Nursing at once supports both evidence-based practice and what have best been termed “sacred cows” (non evidence-based practice). Sacred cows represent long-held practices and deep beliefs, steeped in tradition.
Some sacred cows of practice include:
- Bathing with water
- Aspirating stomach secretions to verify gastric tube placement
- Inflating the balloon of a foley catheter
- Obtaining two doctors’ signatures for emergency consents
- Obtaining a stat serum glucose when a fingerstick is critically low
- Instilling normal saline when suctioning through an ET
- Use of sandbags after sheath removal
- Use of Trendelenberg positioning for hypotension
Reasons for Sacred Cows
Efforts to change practice meet with resistance at the bedside even after lack of evidence has been shown.
Surprisingly, evidence-based findings are not always valued. In an environment of constant change, some believe that the latest study will soon be refuted by yet a newer study with contradicting results. Still others (nurses and doctors) base their practice on previous anecdotal experiences from their own practice that “prove” their beliefs.
The sheer volume of change information to disseminate combined with the huge number of bedside nurses to reach results in ineffective communication of practice change.
The best practice in bathing is a move away from the bath basin and water to use of disposable bath wipes, as an infection prevention measure. Bath basins are a source of bacteria and transmission of hospital acquired infection.
This is a hard change for some caregivers who don’t want to give up bathing patients the traditional way, because “they have always done it that way” and bathing with water and basin feels thorough and complete. Some CNAs especially, who give excellent care, take pride and derive job satisfaction from giving good bed baths.
Verification of Gastric Tube Placement
Over time nursing has developed several methods of verifying gastric tube placement. These include auscultation of instilled air, testing of pH, inspection of aspirate,and radiographic confirmation. The only sanctioned and reliable means is radiographic confirmation with a chest Xray.
Inflating foley balloon prior to insertion
Inflating the balloon can cause micro trauma to the patient from creasing of the silicone balloon. The manufacturer has quality assurance processes in place to test the product before release. While it’s hard to resist inflating the balloon, avoid doing it.
Two doctors signing emergency consent
Not a true sacred cow, but a source of confusion. If a patient is unable to give informed consent, for example, if they are unresponsive or confused, and there are no surrogate decision makers present, the provider need only document that it is an emergency. An emergency procedure is defined as a procedure needed to prevent death, alleviate severe pain, or prevent permanent disability. In such instances, the provider must document a note in the medical record, but two physician signatures are not required on the consent.
Ordering a stat glucose to verify hypoglycemia
This is more of a critical thinking situation. Some nurses “verify” abnormally low blood sugar results obtained via fingerstick and glucometer by ordering a stat serum glucose. But if your patient is symptomatic, follow your hospital protocol and immediately administer oral carbs, or IV D50.
Typically by the time Lab arrives to draw the stat serum glucose, the patient has been treated. Whatever their blood sugar is now, it cannot be used to “verify” the pre-treatment result. (Some protocols include performing a second fingerstick to compare to the first reading.)
If the rationale is to “verify” glucometer readings before treating a patient, then the underlying assumption is that the machine may not be accurate. Current glucometers are very accurate, and QA testing is done regularly on the machines.
Instilling normal saline into an ET tube before suctioning
This was long believed to loosen secretions. Evidence shows that it does not loosen or thin thick mucous secretions. Other studies indicate that the saline may be a cause of ventilator associated pneumonias (VAP). Best practice supports continuous aspiration of subglottic secretions to prevent VAP.
Sandbags after femoral sheath pull
Some MDs still order sandbags to be applied after hemostasis. While this practice won’t hurt the patient, it can give the nurse a false sense of security.
Evidence does not support the use of sandbags as a compression method to decrease vascular complications or discomfort. A sandbag exerts diffuse pressure and will definitely not stop a femoral artery bleed. In addition, sandbags interfere with visualizing the puncture site.
The only advantage to sandbags is that the weight of the sandbag may remind your patient not to flex their affected extremity.
Trendelenburg to treat hypotension
Evidence does not exist for this time-honored intervention.
Current data to support the use of the Trendelenburg position during shock are limited and do not reveal any beneficial or sustained changes in systolic blood pressure or cardiac output. Some deleterious effects have been documented, including increase in intracranial pressure, and cardiac compromise.
Best practice is to position your patient in the supine position, with lower legs elevated to promote right heart sided venous return.
Those are just a few of the sacred cows still roaming out there. You probably have encountered even more in your practice. When in doubt- check the evidence!
Until next time friend,
Johnson, D., Lineweaver, L., & Maze, L. M. (2009). Patients’ bath basins as potential sources of infection: a multicenter sampling study. American Journal of Critical Care, 18(1), 31-40.
Makic, M. B. F., VonRueden, K. T., Rauen, C. A., & Chadwick, J. (2011). Evidence-based practice habits: putting more sacred cows out to pasture.Critical Care Nurse, 31(2), 38-62.
Miller, J., Hayes, D. D., & Carey, K. W. (2015). 20 questions: Evidence-based practice or sacred cow?. Nursing2015, 45(8), 46-55.
Rauen, C. A., Chulay, M., Bridges, E., Vollman, K. M., & Arbour, R. (2008). Seven evidence-based practice habits: putting some sacred c