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Low back pain a change Unknown person College of Nursing Low back pain a change There have been many quotes recited by famous people for decades which in one way or another described change.
One of the quotes was cited by John F. Kennedy, the thirty fifth president who stated that change is the law of life and those who look only to the past or present are certain to miss the future (Kennedy, 1963). I feel that quote states a lot about change and how it is an ever evolving and constant statement.A Model for Change to Evidence-Based Practice by Mary Rosswurm and June Larrabee addresses six steps for implementing changes based on evidence base research which includes: Step 1- Assess the need for changes an practice; Step 2- Link the problem to interventions and outcomes; Step 3- Synthesize best evidence; Step 4- Design a change in practice; Step 5- Implement the change and evaluate the change in practice; and Step 6- Integrate and maintain the changes.In following Rosswurm and Larrabee’s (1999) model for change, each step in the process will be expounded on in regards to initiating an evidence based practice change in regard to lower back pain. The first step of Rosswurm and Larrabee’s (1999) change model is to assess the need for change.
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When assessing the need for change internal data is collected and compared it to external data and benchmarks. An historic review shows that there is no change in the pathology or prevalence of low back pain.What has changed is our understanding and management. There are striking differences in health care for low back pain in the United States and the United Kingdom, although neither delivers the kind of care recommended by recent evidence-based guidelines which states treatment initiated first for low back pain indicates the simple analgesics, such as acetaminophen be used before referring to imaging and advice, education and reassurance of favorable prognosis (Low back pain: AHCPR Clincian Guideline).
Medical care for low back pain in the United States is specialist-oriented, of high technology, and of high cost, but 40% of American patients seek chiropractic care for low back pain instead. National Health Service care for low back pain in the United Kingdom is underfunded, too little and too late and 55% of British patients pays for private therapy instead. Despite the different health care systems, treatment availability, and costs, there seems to be little difference in clinical outcomes or the social impact of low back pain in the two countries.
Future health care for patients with nonspecific low back pain should be designed to meet their specific needs (Waddell, 1996). Step 2 of the 6 steps discussed by Rosswurm and Larrabee (1999) explain that using the language of classifications is needed to link the problem with interventions and outcomes. The classification systems chosen for step 2 will be the International Classification of Diseases (ICD), Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC).
Per the Health Organization (WHO), the ICD provides a classification system by using codes for specific diseases, their signs, symptoms, and other pertinent data. While presently in its 10th edition, the ICD 10 codes for low back pain is M54. 5. The M54. 5 code is a specific code for the ICD-10-CM that can be used to specify a diagnosis. ICD-10-CM comes into effect beginning October 1, 2013; therefore, this and all ICD-10-CM diagnosis codes should only be used for training or planning purposes until then (WHO, 2010).
ICD 9 CM are still being used to code medical procedures until the International Classification of Health Intervention is fully developed; the current ICD 9 code for low back pain is 724. 2 (Low Back Pain – Online ICD9/ICD9CM codes). The Nursing Outcomes Classification (NOC) is a comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. Standardized outcomes are necessary for documentation in electronic records, for use in clinical information systems, for the development of nursing knowledge and the education of professional nurses (Nursing Directorys, 2010).
According to Moorhead, Johnson, Maas and Swanson (2008) the Nursing Outcomes Classification (NOC), the following NOC codes are the most relevant to the change implementation of low back pain: 0208 Mobility (Ability to move purposefully in own environment independently with or without assistive device); 2101 Pain: Disruptive Effects (Severity of observed or reported disruptive effects of chronic pain on daily functioning); 2102 Pain Level (Severity of observed or reported pain); 2000 Quality of Life (Extent of positive perception of current life circumstances); 0313 Self-Care Status (Ability to perform basic personal care activities and instrumental activities of daily living): 0211 Skeletal Function (Ability of the bones to support the body and facilitate movement).The nursing intervention classification (NIC) is a classification system for nursing interventions, both physiological and psychosocial, which provides a language of standardization based on research (Dochterman & Bulecheck, 2004). Several NIC codes are pertinent to low back pain to include: 0740-Bed rest care; 0140 Body mechanics promotion; 1400 Pain management; 1806 Self-care assistance-transferring (Dochterman & Bulecheck, 2004). Step 3 of the 6 steps discussed by Rosswurm and Larrabee (1999) is synthesizing best evidence. The purpose of a synthesis of the research studies is to determine whether the strength of the evidence supports a change in practice (Rosswurm, 1999).
As previously discussed in the literature review component, two hallmark studies were published in regard to low back pain and its treatment. Although there is considerable uncertainty about optimal management for patients with low back pain, investigators agree that most episodes of back pain are best treated with analgesics and self-care (Deyo RA, 2001). Another study indicates the guidelines of treatment initiated first for low back pain indicates the simple analgesics, such as acetaminophen be used before referring to imaging and advice, education and reassurance of favorable prognosis (Low back pain: AHCPR Clincian Guideline). Step 4 of 6 steps discussed by Rosswurm and Larrabee (1999) explains design a change in practice.As acute low back problems are defined as activity intolerance due to lower back or back- related leg symptoms of less than 3 months duration; about 90% of patients with acute low back problems spontaneously recover activity tolerance within 1 month. The approach to a new episode in a patient with a recurrent low back problem is similar to that of a new acute episode. Findings and recommendations include a paradigm shift away from focusing care exclusively on the pain and toward helping patients improve activity tolerance (Low back pain: AHCPR Clincian Guideline).
The guideline does not address the care of patients younger than 18 years or those with chronic back problems.The identified stakeholders for such practice change have been identified as pre hospital emergency service providers, hospital administration, physicians and nurses. Research has proven that when initially assessing the patient with back pain the stakeholders should seek potentially dangerous underlying conditions first; with back pain, the absence of signs of dangerous conditions, there is no need for special studies since 90% of patients will recover spontaneously within 4 weeks. A focused medical history and physical examination are sufficient to assess the patient with an acute or recurrent limitation due to low back symptoms of less than 4 weeks duration.
Hence, the medical history and physical examination can also alert the clinician to non-spinal pathology that can present as low back pain. There are red flags for potentially serious conditions that may present when obtaining a focused medical history and or physical examination such as possible fracture, possible tumor or infection and or possible cauda equine syndrome. When addressing red flags, to include evidence of severe neurologic compromise that correlates with medical history may indicate a need for immediate consultation; the exam may modify suspicions of tumor, infection, or significant trauma. A medical history suggestive of non-spinal pathology mimicking a back problem may warrant examination of pulses, abdomen, pelvis or other areas.Surgical considerations are considered only within the first 3 months when serious spinal pathology or nerve root dysfunction due to a herniated lumbar disc is detected (Low back pain: AHCPR Clincian Guideline).
Step 5 of 6 steps discussed by Rosswurm and Larrabee (1999) explains implementing and evaluating. Implementation is best accomplished with a pilot study, where the coordinator closely monitors progress and is readily available for assistance. My research currently don’t support changing of practice but rather focus on clinicians following the guidelines for assessing and treatment of low back pain. Below is an Algorithm of treatment of low back problems on initial and follow-up visits. pic Step 6 of 6 steps discussed by Rosswurm and Larrabee (1999) explains integrating and maintaining a change in practice.
Change is more likely to be accepted when people participate in making the change (Rogers, 1995). Patient outcomes must reflect discipline-specific and interdisciplinary accountabilities. Nurse’s contribution to patient’s outcome will be measured when nurses consistently use standardized language in defining patient problems, interventions, and outcomes. Practitioners need time and support to access databases and synthesize.
Ongoing communication with stakeholders is vital to the acceptance on change. By continuing education and staff in-service education facilitate changes in practitioners’ behavior and reinforce implementation of the new evidence-based practice Rosswurm and Larrabee’s (1999). Referances Deyo RA, Weinstein JN.Low back pain. N Engl J Med 2001; 344: 363-70. Dochterman, J. C.
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