Abstract
Objective
This study aimed to implement evidence-based practice (EBP) for the prevention and management of catheter-related thrombosis (CRT) in patients undergoing continuous renal replacement therapy (CRRT) and to evaluate its clinical effectiveness in enhancing nurses’ knowledge and reducing CRT incidence rates.
Methods
A systematic approach was employed to retrieve, screen, evaluate, and synthesize literature, identifying best evidence for CRT prevention and management in CRRT patients. From August 1, 2023 to February 29, 2024, the Ottawa Model of Clinical Application guided the development of audit criteria based on best evidence. Clinical audits were conducted to identify barriers and facilitators to the implementation of evidence, refining the EBP content for CRRT patient CRT prevention and management. Subsequently, from March 1, 2024 to September 30, 2024, this EBP was implemented in the ICU of a tertiary hospital in Zhejiang Province. A comparative analysis was conducted to assess the implementation rates of audit criteria, nurses’ knowledge scores on CRRT patient CRT prevention and management, and patient CRT incidence rates before and after the EBP intervention.
Results
A total of 51 nurses and 247 patients were enrolled in this study, with 123 patients assigned to the pre-EBP phase and 124 patients to the post-EBP phase. Compliance rates for all 16 established review indicators demonstrated a significant upward trend following EBP implementation; however, four key indicators failed to meet the 90 % compliance threshold: nurse-conducted risk factor assessment, ultrasound-guided venipuncture, X-ray imaging for catheter dysfunction, and administration of thrombolytic therapy. Nurses’ knowledge regarding CRT prevention and management was significantly enhanced, with questionnaire scores increasing from (77.72 ± 4.96) to (87.02 ± 6.17) (t = -12.180, P < 0.001). Notably, the incidence of CRT decreased substantially from 28.46 % to 15.32 %, with the difference reaching statistical significance (t = 10.257, P < 0.001).
Conclusion
Evidence-based nursing practice tailored to prevent CRT in patients undergoing CRRT significantly enhances nurses’ specialized knowledge in CRT prevention and management, effectively reduces the incidence of CRT, and further fortifies safeguards for patient safety by optimizing clinical nursing quality.
Keywords: Continuous renal replacement therapy, Evidence-based nursing, Critical care nursing, Central venous catheters, Catheter-related thrombosis
What is known?
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ICU patients undergoing continuous renal replacement therapy (CRRT) are at high risk of catheter-related thrombosis (CRT) due to critical illness, prolonged treatment cycle, and frequent catheter manipulations.
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Domestic and international guidelines and consensuses on central venous catheter management are available at present, with the summary of some evidence on CRT prevention and management based on evidence-based principles.
What is new?
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This study developed a structured intervention pathway from evidence selection to dynamic monitoring by employing the Ottawa Model of Research Use (OMRU), thus contributing to the transformation of CRT prevention evidence into actionable audit indicators for the ICU to address workflow fragmentation.
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The implementation of evidence-based practice could also promote the standardization of CRRT catheter maintenance, in addition to reducing the incidence of CRT in CRRT patients.
1. Introduction
Catheter-related thrombosis (CRT) refers to the thrombotic process closely associated with catheter insertion. It occurs when catheter insertion damages the vessel wall, and the end of the catheter remains within the vessel, causing continuous mechanical irritation of the vessel wall, while the catheter itself acts as a foreign body [1]. This condition leads to the formation of a thrombus within the catheter or in the surrounding vessel wall. Continuous renal replacement therapy (CRRT) is an extracorporeal renal replacement therapy that continuously and gently removes solutes and excess fluid from the patient’s body to address conditions such as acute kidney injury, severe edema, and metabolic imbalances. Patients admitted to the ICU are at heightened risk due to critical illness, prolonged CRRT duration (>24 h), and frequent catheter manipulations, the incidence of CRT in CRRT patients reaching 30 % in the ICU [[2], [3], [4]]. The occurrence of CRT can lead to treatment interruptions and even threaten patient safety [5]. Effective prevention can reduce the incidence of CRT by approximately 55 %–60 % [6]. Therefore, improving the management of CRRT catheterization is of great importance. In recent years, the management of central venous catheters has received increasing attention, with various guidelines and consensus statements being published both domestically and internationally [[7], [8], [9]]. Some scholars, guided by evidence-based principles, have summarized the relevant evidence on the prevention and management of CRT [10,11]. Although international guidelines [[12], [13], [14], [15]] emphasize the importance of standardized catheter maintenance, knowledge gaps among nurses [11] and fragmented workflows remain prevalent in clinical practice. Tsujimoto et al. [16,17] highlighted in their review that the translation rate of evidence for non-pharmacological interventions (e.g., catheter securement techniques) is below 40 %. At the same time, existing studies [10,11] predominantly focus on evidence synthesis without providing practical frameworks tailored to multidisciplinary ICU settings. To bridge this evidence-practice gap, this study employed the Ottawa Model of Research Use (OMRU) [18] to develop a structured intervention pathway spanning evidence selection to dynamic monitoring. The OMRU model systematically evaluates the applicability of evidence, clinical barriers, and practice environments, providing methodological support for evidence translation in complex clinical scenarios [19]. This study utilized the OMRU framework to create a structured intervention pathway that encompasses evidence screening and dynamic monitoring. The goal was to transform evidence on CRRT prevention into actionable audit indicators for use in the ICU. The study aimed to evaluate the impact of implementing best practices in clinical care for preventing CRT in patients undergoing CRRT. Additionally, it sought to enhance nurses’ relevant knowledge and standardize nursing practices through evidence-based nursing methods, ultimately bridging the gap between evidence and clinical practice.
2. Methods
2.1. Study design
This study adopted the OMRU [18] for knowledge translation. The entire study was conducted from August 1, 2024, to September 30, 2024. The period from August 1, 2023, to February 29, 2024, was designated as the period before the evidence-based practice group, while the period from March 1, 2024, to September 30, 2024, was designated as the evidence-based practice group.
2.2. Establishing a project team for clinical evidence application
This study was initiated by establishing a CRRT prevention and management program development team (hereinafter, the “program development team”). With eight members included, there was one head nurse responsible for organizing and planning the research program, providing project guidance, formulating the program process, and making personnel adjustments; two research nurses trained from the Evidence-Based Nursing Center of Fudan University, who were responsible for process monitoring of the program formulation, supervising and guiding program implementation, and ensuring quality control; and five CRRT specialist nurses in the ICU, who were responsible for developing and reviewing indicators, conducting current status reviews, implementing the program, as well as collecting, organizing, and analyzing data.
2.3. Establishing evidence-based questions and obtaining evidence
Is the best available evidence for the prevention and management of CRRT CRT consistent with current clinical practices? Using the “6S” evidence model [20], this study retrieved relevant evidence via a top-down approach, using the following search terms: “renal replacement therapy/CRRT” and “thrombosis//thromboemboli/thrombos/embol/microembol.” From database inception to March 2023, evidence retrieval was completed in several public databases such as the Cochrane Library, PubMed, UpToDate, Embase, BMJ Best Practice, Guidelines International Network, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network, Joanna Briggs Institute, Kidney Disease Improving Global Outcomes, China National Knowledge Infrastructure, Wanfang, and China Biology Medicine. Finally, this search yielded 12 articles, comprising three clinical decision articles [[21], [22], [23]], four guidelines [[12], [13], [14], [15]], two systematic reviews [16,17], and three expert consensus documents [[24], [25], [26]]. On this basis, our study obtained and synthesized 27 best-evidence recommendations across the following eight areas [27].
2.4. Establishing evidence-based review indicators
From May to July 2023, nine clinical experts specialized in CRRT, senior medical staff from the ICU and Blood Purification Center of our hospital, were invited to participate in an expert meeting. Among these, there were three CRRT specialist physicians, four CRRT specialist nurses, and two vascular access management specialists. All experts have at least five years of CRRT - related clinical experience and are proficient in the ICU clinical practice environment. All experts made corresponding modifications and adjustments to the evidence based on its feasibility, appropriateness, clinical significance, and effect, to align it with the clinical context better. To represent the level of expertise, the expert authority coefficient was 0.90 for this meeting. Meanwhile, semi-structured interviews were scheduled to evaluate the clinical feasibility of evidence, identify implementation barriers, and prioritize interventions. The interviews involved two head nurses, one nursing department director, five CRRT nurses, two ICU physicians, and three family members of CRRT patients. Specific topics included the acceptability of healthcare providers to thromboprophylaxis protocols and patients’ adherence to catheter maintenance, to facilitate evidence selection and contextual adaptation. Through expert meetings and based on the results of semi-structured interviews, the team determined and selected the most appropriate evidence for introduction into clinical practice, considering the existing environment and resources in the pilot wards. Ultimately, the program development team identified 25 pieces of the best evidence. Due to clinical drug control regulations, two pieces of evidence, specifically items “It is recommended to consider using urokinase or tissue plasminogen activator (t-PA) for thrombolysis when catheter function is impaired” and “It is recommended to maintain the catheter for 30 min during t-PA thrombolysis,” were removed from this study. Based on the clinical context and available resources, our team formulated 16 review indicators and developed corresponding review methods, as shown in Appendix A.
2.5. Evidence implementation in clinical practice
This study was guided by the OMRU [18], whose core objective is to facilitate the systematic translation of research evidence into clinical practice and bridge the “evidence-practice gap.” The model comprises six interconnected core components: evidence-based change, potential adopters, practice context, implementation of intervention strategies, adoption of the change, and outcome evaluation.
2.5.1. Study setting
The present study was conducted with patients receiving CRRT treatment in the ICU and nurses from the department at Zhejiang Provincial People’s Hospital in Hangzhou from August 1, 2023, to September 30, 2024.
2.5.2. Participants
Participants included patients who received CRRT in the ICU of this hospital and all nurses from the pilot wards, with the study period spanning from August 2023 to September 2024. The period from August 1, 2023, to February 29, 2024, was designated as the period before the evidence-based practice group, while the period from March 1, 2024, to September 30, 2024, was designated as the evidence-based practice group. Nurses (n = 51) were compared using a self-controlled pre- and post-study design, with the effect of the evidence-based practice evaluated using a non-synchronous control study.
Eligible patients were selected based on the following inclusion criteria: 1) patients aged ≥18 years; 2) patients undergoing CRRT treatment; and 3) patients who were admitted to the ICU for ≥24 h. While the exclusion criteria were: 1) patients with pre-existing CRT or a thrombosis history; and 2) patients who died during treatment, refused treatment, or were transferred to another hospital. The inclusion criteria for ICU nurses were: 1) nurses with at least one year of ICU experience; and 2) nurses with primary or higher professional title. While the exclusion criteria were: 1) nurses receiving further training; and 2) nurses who were breastfeeding.
The sample size was calculated according to the equation of N = (Uα+Uβ)2∗2∗P∗(1-P)/(P1-P2)2, where Uαand Uβare the critical values from the standard normal distribution corresponding to the significance level, with Uα = 1.64 and Uβ = 1.28 based on the statistical table; while P1 and P2 represent the estimated incidence rates of CRT before and after prevention, with P1 = 0.3 [[2], [3], [4]] based on literature review; and to reduce the incidence of CRT to 10 %, P is the pooled proportion, calculated as P = (P1+ P2)/2 = 0.2. A sample size of 69 cases was obtained by substituting these values into the equation, and the minimum sample size required was adjusted to 83 cases when accounting for a 20 % attrition rate.
2.5.3. Analysis of barriers and facilitators
According to the OMRU’s advocacy, it is necessary to assess evidence-based changes, potential adopters, and the practice environment prior to applying research into practice. In accordance with this framework, this study conducted semi-structured interviews by inviting five CRRT nurses, two ICU physicians, and three family members of CRRT patients. Finally, the barriers and facilitators to implementing evidence-based CRT management practice were identified and summarized in Appendix B.
2.5.4. Evidence-based change
Baseline audits (e.g., initial CRT incidence and nurses’ knowledge scores) and barrier analyses (e.g., insufficient training resources and complex operational workflows) were conducted before developing the evidence-based practice protocol. Based on these findings, the team continued to adjust the training frequency and simplify the catheter locking procedures. On this basis, the team formulated updated catheter sealing protocols and introduced a CRT management workflow, integrating the best available evidence. These efforts culminated in a systematic CRT prevention and management program that included a revised catheter locking strategy and operational guidelines. Eventually, the proposed method contributes to achieving closed-loop optimization from problem identification to clinical implementation.
2.5.4.1. Development of standardized procedures for catheter maintenance
Our program development team refined the evidence-based CRT prevention practice plan for CRRT patients using the best available evidence. Specific corrective measures were implemented. 1) Establishment of a catheter sealing process: a) pulsatile flushing of the arterial catheter lumen with a 20-mL syringe containing saline (10 mL); b) closure of the arterial clamp (the flushing should be repeated in case of any blood residue in the catheter); c) disinfection of the catheter port with an alcohol swab, followed by connection to the heparin cap; d) pulsatile positive-pressure locking of the catheter via a 2-mL syringe (1.5 mL for the internal jugular vein, and 2 mL for the femoral vein); e) the venous catheter patency assessment and locking following the same method as the above relevant operations in terms of core steps such as pulsatile operation and disinfection logic. 2) Sealing of the catheters used intermittently every 24 h. 3) Establishment of standardized sealing solutions: 500 IU/mL and 1,000 IU/mL heparin solutions should be used for patients at high and low hemorrhagic risk, respectively. 4) Thrombolysis procedure for CRT: Dissolution of urokinase to a 5,000 IU/ml, and connection of a 20 mL syringe to one end of a three-way valve (the other end connected to a 5 mL syringe), followed by the injection of urokinase into the lumen and retention for 30 min (with the patient end closed); and then aspiration from the catheter end using a 5 mL syringe after 30 min to observe the presence of any thrombus. Notably, this process was repeated three times before a final evaluation of the catheter’s patency.
2.5.4.2. Enhancement of nurse training on relevant knowledge
Our program development team conducted unified training for all medical and nursing staff across the wards. The training was organized in batches and lasted 5 d, starting at 8:10 a.m. each day, with each session lasting 30 min. The sessions, held in the department’s meeting room, were arranged by each ward's head nurse. The training involved: 1) the concept of CRT, the current state of domestic and international research, as well as the importance of early prevention and management; 2) the objectives, significance, and methods of this study; 3) the use and precautions of assessment tools; and 4) standardized training on the specific content of evidence-based practice.
2.6. Evaluation indicators
2.6.1. Comparison of audit indicator implementation rates before and after evidence-based practice
The implementation of each review indicator was verified by the researchers using a review indicator checklist. Proper implementation was recorded as “Yes,” while non-implementation or incorrect implementation was recorded as “No.” The compliance rate was calculated using the equation: Compliance Rate = (Number of Correct Implementations/Total Number of Review Instances) × 100%.
2.6.2. Outcome evaluation of the translation of evidence into clinical practice
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(1)
CRT knowledge questionnaire scores for ICU nurses. This study developed a nurse CRT knowledge questionnaire based on the best available evidence [27]. It surveyed respondents’ general information (e.g., gender, age, educational background, years of work experience, job level, and professional title), as well as the current knowledge status of CRRT prevention and management among CRRT patients (25 items). Each item was worth 0–4 points, with 4 points for a correct answer, and 0 points for an unanswered or incorrect answer. Respondents with higher scores would have greater knowledge of CRRT prevention and management. The content validity was evaluated by a panel of 6 experts (CVI = 0.92). A pilot study (n = 35) showed good internal consistency, given a Cronbach’s α coefficient of 0.831.
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(2)
Incidence rate of CRT. The incidence rate of CRT is calculated as follows: (number of CRT cases/total number of catheter patency evaluations) × 100 %. Diagnostic criteria for CRT [28]: detection of a solid echo within the lumen of the CVC, on the catheter wall, or in the vein where the catheter was placed; failure of closure or complete closure when the venous lumen was compressed with an ultrasound probe; detection of no blood flow signal by color Doppler flow imaging; and weakening or disappearance of the phase position of the blood flow spectrum morphology.
2.7. Data collection
Based on the characteristics of each review criterion, select appropriate, scientifically sound data collection methods. A “Review Indicator Compliance Record Sheet” containing 16 review indicators was developed to facilitate clinical audits, with columns for general patient information, indicator number, indicator content, assessment method, implementation status, and remarks. All data were collected daily by two nursing master students to ensure complete data collection before patient discharge. Data collection methods include medical order and nursing record review, on-site observation, examination result review, checking the department's materials collection list, and department team formation and department training record review, as shown in Appendix A.
The CRT knowledge questionnaire was distributed in electronic format, and respondents were instructed to complete it after standardized training. It surveyed respondents’ general information and the current knowledge status of CRRT prevention and management among CRRT patients, yielding a total score of 100.
The CRRT incidence rate was traced and recorded by the CRRT task force leader in the department. All data collectors received standardized training, and all data were entered into the system on the same day of collection, with verification by two individuals to ensure data accuracy, authenticity, and reliability.
2.8. Data analysis
With the organization, import into Excel, and verification of the initial data, the sorted data were imported into SPSS 26.0 for statistical analysis. Continuous variables with normal distribution were expressed as Mean ± SD, and t-tests were employed for inter-group comparisons. Meanwhile, categorical data were described as frequencies, percentages, or proportions, with Chi-square tests or Fisher’s exact test used for inter-group comparisons. When both groups of data do not conform to a normal distribution, the Mann-Whitney U test is used as a non-parametric alternative to the independent-samples t-test. A P-value of < 0.05 was considered statistically significant.
2.9. Ethical consideration
This study was approved by the Ethics Committee of Zhejiang Provincial People’s Hospital (2021QT364), and written consent was obtained from all participants.
3. Results
3.1. Comparison of general information
This study enrolled 123 CRRT patients before best-evidence practice implementation, including 90 males (73.17 %) and 33 females (26.83 %), with an average age of (68.99 ± 14.89) years. After evidence-based practice, 124 CRRT patients were included, involving 92 males (74.19 %) and 32 females (25.81 %), with an average age of (69.08 ± 17.07) years. There was no statistically significant difference in general information between before and after practice implementation (P > 0.05; Table 1). Meanwhile, this study incorporated 51 ICU nurses, of whom 8 were males (15.69 %), and 43 were females (84.31 %), with an average age of (31.36 ± 3.99) years. Among them, 25 were junior nurses (49.02 %), 25 were senior nurses (49.0 %), and one was a head nurse (1.96 %).
Table 1.
Comparison of general patient information.
| Characteristic | After evidence-based practice (n = 124) | Before evidence-based practice (n = 123) | t/χ2/Z | P |
|---|---|---|---|---|
| Gender | 0.038 | 0.845 | ||
| Male | 92 (74.19) | 90 (73.17) | ||
| Female | 32 (25.81) | 33 (26.83) | ||
| Age (years) | 69.08 ± 17.07 | 68.99 ± 14.89 | −0.048 | 0.962 |
| APACHE II | 22.19 ± 7.72 | 24.05 ± 7.70 | 1.891 | 0.06 |
| Fibrinogen (g/L) | 4.22 (2.78–5.24) | 3.82 (2.42–4.63) | −1.723a | 0.085 |
| D-dimer (μg/L) | 9,057 (1,480–8,060) | 11.396 (1,840–9,280) | −0.474a | 0.636 |
| Urea nitrogen (mmol/L) | 24.21 (14.20–29.06) | 24.36 (13.16–31.92) | −0.056a | 0.955 |
| Creatinine (μmol/L) | 238.43 (94.45–333.60) | 296.32 (119.90–390.10) | 1.679a | 0.094 |
| PT (s) | 17.65 ± 8.93 | 17.45 ± 8.37 | −0.182 | 0.856 |
| APTT (s) | 40.57 (30.30–43.88) | 42.77 (31.80–44.20) | −0.794a | 0.427 |
| Hemoglobin (g/L) | 87.72 ± 22.69 | 85.67 ± 27.35 | −0.632 | 0.532 |
| Platelets (×109/L) | 117.76 (61.25–152.75) | 120.35 (58.00–163.00) | −0.502a | 0.615 |
| CRRT duration (h) | 182.77 (60.50–221.00) | 221.36 (57.00–223.00) | 0.972a | 0.355 |
| ICU length of stay (h) | 473.48 (120.00–581.75) | 505.13 (132.50–448.00) | 0.363a | 0.717 |
| Treatment modality | 4.172 | 0.124 | ||
| CVVH | 3 (2.42) | 4 (3.25) | ||
| CVVHD | 59 (47.58) | 48 (39.03) | ||
| CVVHDF | 62 (50.00) | 71 (57.72) | ||
| Disease types | 10.632 | 0.156 | ||
| Respiratory system | 30 (24.20) | 23 (18.70) | ||
| Circulatory system | 28 (22.58) | 27 (21.95) | ||
| Sepsis | 16 (12.90) | 15 (12.20) | ||
| Nervous system | 10 (8.06) | 16 (13.01) | ||
| Urinary system | 13 (10.49) | 12 (9.75) | ||
| Digestive system | 10 (8.06) | 14 (11.38) | ||
| Cancer | 7 (5.65) | 7 (5.69) | ||
| Other | 10 (8.06) | 9 (7.32) |
Note: Data are Mean ± SD or n (%) or Median (P25–P75). APACHE = Acute Physiology and Chronic Health Evaluation. PT = prothrombin time. APTT = activated partial thromboplastin time. CRRT = continuous renal replacement therapy. CVVH = continuous veno-venous hemofiltration. CVVHD = continuous veno-venous hemodialysis. CVVHDF = continuous veno-venous hemodiafiltration.a Mann-Whitney U test. Cancer: malignant tumors of all systems. Other: trauma, poisoning and other unclassified diseases.
3.2. Review indicator compliance rates
This study continuously tracked nurses’ and patients’ compliance with review criteria. As illustrated in Table 2, a comparative analysis of compliance with 16 review indicators was performed pre- and post-evidence implementation. The results demonstrated that ten indicators yielded statistically significant improvements in compliance rates following evidence application (all P < 0.05); notably, Indicators 11 and 12 transitioned from 0 baseline compliance to full adherence (100 %). In contrast, six indicators (4, 6, 7, 9, 10, 16) maintained 100 % compliance across both study phases, with no statistically significant differences observed. In the baseline review, the compliance rate for most of the review criteria (except for criteria 1, 3, 8, and 14) increased to over 90 %, indicating a gap between clinical practice and the “evidence summary”.
Table 2.
Comparison of the compliance rate of review indicators before and after evidence-based practice.
| Review indicators | n | After evidence-based practice |
Before evidence-based practice |
χ2 | P | ||
|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | ||||
| 1 | 51a | 40 (78.43) | 11 (21.57) | 27 (52.94) | 24 (47.06) | 7.351b | 0.007 |
| 2 | 124/123c | 115 (92.74) | 9 (7.26) | 87 (70.73) | 36 (29.27) | 20.077b | <0.001 |
| 3 | 124/123c | 110 (88.71) | 14 (11.29) | 84 (68.29) | 39 (31.71) | 15.273b | <0.001 |
| 4 | 124/123c | 124 (100) | 0 | 123 (100) | 0 | - | - |
| 5 | 51a | 49(96.08) | 2 (3.92) | 26 (50.98) | 25 (49.02) | 26.646b | <0.001 |
| 6 | 124/123c | 124 (100) | 0 | 123 (100) | 0 | - | - |
| 7 | 51a | 51 (100) | 0 | 51 (100) | 0 | - | - |
| 8 | 51a | 40(78.43) | 11 (21.57) | 13 (24.49) | 38 (74.51) | 28.632b | <0.001 |
| 9 | 51a | 51(100) | 0 | 51 (100) | 0 | - | - |
| 10 | 51a | 51 (100) | 0 | 51 (100) | 0 | - | - |
| 11 | 51a | 51 (100) | 0 | 0 | 51 (100) | - | - |
| 12 | 51a | 51 (100) | 0 | 0 | 51 (100) | - | - |
| 13 | 124/123c | 119 (95.97) | 5 (4.03) | 86 (69.92) | 37 (30.08) | 29.690b | <0.001 |
| 14 | 51a | 45 (88.24) | 6 (11.76) | 31 (60.78) | 20 (39.22) | 10.117b | 0.001 |
| 15 | 51a | 51 (100) | 0 | 39 (76.47) | 12 (23.53) | 13.600d | <0.001 |
| 16 | 51a | 51 (100) | 0 | 51 (100) | 0 | - | - |
Note: Data are n (%). a Participants were nurses from the settings where evidence-based practice was implemented, with a sample size of 51.b Chi-square test.c Participants were patients from the settings where evidence-based practice was implemented, including 123 cases before evidence implementation and 124 cases after implementation. d Fisher’s exact test. Yes: Proper implementation was recorded as “Yes”; No: non-implementation or incorrect implementation was recorded as “No”. 1-16: review indicators 1-16, detailed descriptions are provided in Appendix A.
3.3. Nurse knowledge questionnaire scores
According to the results of the nurse knowledge questionnaire regarding CRT prevention management for CRRT patients, the nurse scores were (77.72 ± 4.96) and (87.02 ± 6.17) before and after the evidence-based practice, respectively. There was a statistically significant difference in inter-group comparison (t = −12.180, P < 0.001).
3.4. Incidence of CRT before and after evidence-based practice
The incidence of CRT was 28.46 % (105/369) before and 15.33 % (65/424) after the evidence-based practice, respectively. A statistically significant difference in CRT incidence was detected between groups (t = 10.257, P < 0.001).
4. Discussion
4.1. Effect of implementing evidence-based practice on reducing the incidence of CRT in CRRT patients
In this study, the incidence of CRT decreased from 28.46 % to 15.33 %, a larger reduction than the 8 % reported in comparable research [4]. Our more obvious decrease in this rate may be closely associated with the implementation of a stratified locking strategy and dynamic monitoring mechanisms in the ICU. For instance, in patients at high bleeding risk, the use of a low-concentration heparin-locking solution (500 IU/mL) maintained catheter patency while reducing hemorrhagic complications, aligning with the individualized anticoagulation protocol proposed by DeBourdeau et al. [6]. Significantly, our achieved closed-loop management of prevention and treatment, based on multidimensional audit indicators, outperforms the single-risk assessment model based on the Caprini score adopted by Tang et al. [29]. Notably, the corresponding evidence translation rate remained below 40 %, despite the emphasis in some studies on non-pharmacological interventions (e.g., catheter securement techniques) [16,17]. In contrast, our study achieved operational compliance of over 90 % following the integration of nurse training and process simplification, highlighting the necessity of structured training programs and multidisciplinary collaboration in complex clinical scenarios.
4.2. Effect of implementing evidence-based practice on promoting the standardization of CRRT catheter maintenance
This study achieved systematic optimization of catheter maintenance processes through a stratified locking strategy (high- and low-bleeding-risk groups) and dynamic monitoring mechanisms. For instance, adjusting the locking interval from 48 h to 24 h aligns with the recommendation for “daily maintenance for intermittent catheters” in international guidelines [29]. However, and notably, this research further individualized heparin-locking solution concentrations (500/1,000 IU/mL) based on individuals’ bleeding risk assessment, addressing the clinical controversy over the “one-size-fits-all” approach to heparin dosing [6]. Different from the strategy of sole consideration of locking frequency proposed by Cheng et al. [30], the audit indicators in this study (e.g., indicators 11 and 12) improved the compliance rate from 0 % to 100 % through closed-loop quality control measures (e.g., post-thrombolysis blood return assessment), demonstrating the effect of structured workflow design on optimizing complex procedures. The Knowledge-Belief-Behavior (KBB) model-based intervention applied by Li et al. [31] enhanced nurses’ compliance, yet lacked integration with multidisciplinary collaboration. In contrast, this study identified the issue of resource allocation during the “practice environment assessment” phase of the OMRU model, with subsequent construction of standardized operating procedures, leading to compliance rates of over 90 % across 12 review indicators. Similar to other related evidence-based studies [32,33], this study found that the majority of the evidence was effectively translated and applied clinically. Although the review indicators 1, 3, 8, and 14 in the current study showed statistically significant improvements following the evidence implementation, none reached the 90 % compliance benchmark. This sub-optimal compliance outcome is attributed to a partial misalignment between evidence-based operational protocols and existing clinical workflows, as well as insufficient motivation for implementation among a subset of nurses. Consistent with the findings of this study, Zhang et al. [34] emphasized that the successful promotion of EBP requires not only a rigorous foundation in theoretical evidence but also the seamless integration of practical operational needs, thereby facilitating its effective translation into routine clinical practice. Future research should continue to explore the role of information systems in maintaining long-term standardization to address the cost loss associated with manual audits.
4.3. Effect of implementing evidence-based practice on improving nurses’ knowledge of CRT prevention management for CRRT patients
In this study, there was a remarkable increase in nurses’ knowledge scores to 87.02 ± 6.17, a substantially greater improvement than the intervention effect of the KBB model implemented by Li et al. [30]. This difference may be attributed to the short-term intensive training implemented in our study, which accelerated the translation of theoretical knowledge into practice; conversely, Li et al. [31] prioritized sustainability through prolonged decentralized training at the expense of translational efficiency. Contrary to the “non-pharmacological intervention-first” concept proposed by Tsujimoto et al. [16,17], our findings revealed that enhanced nursing knowledge was associated with reduced CRT incidence, underscoring the superiority of procedural standardization over isolated technical optimization in ICU settings. But it should be noted that there may be a weakening of short-term knowledge gains over time, necessitating integration with digital platforms for dynamic reinforcement—a perspective that aligns with the idea of a “sustained education framework” put forward by Cheng et al. [13]. Nzengya et al.’s [35]. study highlighted the need to strengthen and prioritize relevant future strategies to enhance nurses’ evidence translation competence—a core capability encompassing the identification of contextual barriers, evidence evaluation, and collaboration to adapt evidence to clinical practice. Accordingly, to refine training strategies, further well-designed studies are required to investigate the correlation between knowledge retention and long-term CRT incidence.
4.4. Limitations
This study has certain limitations. First, this single-center study might have limited generalizability. Second, due to staffing constraints and limitations in the functionality of the electronic medical record system, four review indicators failed to achieve compliance rates >90 %, necessitating subsequent process optimization and enhanced information technology support. Collectively, the results of this study should be analyzed more comprehensively and further validated based on the performance of multi-center, large-sample, long-term studies.
5. Conclusion
This evidence-based quality improvement initiative contributes to a significant reduction in CRT incidence among CRRT patients while enhancing nurses’ knowledge. It facilitates effective improvements in clinical practice compliance through targeted interventions, such as optimized training strategies and operational protocols. Future efforts should focus on validating the long-term efficacy and scalability of this protocol through multicenter collaboration, thereby advancing the quality of care for CRRT patients clinically.
Data availability statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.
CRediT authorship contribution statement
Lili li: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing - original draft, Writing - review & editing, Project administration. Jing Wu: Visualization, Data Curation, Investigation, Writing - original draft, Supervision. Ying Zhang: Data curation, Project administration, Writing - original draft. Miaojie Yu: Formal analysis, Investigation, Resources, Writing - review & editing. Hangyan Ye: Investigation, Resources, Writing - review & editing. Yongze Dong: Validation, Formal analysis, Investigation, Resources, Writing - review & editing, Funding acquisition. Huiping Yao: Conceptualization, Methodology, Validation, Formal analysis, Funding acquisition, Writing - review & editing, Supervision, Project administration.
Declaration of competing interest
The authors declare that they have no competing interests.
Footnotes
Peer review under responsibility of Chinese Nursing Association.
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2026.02.002.
Appendices. Supplementary data
The following are the Supplementary data to this article:
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.