 11 a.m. to 12 noon and from 10 p.m. to 11 p.m. Six
brochures to notify staff of the in-service dates and times will be prepared and placed in the
restrooms, break rooms and in hallways within the unit (Appendix D).
A power point presentation along with two poster boards containing evidence based
information about VAP prevalence and its outcomes and changes in practice will be prepared
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and presented to staff during the in-service. One poster board will be placed in break room and
the other poster will be placed in meeting room of ICU to enhance teaching. Time for answering
any questions will be provided at the end of the teaching session. The teaching will be
conducted in an informal way, and the research assistant will be available to re-educate and
answer questions for staff as needed. One day shift nurse and one night shift nurse will be
prepared by the nurse educator to do the teaching for the rest of the ICU staff. The physicians
and respiratory therapists of ICU will also be notified of this evidence based plan so they will be
knowledgeable about this VAP pilot project.
The resources needed for the implementation of this plan are two poster boards, a power
point, and a jump drive to store the teaching material. Also required would be the chlorhexidine
gluconate oral rinse, which would be ordered from pharmacy for each ventilated patient in the
intervention group. The other resources needed are the staff education time for the RNs who are
teaching the in-service and the staff who is attending the in-service. There are twenty-three day
shift RNs and twenty night shift RNs in ICU who will need to attend these in-services, so one
hour in-service for each RN will need forty-three hours of education time for registered nurses in
addition to five hours of teaching time for the RNs who are teaching these in-services. Most of
the cost of this project is the cost of education time for the staff nurses. The two poster boards
will cost seven dollars each, a small jump drive for twenty dollars and the power point is free.
The cost of chlorhexidine is also negligible when compared with the cost of VAP. This will be
the money well spent and pay for itself with shorter length of stay of ventilated patients due to
VAP prevention or reduction. This project will save money for the hospital by improving patient
outcome and decreasing VAP rates and the hospital length of stay.
Having a theoretical framework enhances the worth of the study according to Polit and
Beck (2008). This plan will be guided by the Kurt Lewin’s change theory to improve delivery
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of information to staff. Lewin’s change theory involves a three stage model of change, which are
unfreezing, change, and re-freezing (Neil, 2004). The first stage of unfreezing involves the
concept of becoming motivated to change or unfreeze from previous practices. In ICU, the staff
will be prepared for the change by explaining them the magnitude of the problem, so that they
feel the need for the change. They will be notified about the statistics of VAP prevalence and the
magnitude of the complications of VAP. These measures will motivate the staff for a change in
practice.
The second stage of Lewin’s change theory is implementation of the change. This stage
is the actual stage of alteration and will be most essential in maintaining consistency with the use
of chlorhexidine in oral care and suctioning the patients prior to position change. Support will be
provided to staff during this stage by answering their questions and addressing any concerns they
have. The registered nurses will implement the learned techniques of using chlorhexidine in oral
care and suction patients prior to position change every two hours and as needed for the duration
of plot project from June 1, 2010 to April 1, 2011. The multidisciplinary vent round will
continue to enforce the change and collect data on ventilated patients. The physicians will also be
supported and welcomed for their input in this process.
Lewin’s final stage of the change theory is the concept of re-freezing or making the
change permanent. In this last stage of change theory, the newly learned changes become
habitual for the staff (Neil, 2004). The staff will be reinforced and encouraged to continue to
follow the recommended changes at each month’s staff meeting and daily multidisciplinary vent
rounds for the duration of pilot project. The staff will also be encouraged for their feedback on
this project. They will also be reinforced about this newly learned skill at the annual skills fair
and have opportunity to get their questions answered. The future of the healthcare is moving
13
towards pay for performance measures and this teaching plan will lead Scottsdale Healthcare
towards delivering a better patient outcome.
Evaluation Plan
The evaluation of this teaching plan is relatively simple. The infection control nurse
keeps the data of VAP rate of all ventilated patients. The data including VAP rate obtained by
infection control nurse from vent rounds during the pilot project will be compared with the VAP
rate of ventilated ICU patients of this unit from the previous year. The VAP rate during pilot
project for the months of June 1, 2010 to April 1, 2011 will be compared with the VAP rate of
previous year for the months of June 1, 1009 to April 1, 2010 to promote validity. The types of
patients vary by season, and by doing this we increase the likelihood of having a similar patient
population which is representative of the months of June to April. These findings will be
discussed among the ICU manager, supervisors, clinical educator and infection control nurse in
May 2011 upon completion of pilot project. A decision will be taken to adopt the change or
reject the change depending on the findings if VAP rate was reduced or not.
Dissemination Plan
The staff will be will be notified of the project completion in monthly staff meeting in
May 2011. The goal of this dissemination plan is to utilize this new research or evidence based
information to improve patient outcome. If the finding suggests a decrease in VAP rate during
pilot project, the change will need to be implemented to other ICUs of Scottsdale Healthcare.
All the nurses at Scottsdale Healthcare ICUs will need to be reached to ensure that everyone can
benefit from this information. Since the problem of VAP pertains to all the ICUs of Scottsdale
Healthcare hospitals this information needs to be disseminated to the Scottsdale Healthcare Shea
CVICU, and eventually to ICUs at Osborn and Thompson Peak campuses. With the permission
from the PCC’s chair, the committee will be presented with recommended changes. The project
14
will be presented in detail and the importance of the need for a change in practice for VAP
reduction will be stressed with the supporting evidence. Again the goal will be to obtain
permission to expand the changes to CVICU of Scottsdale Healthcare Shea. Two to four nurses
from each floor can be prepared to teach the rest of the staff on CVICU. In-service time to
prepare them will be arranged at a convenient time.
The power point presentation containing the teaching material will be made available to
all the hospital employees on the Scottsdale Healthcare Shea campus’s Special Care Unit’s web
site. This will promote access to the teaching contents for the staff. The other sources of
information will be the RNs of ICU who performed the in-service for their staff. A copy of this
plan will be made available to the staff through Scottsdale Healthcare Library also.
To include Osborn and Thompson Peak in the teaching plan, the Nursing Leadership
Committee will be approached, where the nursing managers from all three campuses are
available. They will also be approached the same way as mentioned above to disseminate the
pilot project recommended changes plan to the two other campuses. The resources, the contents
of the VAP teaching plan, and the medium will be made accessible to them as well. A
dissemination plan as mentioned above will be carried out in a similar fashion for the other two
campuses also.
Integration and Maintenance of Change
Initiating the changes to the pre-existing protocol would first involve several steps as
previously mentioned. There would be a decision on who would be collecting the research data.
After the Quality Care Committee approves the change, we would select a research assistant
experienced in infection control to collect data and monitor the process during the study. This
study would also require a qualified personal to educate the staff on the protocol changes and be
available to answer any questions which may arise. The pilot study (see Appendix A) would
15
then take place. Prior to the study, daily rounds are completed on each ventilated patient to
collect information for VAP. After implementing this study, this research assistant would
accompany the ventilator rounds team and collect information applicable to the study. This
would help facilitate monitoring the process and outcomes of the intervention. See Appendix B
for examples of major questions included during ventilator rounds. Questions italicized would
be additions made to the rounds during the study for data collection purposes. This information
on VAP rates and patient length of stay after implementing the new interventions would be put
together and submitted to the appropriate committees.
Integrating the new policy on the unit, staff will be much more likely to accept and support
the new process if they know what to expect at each phase of the change. Additionally, staff
members are able to contribute ideas drawn from their varied experience. Staff ideas often
improve the process, save money, and avoid potential obstacles (Gotsill & Natchez, 2007).
Implementing this change of protocol would involve the cooperation of both the research and
hospital staff. Communication between both groups is crucial, and a key concept of
implementing a practice change. Providing updates to the Quality Care Committee, Infection
Control Team, unit manager, and the staff throughout the study would be crucial. Quarterly
feedback to the staff alone will help visually show their cooperation in this study and the
beneficial outcomes yielded from the implementation change.
Barriers and Strategies of Change
The work environment healthcare professionals face daily is demanding. Nurses manage
heavy workloads and high acuity patients along with staffing shortages and cost cuts, which
reduce all available resources. This creates challenges to implementing new policies, protocols,
or evidence-based practice (EBP). Some of the potential barriers to implementing EBP clinical
changes can be categorized as individual, organizational, environmental, and communication
16
based barriers (Udod & Care, 2006). Although it appears to be an impossible task, there are
many strategies to help gain cooperation from the individuals responsible for implementing
change. A few strategies are managerial support, clearly written research, exposure to real-life
case studies, role modeling, staff engagement opportunities, and psychosocial support (Udod &
Care; Thompson, Bell & Prevost, 1999).
Potential Barriers to Implementing EBP
Healthcare professionals have reported a variety of barriers to implementing EBP.
Nurses can be skeptical, especially if they have misperceptions, fears, or anxiety that prevents
them from having a clear vision when implementing change (Melnyk & Fineout-Overholt,
2005). Individual barriers include a lack of competence of nurses and managers regarding the
implementation of EBP strategies, a lack of academic skills, and an inability to apply research to
practice as evidenced by the large research-practice gap that exists in the profession (Udod &
Care, 2006). Overwhelming workloads may also leave nurses drained, lacking motivation,
confidence, awareness, and time (Thompson, Bell & Prevost, 1999). Melnyk and FineoutOverholt state that barriers to EBP implementation and adherence are oftentimes related to
individual attitudes. A lack of confidence in the plan or its creator, an inability to visualize a
positive outcome, or doubt in one’s own skills are a few examples (2005).
Some individual barriers can be associated with the organization. However, nurses must
overcome other organizational barriers. Examples are administrative constraints such as a lack
of funding for skill development, opposing managerial priorities, or a lack of support from
management and administration (Udod & Care, 2006). Other workplace barriers are difficulty
accessing journals and evidence to support EBP, peer pressure to continue traditional practices,
patient demands for widely prescribed treatment, and heavy patient loads which prevent learning
and EBP implementation (Melnyk & Fineout-Overholt, 2005).
17
Nursing professionals face environmental barriers, as well, in the implementation of EBP.
EBP can be affected by government policy or may be controlled by laws and legislation. An
example is the use of medical marijuana for nausea and anorexia in cancer patients, which is
illegal in many states. Coworkers and managers with different agendas in the workplace can be
considered an environmental barrier to change. Occasionally an organization has such a fast
moving culture of change, it leaves nurses too overwhelmed to cope (Udod & Care, 2006).
Finally, there are communication barriers in every aspect of life. The implementation of
EBP can be affected by a lack of appropriate collaboration and communication between every
level of provider involved including researchers, nurses, educators, managers, and administrators
(Thompson, Bell & Prevost, 1999). Communication errors and barriers can occur in the
educational programs and training for EBP, the interpretation of research, and in publications
and presentations (Melnyk & Fineout-Overholt, 2005). This issue can be further complicated
with the addition of multidisciplinary involvement, which requires another level of
communication to be successful.
Strategies for Successful Implementation of EBP
The implementation of EBP provides for safer, more cost-effective care with patientspecific interventions. In order to accomplish this, organizations must employ a plan to gain
cooperation from the individuals who are responsible for implementing the EBP. Successful
implementation requires organizational change and buy-in. The most important strategy for EBP
implementation is ensuring the support of the organization and management. This will assist in
eliminating constraints, allow for budgeting and possibly funding for education and incentives,
and provide encouragement and persuasion as the organization forms its opinion about the EBP
implementation (Newhouse, Dearholt, Poe, Pugh & White, 2007).
18
Nurses and physicians cite the desire for clearly written research reports and exposure to
case studies where EBP resulted in improved outcomes. Providing appropriate education and
tools for EBP implementation and ensuring access to evidence will reinforce and help providers
understand the benefits (Melnyk & Fineout-Overholt, 2005). Psychosocial support is an
important strategy, which simply means nurses are enabled and encouraged to perform the
desired change. This is accomplished with good education, clear-cut expectations,
reinforcement, acknowledgement, and rewards. Another similar strategy is role modeling
nursing practice. This is done by demonstrating commitment and supporting the cause for
advancing the EBP, while performing or educating staff about the desired change.
Staff involvement is important when implementing change. Strategies can include encouraging
nurse participation in a journal club or other collaborative opportunity to share evidence. Super
users, trainers, champions or stakeholders, whatever title one chooses, can be trained to coach
staff and provide collegial support and role modeling. Staff can also share in leadership and
decision-making, give their feedback and opinions, and contribute new ideas regarding EBP
implementation through Shared Leadership, focus groups, and surveys. This allows the
organization to measure nursing staff knowledge, attitudes, and beliefs and identify
implementation challenges (Melnyk & Fineout-Overholt, 2005).
Conclusion
The evidence in totality supports this practice change. This implemented change would
include the variables of interest discussed previously in the literature review and pilot plan. The
benefits of such an intervention change have the potential to support EBP and nursing practice.
Contrary to the misperceptions many nurses have about EBP, it does not take away from the
nurses’ clinical expertise. EBP integrates the best care with research evidence, patient’s
individualized needs, preferences and circumstances (Polit & Beck, 2006). It also allows for
19
exceptions in clinical setting and resource constraints. EBP can also be used as a problemsolving strategy in clinical care by taking away decisions based on custom, authority, opinion, or
ritual (Polit & Beck).
20
References
American Association of Critical-Care Nurses. (2005). AACN procedure manual for critical
th
care, (5 ed.). St. Louis, MO: Elsevier Saunders.
American Association of Critical-Care Nurses (rev. 1 0/07). AACN Practice alert: Oral
care in the critically ill. Retrieved June 3,2008 from
http://www.aacn.orgIWD/PracticeIDOCS/Oral_ Care_in_the_ Critically_1I1.pdf
Augustyn, B. (2007). Ventilator-associated pneumonia: Risk factors and prevention. Critical
Care Nurse, 27, 32-39. Retrieved from
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Chao, Y. C., Chen, Y., Wang, K. K., Lee, R., & Tsai, H. (2008). Removal of secretions prior to
position change can reduce the incidence of ventilator-associated pneumonia for adult
ICU patients: A clinical controlled study. Journal of Clinical Nursing, 18, 22-28.
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Coffin, S. E., Klompas, M., Classen, D., Arias, K. M., Podgorny, K., Anderson, D. J.,...Yokoe,
D. S. (2008). Strategies to prevent ventilator-associated pneumonia. Infection Control
and Hospital Epidemiology, 29, 31-40. doi:10.1086/591062
DeRiso, A., Ladowski, J., Dillon, T., Justice, J., & Peterson, A. (1996). Chlorhexidine gluconate
0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. CHEST,
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Garcia, R., Jendresky, L., Colbert, L., Bailey, A., Zaman, M., & Majumder, M. (2009). Reducing
ventilator-associated pneumonia through advanced oral-dental care: A 48-month study.
American Journal of Critical Care, 18, 523-532. doi:10.4037/ajcc2009311
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Gotsill, G., & Natchez, M. (2007). From resistance to acceptance: How to implement change
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Houston, S., Houghland, P., Anderson, J., LaRocco, M., Kennedy, V., & Gentry, L. (2002).
Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of
nosocomial pneumonia in patients undergoing heart surgery. American Journal of Critical
Care, 11, 567-570.
McEwen, M., & Wills, E. M. (2007). Theoretical basis for nursing (2nd ed.). Philadelphia, PA:
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guide to best practice. Philadelphia, PA: Lippincott, Williams & Wilkins.
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http://wilderdom.com/theory/UnfreezeCgangeRefreeze.html
Newhouse, R., Dearholt, S., Poe, S., Pugh, L., & White, K. (2007, December 1). Organizational
change strategies for evidence-based practice. The Journal of Nursing Administration,
37(12), 552-557.
Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for
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Smulders, K., Hoeven, H., Pothoff, I. W., & Grauls, C. V. (2002). A randomized clinical trial of
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23
Appendix A
Management of Mechanically Ventilated Patients: Pilot Project
Goals/outcomes
The patient will maintain adequate breathing pattern to provide appropriate
oxygenation and acid/base balance while providing respiratory muscle rest. The incidence
for VAP will be reduced due to EBP pilot project interventions.
Definitions
Acid/base balance = determined by pH values from arterial blood gas
VAP = Ventilator Associated Pneumonia
RCP = respiratory care practitioner
EBP = evidence based practice
Assessment
•
Assess and document breath sounds every four (4) hours and as needed.
•
Monitor and verify ventilator settings every two (2) hours and as needed. Assure that
ventilator alarm volumes are audible at all times.
•
Monitor arterial blood gases per physician order. Notify physician as needed.
Interventions
A. Wash hands with antiseptic soap and water or apply alcohol-based hand gel
before and after performing interventions.
B. The patient will be assigned to a hospital bed allowing maximum visibility at all
times.
C. Utilize oral airway if patient is obstructing oral endotracheal tube.
D. Suction as needed; document amount, color and character of tracheal secretions.
(Utilize humidified oxygen set-up to maximize mobilization of secretions.)
E. Reposition every two hours and as needed (unless contraindicated), suction oral
24
Appendix A Continued
secretions prior to position change. Elevate head of bed to at least 30 degrees (unless
contraindicated).
F. Use oral cleaning and suction system.
1. Brush teeth and tongue a minimum of once every 12 hour shift.
2. Provide oral care every 2 hours with chlorhexidine rinse.
3. Perform oral suctioning every two hours and prior to position change.
G. Document and report to physician significant changes in pulmonary status and
secretions through collaboration of RCP and RN.
H. Culture tracheal secretions per physician's order.
I. Keep Ambu-bag mask and adapter with patient at all times for transport and/or
emergency.
J. If the patient exhibits signs/symptoms of respiratory distress or ventilator alarm
sounds and problem cannot be quickly identified, disconnect patient from the ventilator,
manually ventilate, and call for appropriate assistance.
K. Reduce anxiety by:
1. Explaining all procedures to the patient.
2. Providing alternative methods of communication while intubated.
3. Re-assuring the patient that extraneous alarms are normal and do not usually
indicate an emergency situation. Indicate appropriate medical personnel are
always close by.
4. Placing the "nurse call" button within patient's reach.
5. Administering sedatives/analgesics as ordered.
L. Weaning - Follow specific weaning/extubation orders per respiratory protocol or as
written by the physician.
Supportive Data
See Reference list
25
Appendix B
Questions for Patient Ventilator Rounds
Patient Care Question
Answer from Staff
Hospital day number
Number of days ventilated
Oral care Q2
Use or Chlorhexidine with oral care*
Removal of secretions prior to position changes*
Head of bed 30 degrees
Repositioning Every 2 hours
SUP prophylaxis
DVT prophylaxis
Sedation vacation
White Blood Cell Count
Temperature (max/low in 24 hours)
“*” indicates interventions added to the current existing protocol
26
Appendix C
Methodological Matrix and Evaluation Matrix
Country
Theory
Dependent
Variables
Independent
Variables
Study design
Sample
size
DeRiso,
2002
A.
Ladowski
, J.Dillon,
T. Justice,
J.Peterson
, A.
USA
Quantitative
nosocomial
infections
chlorhexidine
gluconate oral
rinse
Prospective
randomized
placebocontrolled
double-blind
experiment
353
Randomized surgical
patients undergoing heart
surgery
data
analyzed of
patient
outcomes
after
interventions
complete
Houston, 1996
S.
Hougland
, P.
Anderson,
J.
LaRocco,
M.
Kennedy,
V Gentry,
L.
USA
Quantitative
nosocomial
pneumonia
chlorhexidine
gluconate oral
rinse
Prospective
Randomized
case-controlled
561
Randomized surgical
patients undergoing heart
surgery
Observation
&Self report
Author
Pub
Yr
Sampling
Method
How data
collected
27
Appendix C
Methodological Matrix and Evaluation Matrix Continued
Author
Pub
Year
Country
Theory
Dependent
Variables
Independent
Variables
Study Design
Sample Sampling Method
Size
How data
collected
Smulders,
K.,
Hoeven,
H.,
Pothoff, I.
W., &
Grauls, C.
V.
2002
Netherlands
None
Incidence of
VAP;
duration of
mechanical
ventilation;
length of
ICU stay;
length of
hospital
stay; and
mortality
Intermittent
suctioning of
subglottic
secretion
with 100mg
Hg for 8 sec.
duration and
20 sec.
interval.
A randomized
clinical Trial
N=
150
Random assignment of
patients into
experimental or control
group, who were
admitted to ICU over 13
month period and were
expected to receive
mechanical ventilation
>3 days
Observation
&
Self report
Chao, Y.
C.,
Chen, Y.,
Wang, K.
K.,
Lee, R.,
& Tsai, H
2008
Pulmonary
infection
causing
VAP
Removal of
secretions prior
to position
change
2-group
comparison
randomized
study
Random ICU patient
admission.
Patients 18 yrs of age or
older.
On a ventilator for more
than 24 hours.
Observation
&
Self report
from staff
Taipei,
Taiwan
Not
listed in
Article
but
assumed
by
reader=
Germ
Theory
of
Louis
Pasteur
Study
group=
75
Control
gp= 75
Control
group=
159
Study
group=
102
(Those with pneumonia
before intubation or
within 48 hours after
intubation were
excluded)
28
Appendix C
Methodological Matrix and Evaluation Matrix Continued
Author
H-H Tsai,
F-C Lin,
S-C Chang
Pub
Year
2008
Country
Theory
Taiwan
None
Dependent
Variables
VAP
occurrence
and incidence
Independent
Variables
Intermittent
suction of
Oral
Secretions
before each
position
change
Study Design
Quasi-exp.
Nonrandomized
Pilot Study
Sample
Size
Study
group=
227
Control
group=
237
Sampling Method
How data
collected
All patients admitted Self-report
to ICU who did not
and
have:
observation
endotracheal
by senior
intubation (EI) and
staff
mechanical
ventilation
(MV) more than 3
days prior to ICU
admission, presence
of tracheostomy,
pneumonia before
ICU admission, nonventilated, EI & MV
< 48 Hours, ICU
admission less than
48 Hours.
29
Appendix D
VAP Prevention In- Service Flyer
VAP Prevention In-service for
New Interventions!
Mandatory for All Nursing Staff in ICU.
Please attend one of the following:
November 20, 2010
8 a.m. – 9 a.m. and 8 p.m. – 9 p.m.
Or
November 23, 2010
11 a.m. - 12 noon and 10p.m. - 11p.m.
Evidence-Based Practice Project Proposal Format
Use the following format and headings when constructing your final evidence-based practice
project proposal paper.
1) Abstract (Needs to be between 120 and 350 words)
a) Contains project title, project director’s name, and affiliation.
b) Presents a complete concise overview of all phases of the proposed project.
2) Section A: Organizational Culture and Readiness Assessment
3) Section B: Problem Description
4) Section C: Literature Support
5) Section D: Solution Description
6) Section E: Change Model
7) Section F: Implementation Plan
8) Section G: Evaluation
9) Appendices
a) Critical Appraisal Checklists
b) Evaluation Table
c) Conceptual Models
d) Timeline
e) Resource List
f) Proposal Instruments
g) Data Collection Tool
h) Budget
i) Optional
i) Approval Forms
ii) Handouts
iii) Evaluation Tools
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