A Diabetes Clinical Nurse Specialist Utilized a Creative Approach to Sharing Hypoglycemia Management Information with Registered Nurses
Margie Hull, MSN, MEd, ACNS-BC,CDE, Wishard Health Services, Indianapolis, Indiana, and Loice Ongwela, MSN, RN, Wishard Health Services, Indianapolis, Indiana
Purpose/Objectives: The purpose of this clinical nurse specialist (CNS)-driven project was to assess and increase registered nurses' (RNs') knowledge about hypoglycemia management using a creative targeted educational approach.
Significance: Nurses' inconsistency in treatment of hypoglycemic episodes in a population of patients with diabetes receiving inpatient care.
Design/Background Rationale: The CNSs assessed RNs' knowledge about hypoglycemia management with a pretest. A total of 29 RNs working on 2 specialty units at a large county public hospital were tested. The average pretest score for the RNs was 45.85%. This low score indicated a need for an educational intervention.
Description of Methods: The CNS competencies utilized to implement the educational intervention for the RNS were educator, consultant, mentor, and role model. The creative educational approach was 2-fold consisting of focused one-on-one just-in-time teaching and distributing a quick-reference badge card entitled, "Diabetes Highlights." Hypoglycemia management information shared with RNs and topics addressed in Diabetes Highlights were glucose values indicative of hypoglycemia, signs of hypoglycemia, treating hypoglycemia, oral hypoglycemic agents, and insulin types. After the creative educational approach, a posttest was administered to the participants. This type of creative educational approach enables nurses to increase their knowledge while working at the bedside instead of having to go to a designated location for an in-service. The quick-reference badge cards instill a sense of confidence in nurses' ability to readily acquire needed information.
Findings/Outcomes: The average posttest score for the RNs was 91.45%. This was a gain of 45.6% indicating a significant increase in RNs' knowledge about hypoglycemia management.
Conclusions: The 2-fold creative educational approach implemented by the diabetes CNS was a successful strategy in increasing RNs' knowledge about hypoglycemia management.
Implications: A CNS-driven creative educational approach consisting of focused one-on-one, just-in-time teaching and a quick-reference badge card with Highlights may increase RNs' knowledge of specialty care. Other creative educational approaches for increasing RNs' knowledge should be examined.
A Multidisciplinary Approach: Improving Documentation Key to Serum Drug Level Interpretation
Myra Woolery, MN, RN, CPON, Joan Sheeron, and Paul Jarosinski, National Institutes of Health, Bethesda, Maryland
Purpose/Objectives: This project addressed missing clinical documentation necessary for interpreting serum drug levels and management of patient care.
Significance: Inaccurate or missing documentation related to serum drug levels impacts clinical interpretation of results affecting the management of the patient's care.
Design/Background Rationale: The pharmacist alerted the clinical nurse specialist (CNS) and Nurse Manager (NM) documentation required for the interpretation of serum drug levels was inconsistent. Our institution converted to an electronic system for communicating this critical information. There were issues unique to the outpatient setting.
Description of Methods: The CNS and NM reviewed serum drug level data and selected clinical areas to identify barriers. The CNS and NM met with nursing staff, outpatient NMs, department of clinical research informatics, phlebotomy, and department of laboratory medicine (DLM). Areas for improvement were identified, and strategies formulated and implemented. Subsequent data extraction was reviewed.
Findings/Outcomes: Barriers identified (1) nurses' understanding of serum drug level documentation inconsistent. Unit-level education is not standardized. (2) Manual documents sent by phlebotomy to DLM are incomplete for multiple reasons. (3) The patient is often unable to self-report required information. (4) DLM was not transferring information into the electronic record and does not have access to the serum drug level task form.
Conclusions: A multidisciplinary approach to identifying and implementing strategies proved to be effective. Documentation of required information on the serum drug level task form presents different challenges to the multidisciplinary team in the outpatient clinics. A challenge affecting clinical interpretation of results was the inability of all departments to document on the serum drug level task form. The lack of the utilization of the centralized documentation tool affected the accuracy and reliability of QI audits. The need for enhanced patient education related to the required information for drug level testing was identified.
Implications: When planning and implementing a new electronic document tool, it is important to include all stakeholders. All departments that need to input and utilize the data need access to the tool. Standardization of education is required across departments and a consistent method of educating new employees needs to be implemented. Patient education is fundamental to obtaining accurate information necessary for the interpretation of these results.
A Three-Pronged Approach Using Patient Scenario, Hands-on Skills, and Case Presentation to Maintain Nursing Best Practice in High-Acuity, Low-Volume Emergencies in a Military Post Anesthesia Care Unit (PACU)
Allison L. Andersen, MSN, RN, CPAN, CCNS Captain, USAF, Nurse Corps, David Grant US Air Force Medical Center, Travis AFB, CA
Purpose/Objectives: The hallmark of a good PACU staff is the ability to respond quickly and effectively to developing emergency situations that arise during the recovery period.
Significance: The PACU presents a challenge for a clinical nurse specialist due to frequent emergencies that develop quickly and are often related to anesthesia and surgery. In the military, high staff turnover and frequent deployments create an environment where increased attention must be paid to training.
Design/Background Rationale: The literature suggests that a multi-focal learning approach is effective in training individuals who learn in different ways. By combining scenario simulation, hands-on practice, and peer case presentation, PACU staff will become familiar and confident in their ability to handle emergency situations.
Description of Methods: Two days monthly are set aside for training, one day is a dedicated group training day for the nursing staff, scenarios are developed and presented by the CNS. Specific patient emergencies are discussed at length including early recognition, differing presentations, definitive treatment, and common pitfalls. The second dedicated day, called 'skills day,' is a typical OR day where the RN is not scheduled to recover patients but to spend the day with an anesthesia provider in the OR or procedural area (GI lab, IR, ICU) practicing skills such as bagging a paralyzed patient, rapid sequence intubation, placement of nasal and oral airways, arterial lines, regional blocks, and other skills needed in an emergency. The third prong of this training involves a detailed case presentation, prepared and presented by a staff RN, of an actual patient situation where they managed an emergency. All aspects of the case are discussed including any system level processes involved. The RN brings relevant literature surrounding best practice as well as any published case reports suggesting alternative treatments.
Findings/Outcomes: Compared to previous training methods, this three part approach reaches each staff member individually allowing the CNS to evaluate understanding.
Conclusions: Although time intensive to prepare and organize this training program, it has empowered staff to act quickly and confidently in high-acuity, low-frequency emergencies.
Implications: As a by-product it has helped the staff use evidence in a non-threatening, self-initiated forum, and has stimulated many interdisciplinary discussions with colleagues.
An Evidence-Based Approach to Pain and Sedation Assessment in the Intensive Care Unit
Lindsey Siewert, MSN, ARNP, CCNS, CCRN, University of Louisville Hospital, Jeffersonville, Indiana
Purpose/Objectives: Pain and sedation assessment has been a hot topic in the critical care area for the last few years. An evaluation of the standard of practice for assessment of pain and sedation in the intensive care areas of a metropolitan medical center led to a need for the implementation of an evidence-based approach to this concern. The purpose of this presentation is to discuss the evaluation and implementation of the Richmond Agitation Sedation Scale and the Adult Nonverbal Pain Scale in the intensive care units of a level I trauma center.
Significance: Analgesia and sedatives are often used continuously for mechanically ventilated patients, with the goal being to achieve pain control and comfort for critically ill. Verbal assessment is the best method of evaluation, but critically ill patients often are unable to communicate due to medications, neuromuscular blockade, or the complexity of the medical condition.
Design/Background Rationale: This evidence-based practice project was started in the summer 2010. A review of the literature led to the current best practices of sedation and pain assessment. A subcommittee of bedside practitioners, known as Pain Champions, evaluated best practice tools for effectiveness and ease of use in their clinical areas.
Description of Methods: The Richmond Agitation Sedation Scale and Adult Nonverbal Pain Scale were built into the electronic medical record. Intensive nursing education was provided with ongoing evaluation.
Findings/Outcomes: Evaluation of the ventilator-associated pneumonia rates has shown a decrease in incidence since the implementation of this project; however, this decrease cannot solely be attributed to this project, as several other initiatives have also been implemented.
Conclusions: Pain and sedation assessment are a valuable part of the ongoing standard of practice in the ICU. An evidence-based approach to this assessment is the cornerstone of comfort in critical care.
Implications: This foundational piece of assessment has led to other projects, including ICU mobility and sedation vacation projects.
An Innovative Clinical Nurse Specialist Partnership: Chemotherapy, Biotherapy, and Neurosciences
Kristen Maloney, MS, RN; Kathleen Wiley; Amy Moore; and Phyllis Dubendorf, Hospital of the University of Pennsylvania, Philadelphia
Purpose/Objectives: Describe an innovative curriculum developed by neuroscience and oncology clinical nurse specialists for the purpose of certifying neuroscience nurses to safely administer chemotherapeutic and biotherapy agents for neurological conditions.
Significance: Previously administered only on oncology units by chemotherapy-certified nurses, chemotherapy and biotherapy are now used to treat autoimmune neurological diseases. The expansion of these agents into the neuroscience inpatient setting raises patient safety concerns as neuroscience nurses are not practiced in the delivery of chemotherapy and biotherapy. In addition, order sets in the computer-based ordering system are utilized to ensure methods and processes in the oncology practice; however, these are not yet in place for neuroscience practice.
Design/Background Rationale: The cell-killing and immunosuppressive effects of chemotherapy and biotherapy have been the mainstay of cancer treatment for several decades. The role of B and T lymphocytes in autoimmune-mediated neurological diseases has expanded the use of chemotherapy and biotherapy agents in this population.
Description of Methods: While oncology nurses are expert in the administration of chemotherapy for the treatment of oncologic conditions, they lack specific knowledge of the therapeutic indications for neuroscience patients. Neuroscience nurses may lack understanding of chemotherapeutic agents, however well educated in neurological disease. Given the potential for toxicity and the hazardous nature of these drugs, nurses administering these medications should be expert in both administration of agents and disease management.
Findings/Outcomes: The creation of a chemotherapy and biotherapy course tailored to neurological indications prepares neuroscience nurses to independently deliver such agents.
Conclusions: The development of a chemotherapy and biotherapy course for nononcologic indications blends 2 nursing specialties allows for comprehensive nursing care and ensures patients safety. Collaboration between clinical nurse specialists from both departments plays a vital role in the preparation of clinical nurses to administer these agents to the neuroscience population.
Implications: It is essential to have neuroscience nurses deliver chemotherapeutic agents to their patient population. Chemotherapy certification for neuroscience nurses enables them to remain the primary caregiver, supports effective teaching regarding medication side effects, and keeps the nurse trained in disease management at the bedside.
Arterial Line Insertion Service From a Nurse-Driven Vascular Access Team
Jennifer McCord, MSN, RN, PCCN, CCRN, CCNS, Bethesda North Hospital, Cincinnatti, Ohio
Purpose/Objectives: To improve arterial line insertions by the utilization of a nursing team.
Significance: Arterial line allows for acute management of critically ill patients. It can be difficult to get this provided for patients considering that physicians are busy with the full practices. The use of a specially trained team can eliminate the need for physicians to place arterial lines in the critical care setting.
Design/Background Rationale: Arterial lines are used to draw blood and arterial blood gases and closely monitor critically ill patients. In a community-based hospital with limited resident coverage, it is difficult to get the access for the patients that we serve.
Description of Methods: Critical analysis of the literature was performed in 2008. Support from both pulmonary section as well as anesthesia was obtained. Policy and training programs were written and approved by nursing administration. It was determined to maintain tight control of the proposed service that the tightly monitored vascular access team members be trained to provide this service. A self-learning module and written test were given to 4 team members. Once this was passed, each team member inserted radial arterial lines under the direct supervision of anesthesiology and the clinical nurse specialist.
Findings/Outcomes: In the first 10 months, over 75 arterial lines were inserted with no side effects of the line suffered by the patients. Physician and nursing satisfaction was high for this service. Bedside nurses could receive arterial lines for their patients on the same day of request. Vascular access team members increased their knowledge and skill set.
Conclusions: Training of and utilizing a nurse-driven team to insert arterial line increase patient safety and physician and nurse satisfaction while improving care.
Implications: Placement of arterial line by nursing staff is possible with collaboration between physician staff and nursing staff and the intervention of an innovative clinical expert.
Client Acuity in Advanced Practice Community-Based Case Management
Mary K. Johnson, MS, RN, OCN; Mary M. Schmidt; Karen Brubakken; and Paula A. O'Hearn Ulch, Aurora Health Care-Mid Market, Milwaukee, Wisconsin
Purpose/Objectives: Advanced practice community-based nurse case managers are clinical nurse specialists (CNSs) practicing beyond the walls of acute care. Community-based nurse case managers focus on care coordination and outcomes improvement for chronically ill adult clients.
Significance: Although determining the scope and severity of client's needs is useful to the advanced practice nurse (APN) providing care and to the organization in resource allocation, no tool has been available to measure the acuity of clients receiving community-based case management (CBCM).
Design/Background Rationale: A telephonic case management (CM) tool (Huber and Craig 2007) served as the basis for the CBCM tool.
Description of Methods: Experienced APN case managers reviewed the telephonic CM tool to incorporate descriptors of health management from a community perspective, making it relevant to the population. Weekly case conferences, involving APNs and master's-prepared social workers, provided the forum to discuss and verify tool interrater reliability.
Findings/Outcomes: The CBCM acuity tool is composed of 3 sets of indicators with 4 acuity levels each: (1) clinical includes the client's physical status, primary symptoms, co-morbid symptoms and behavioral health symptoms; (2) psychosocial/support system describes client characteristics and family and support system; and (3) health system encompasses client: provider relationships, access, and utilization. The client's total acuity is the sum of indicator ratings.
Conclusions: The acuity tool aids the APN case manager to visually depict a client's unique clinical, psychosocial, and health system issues and clarifies leverage points. This information provides direction for APN interventions that help clients progress toward positive outcomes. Tool utilization facilitates decision making regarding case closure, recognizes changes in overall client acuity, provides information on caseload complexity, and supplies data to determine staffing needs.
Implications: Chronically ill, community-based clients have varying needs, the severity of which changes over time. Ratings for psychosocial and health system indicators are more dynamic and amenable to APN intervention than are ratings for the clinical indicators. A valid and reliable tool describing clients' needs is useful to the individual APN and the organization.
Reference: Huber DL, Craig K. Acuity and case management: a healthy dose of outcomes, part I. Prof Case Manage. 2007;12(3), 132-144.
Clinical Nurse Specialist as a Facilitator of Learning: Innovative Safe Sleep Initiative
Michalena Levenduski, MSN, RNC, PinnacleHealth, Harrisburg, Pennsylvania
Purpose/Objectives: To reduce sleep-related infant deaths in a community, it is critical to provide a consistent and repetitive message regarding infant sleep safety. The CNS is poised to facilitate the development and implementation of a hospital-based program.
Significance: A hospital-based program utilizing multiple processes will achieve the goal of reducing the risk of injury and death referred to as sudden infant death syndrome (SIDS) to infants while sleeping. The program will (1) provide accurate and consistent infant safe sleep information to hospital personnel, (2) enable the hospital to implement and model infant safe sleep practices throughout the facility, (3) provide direction to health care professionals so that safe sleep education for parents is consistent and repetitive from inpatient to the community.
Design/Background Rationale: After hearing a passionate presentation on Safe Sleep Practices from a neonatologist and the director of County Cribs to Kids Program, the CNS contacted the VP to discuss the feasibility of initiating a similar program in our health care system. At the time (fall 2009), there was a resolution in our State's House of Representatives for this program to be mandated for all hospitals. We decided to be proactive, implement the program, and thus educate the community.
Description of Methods: It is imperative to have buy-in from nurses and physicians for a program to be successful. The CNS identified "champions" from women care, child birth education, nurse family partnership, neonatal intensive care, maternity, labor and delivery, and pediatrics. The champions attended educational in-services regarding the risk of SIDS, Safe Sleep Practices, and the importance of implementing the program that the CNS scheduled. The CNS obtained educational posters, videos, and brochures and distributed them to the champions to utilize on their perspective units. Through a grant from a local financial institution, our facility was able to become a "Crib to Kids" chapter whereby parents with low income are eligible to receive a "Pack-N-Play crib. Our program was implemented April 2010.
Findings/Outcomes: All parents of newborn infants view the video, discuss SIDS risk reduction strategies, and sign the voluntary commitment form to adhere to Safe Sleep Practices. To date, 60 cribs have been issued as part of the program. The Healthcare Foundation has committed to this program and will continue funding.
Conclusions: The CNS is the key to facilitating an innovative hospital and community-based program. The CNS is also a key factor in the success and adherence to the program.
Implications: As important role models, CNSs are critical in communicating SIDS risk reduction strategies and Safe Sleep Practices to parents and families prior to the delivery. Modeling safe sleep practices and educating the parents on safe sleep while the infant is in the hospital will reduce the incidence of infant morbidity and mortality. It is also paramount for the CNS in collaboration with community health care providers to continue with the same consistent message.
Connecting on Common Ground: An Advanced Practice Provider Group
Patrick Schultz, MS, RN, CNS, CCRN, Sanford Medical Center Fargo; and Patricia Maurer, Pinancle Health System, Fargo, North Dakota
Purpose/Objectives: This poster will describe how an Advanced Practice Provider Group (APPG) can help fulfill the need of a new clinical nurse specialist (CNS) for peer association and facilitate the move into the advance practice role.
Significance: Spending time with and learning from experienced CNSs can ease the challenging transition into the advanced practice role for the new CNS. Unfortunately, in smaller or rural institutions, there may not be many experienced CNSs working. Joining with other advanced practice providers offers camaraderie, support, and political power.
Design/Background Rationale: A health system survey showed that advanced practice providers face many similar challenges. However, not all groups of providers are equal in numbers or influence. Advanced practice providers collaborating together allow a larger, more cohesive group with greater power to work to address issues and support members.
Description of Methods: The founders of the APPG began with a charter and a call for members. As it grew, a leadership council was created and bylaws were written. Special interest committees were formed. The APPG represents and serves (a) clinical nurse specialists, (b) certified registered nurse anesthetists, (c) nurse practitioners, and (d) physician assistants. It is a strong, collective voice within the organization and a professional resource offering a forum for discussion and evaluation of issues regarding interdisciplinary practices.
Findings/Outcomes: The CNS member enjoys camaraderie through networking at gatherings held 3 times per year. The CNS member is supported by other advanced practice professionals striving together to provide safe, high-quality, patient-centered care. The role of the CNS is promoted and upheld by a joint APPG Web site. Special interest committees represent the CNS in areas such as compensation.
Conclusions: The APPG can improve the transition into the advanced practice role for the new CNS.
Implications: A quicker, easier move into the CNS role will increase the effectiveness of the CNS's practice. Increasing the effectiveness of the new CNS will positively affect patient care, nursing practice, and the organization.
Creating an Optimal Competency Assessment Experience Through the Use of Innovative Validation Instruments
Brenda Shelton, MS, RN, CCRN, AOCN, and Barbara Van de Castle, MSN, RN, APRN, BC, OCN, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
Purpose/Objectives: To provide guidance for creating quality skills competency validation checklists with embedded scenarios to guide staff nurse validators.
Significance: Competency assessment is an essential component of staff education and necessary to validate clinical skills. One role of the clinical nurse specialist (CNS) is to conceptualize and create competency assessment tools that validate essential clinical skills of nursing staff. In practice, the volume of staff to access, diverse work hours, and CNS workload may result in many competencies being validated by senior staff nurses. These nurses frequently have strong individual clinical skills, but may not possess expertise in teaching and coaching.
Design/Background Rationale: Competency checklists are skill-based, but often do not provide cues for guiding independent demonstration by the participant. They also do not include strategies to manage common errors in practice, or a structure to prevent issues such as incomplete assessment or acknowledgement of understanding rather than skill or critical thinking abilities. Staff validators may also be ill-equipped to handle challenges raised by their peers.
Description of Methods: The CNS must provide clinical validators with an assessment tool having embedded information via sample scenarios within a guided checklist format. Each checklist incorporates clinical examples, common mistakes, and signs of incorrect execution. Validator training includes discussions and role play regarding difficult situations and their management.
Findings/Outcomes: Structured competency assessment tools can provide a complete immersion assessment which is more effective than a check off list. When an instructor uses checklists that are embedded with realistic scenarios such as patient information or troubleshooting prompts like "no blood return noted," this elevates the assessment beyond basic knowledge or psychomotor skills.
Conclusions: The CNS can provide a guided checklist for competencies that is an excellent indicator of staff nurse competency and a reliable tool for the staff nurse validator. This session provides specific suggestions and examples for development of competency checklists that coach the validator and ensure true assessment of competence.
Implications: Complex problem solving skills necessary to safely provide care in today's health care can be incorporated into the competency process by enhancing tool development.
Decreasing the Risk of Postoperative Pulmonary Complications in the Obese Patient
Jo Podjaski, DNP, APRN, CNS-BC, Grand Canyon University College of Nursing, Phoenix, Arizona
Purpose/Objectives: The purpose of this evidence-based clinical project was to evaluate how the use of the bilevel positive airway pressure (BiPAP), an evidence-based best practice for obese postsurgical patients, affected postoperative pulmonary complications (PPCs).
Significance: Obese patients undergoing surgical procedures may be at risk for pulmonary complications in the postoperative period. Anesthesia and narcotic use for analgesia increase this risk. Anesthesia decreases ventilatory drive and lung volume and decreases cough, while narcotics for pain relief often augment the effects of anesthesia, the combination of which leads to atelectasis, hypoxemia, and respiratory failure. The use of incentive spirometry (IS) postoperatively is a common practice used to prevent pulmonary complications; however, the evidence that indicates using noninvasive positive pressure ventilation is superior to IS in prevention of PPCs, such as atelectasis and respiratory failure. Implementing noninvasive positive pressure ventilation, such as BiPAP, may improve obese patient's risk of pulmonary complications after surgery.
Design/Background Rationale: Two obese patients who underwent surgery experienced hypoventilation and respiratory acidosis requiring a rapid response team intervention, which prompted the question of what nursing interventions might have been employed that could have prevented this outcome.
Description of Methods: Structure of the project included the CNS model related to the role function as a facilitator of research utilization. This conceptual framework underpins the implementation and synthesis of the evidence. The Stelter Model was also utilized as a guiding framework to organize the evidence-based practice process.
Findings/Outcomes: Outcome analysis included t test and [chi]2 results. The small total number of patients in the project (n = 15) resulted in non-statistically significant findings.
Conclusions: Also, patient preferences to not use the BiPAP mask and accept the treatment contributed to inconclusive results. Despite the project's participant size, the evidence in the literature supports the use of BiPAP over IS.
Implications: Implications for practice strongly suggest the use of BiPAP rather than IS to prevent PPCs in the obese postoperative patient.
Designing Skills Day Incorporating Simulation
Sharon Perkins, MS, RN, CRRN, South Shore Hospital, South Weymouth, Massachusetts
Purpose/Objectives: Improve job performance, enhance patient outcomes, promote economic efficiency, and increase organizational effectiveness.
Significance: As many hospitals struggle to measure yearly competency, using simulation that meets requirements and allows you to incorporate several tools during the scenario.
Design/Background Rationale: Skills day has previously been a day for staff to come and review policies with no way to observe or measure what the registered nurse (RN) has learned. After setting up 4 separate rooms with previously identified areas that were identified using exception reports, simulated clinical practice sessions were developed for skills day. In the simulation laboratory, a scenario was presented that incorporated skills that the RN does not use frequently (chest tubes) but needs to understand as well as other skills that are frequently used (IV smart pump, bedside walking rounds, etc). Room 2: there were 15 interventions that the RN needed to identify that had been done wrong to measure how well the RN incorporates and retains previous learned material. Room 3 had several smaller stations that the RN was observed for understanding correct implementation of Stericycle, which is identifying proper disposal of medical waste. How well they understood entering medications into the IV smart pump drug library which has shown that overall compliance has only been in the high 80% range. 1:1 testing of the defibrillator, yearly glucometer competency, and diabetes education review. The fourth room was a questions and answer review of the online documentation system and bedside medication verification system currently in use at the hospital. By using a safe environment to increase RN knowledge, the CNS/clinical educator was able to observe skills that the RN may need further education with. After a debriefing and post test to see what went well and how things could have been done better, staff have been scheduled with their own CNS for further learning sessions. IV smart pump compliance has improved in the month following the skills day, and other measurements are being reviewed.
Description of Methods: The methods that I have chosen to use incorporated a scenario using the simulation lab. There was a debriefing session following the experience at this station. To provide insight into the problems of using the drug library staff were required to pick a medication out of a basket that was preselected from a list of most often entered wrong drugs and individually enter the medication into the IV smart pump. The Stericycle station required that each RN was given a bag with 15 pictures of items most frequently placed in the wrong container and properly identify which container they were supposed to be placed in. Annual Mandatory for Glucometer and Zoll Defibrillator required 1:1 testing per policy. Physical therapy training in proper use of gait belts trained staff using a 1:1 technique with a return demonstration to measure competency.
Findings/Outcomes: The project is ongoing as only one-half of the nursing staff attended the spring skills day. The second half will attend the fall make up session. The exception reports are reviewed by the CNS quarterly, and there has been a steady improvement in the correct use of the smart pumps. Press Ganey scores have continued to improve, but the direct link cannot be connected to skills day as there are many initiatives going on to increase scores. Staff evaluations were very positive with using simulation for yearly skills day.
Conclusions: Review all areas that require yearly competency testing. Keep topics to a minimum, no more than 6 to promote learning to occur. Identify staff that will be educated prior to skills day that will implement the competency on selected day. Scenario needs to incorporate areas that will test the knowledge of staff during simulation experience.
Implications: Simulation does not require an expensive room to simulate areas of practice that nurses provide at the bedside. By identifying areas that need to be reviewed then creating a scenario that incorporates tools used at your institution, you can easily identify staff that requires further education with each tool. Staff found it was less stressful to complete the task when a scenario used to demonstrate proficiency with equipment that they use on a daily and sometimes infrequent task.
Developing an Easy Continuous Ambulatory Peritoneal Dialysis (CAPD) Process
Kathleen Wright, MSN, RN, AOCNS, Inova Fairfax Hospital, Falls Church, Virginia
Purpose/Objectives: Develop a complete CAPD process that would be easy to use on any unit in the hospital.
Significance: Continuous ambulatory peritoneal dialysis, a treatment chronic renal failure, can be performed anywhere, at any time, by anyone. Patients are placed on specialty units related to their diagnosis. Nurses on all units must be able to perform CAPD.
Design/Background Rationale: Historically, CAPD patients were placed on the "renal unit," but as the need for medical telemetry capable units increased and the number of renal patients decreased, it was evident that we would need a "plan B" for these patients. Earlier this year, our facility was changing equipment and I felt that it was the opportune time to change and update the process. The "old renal unit" supplied the entire hospital with PD equipment adding thousands of dollars to their budget.
Description of Methods: The policy, flow sheet, and physician order set were written and approved, reflecting the change in practice. A patient education form and plan of care were created that could be used for chronic renal failure, hemodialysis, and peritoneal dialysis patients. A self-learning module was written and added to the nurse's education plan on the internal learning network. A "PD kit" was assembled that includes a 24-hour supply of needed equipment, including the paperwork. Roving in-services were held on the units where, in the past year, patients had been placed.
Findings/Outcomes: Patients requiring CAPD are placed on the specialty units necessitated by their admitting diagnosis. The nurses have been able to perform CAPD safely and comfortably with minimal assistance. The PD kit holds all of the necessary equipment, decreasing costs.
Conclusions: When developing a new process that will affect nurses in all areas, simplicity is best. The PD kit provided everything that was needed to care for this special group of patients, decreasing the anxiety of the staff and patients. This process changed has decreased waste of time and supplies and therefore cost.
Implications: Nurses must have all the equipment they need to care for patients. A new process must provide nurses with the tools and confidence necessary to do their job.
Dyeing to Identify IV Medication Errors: A Clinical Nurse Specialist Group Identifies Factors Contributing to IV Push Medication Errors, and the Resulting Housewide Education Initiative
Anne Carter, MS, RN, ACNS-BC, CEN; Kathleen Gelchion, MSN, RN, AOCNS-BC; Patricia Saitta, BSN, RN-BC; and Doreen Clark, BSN, RN, CCRN, Riverview Medical Center, Red Bank, New Jersey
Purpose/Objectives: Develop a method to visually assess nurses' administration of intravenous push (IVP) medications while raising the awareness of the impact of improper administration by the IVP route.
Significance: Giving medications by the IVP route is highly potent and may result in serious outcomes if performed incorrectly. Assessing nurses giving IVP medications is a difficult skill to verify and the terminology is confusing. Clinical nurse specialists can use this simple dye method as a visual tool to observe the nurses' skill.
Design/Background Rationale: Medication errors are a major reason for hospital errors resulting in patient injury and an increased length of stay. Smart pumps have been introduced to add safeguards and prevent errors with intravenous drip medications, but it is more difficult to assess the impact of errors involving the IVP route of administration. After suspecting a connection between increasing medication variances and the administration of medications by the IVP method, the clinical nurse specialists at a community hospital used a process-focused approach to assess nurses' method of delivering IV push medications.
Description of Methods: The CNS group used their knowledge of learning styles at an annual nursing competency day utilizing an innovative way of demonstrating the movement of medication through the IV line using a bottle of red food dye.
Findings/Outcomes: In our analysis, more than 50% of RNs' techniques in administering IVP medications were incorrect. Nurses did not recognize the mechanics of the movement of drugs through the IV line. This resulted in a hospital wide "train the trainer" program, raising awareness of medication safety using a peer review format.
Conclusions: Intravenous push medications are being delivered incorrectly by a large percentage of nurses. This may contribute to the increased number of medication variances after administration of IVP meds.
Implications: Empower nurses to clarify "push" or "bolus" orders to include a timed delivery. Inconsistent standards for delivering IVP meds may increase medication errors, patient injury, or death. Nursing competency should evaluate the proper technique in delivering IVP medications. Nursing curriculums should encompass more active psychomotor skill assessment of IVP medication administration.
Early Recognition and Treatment of Alcohol Withdrawal Syndrome In Burn Patients: Impact of Nursing Care and Patient Outcomes Using New Clinical Guideline
Rebecca Coffey, Janice Kulisek, and Esther Chipps, The Ohio State University Medical Center, Columbus, Ohio
Purpose/Objectives: The purpose of this study was to compare the early recognition and treatment of alcohol withdrawal preimplementation and postimplementation of the Clinical Institute Assessment for Alcohol-Revised (CIWA-AR) guideline in the burn population.
Significance: It is estimated that 25% of burn patients admitted to the hospital have a history of alcohol abuse or positive blood or urine alcohol levels. Early recognition and treatment of alcohol withdrawal have been shown to improve outcomes. The CIWA-AR scale to identify and initiate alcohol withdrawal treatment early in the course of hospitalization was adopted by our institution in 2008.
Design/Background Rationale: This was a retrospective study in which data were extracted from a National Burn Database NTRACS and the medical chart. The NTRACS is burn specific registry established by the American Burn Association.
Description of Methods: Data collected included alcohol use, use of benzodiazepines, sitter use, restraint use, total body surface area (TBSA), inhalation injury, previous alcohol withdrawal, and length of stay.
Findings/Outcomes: The mean TBSA was 6.85%, and the predominant mechanism of injury was thermal (77%). Mean length of stay for both groups was 37 days which included burns <10% TBSA and major burns >50%. There was an increase in the presence of alcohol screening on the nursing database from 56% to 77% (P = < .0001) and in the physician's documentation of alcohol use in the history and physical 65% to 85% (P = < .0001). There was no significant difference in benzodiazepine use for withdrawal pre and post CIWA-AR however, the use increased from 50% to 58%.
Conclusions: The use of the CIWA-AR tool has provided staff with a mechanism to recognize and assess for alcohol withdrawal symptoms earlier in the burn patients' hospitalization. Once alcohol withdrawal symptoms appear treatment can begin and referrals for follow-up as an outpatient can be made.
Implications: (1) Nursing staff were uncomfortable asking the patient questions related to their history of alcohol abuse. (2) Nursing staff were educated on use of the new CIWA protocol; medical staff were not. This incongruity resulted in creation of issues related to implementation of an individual plan of care.
From Unit Based to Disease Focused: Transforming the Role of Oncology Clinical Nurse Specialists
Deborah Hanes, MSN, RN, CNS, ARNP; Kimberly Catania; and Elizabeth Delaney, The Ohio State University Comprehensive Cancer Center-The James Cancer Hospital, Columbus, Ohio
Purpose/Objectives: This presentation will describe how the clinical nurse specialist role is being positioned to proactively plan and facilitate evidenced based best patient care practices in collaboration with an interdisciplinary disease focused team that manages the patient from diagnosis thru survivorship. Included is the opportunity to elucidate efficacious nursing care among oncology medical, surgical and research practices. The vision for disease management is to capitalize on the spheres of clinical nurse specialist (CNS) practice (patient/family, nurse/nursing, and organization/system) through the functional roles of the CNS (clinical expert, researcher, educator, and consultant) to maximize quality care to patient and family.
Significance: Clinical nurse specialist practice in a Midwest freestanding comprehensive cancer center has been unit based and focused on nursing staff education, skills, and competencies. Clinical nurse specialist practice varied based on the needs of the organization and nursing unit. Recently though, the effects of the aging population, rapid growth in research accrual, increasing patient referrals, and the expansion of facilities and programs have led to a reexamination and reorganization of CNS practice.
Design/Background Rationale: The cancer hospital nursing administration and clinical nurse specialists discussed how a disease focused model would impact CNS practice and how CNS practice would contribute to the model. The CNSs provided feedback and suggestions. Nursing administration developed an institutional reorganization plan utilizing the CNSs feedback. Specifically, a director of professional nursing practice was named to whom the CNSs report instead of individual nursing units' managers.
Description of Methods: Clinical nurse specialists practice has been examined, and tasks were identified that can be transferred to other roles within nursing, freeing up CNSs to integrate themselves in the transformed role.
Findings/Outcomes: When the new practice model has been fully integrated, outcomes will include general and specific quality measures and patient satisfaction.
Conclusions: Health care organizations need to examine organizational roles for opportunities to focus on incorporating evidence-based practices that will result in improved patient care and satisfaction.
Implications: A model of health care that integrates interdisciplinary care across the continuum has the capacity to improve current care and plan future care of cancer patients.
Healing Touch (HT) as an Innovative Method of Care for Patients
Christine Valdez, MN, CNS-BC CNOR; Christy Locke, DNP, CNOR, CNS; and Nancy Sloan, DNP, APRN, US Department of Veterans Affairs Medical Center, Portland, Oregon
Purpose/Objectives: To develop a comprehensive revitalizing touch program for clinicians and 2) to educate clinicians revitalizing touch techniques.
Significance: In March 2009, a chronic and acute pain learning needs assessment showed providers want more education and skills in integrative therapies to offer pain relief treatments to patients. Developing a sustainable program that can educate health care professions in touch techniques meets the identified needs of both women and providers.
Design/Background Rationale: A certified holistic nurse and a certified integrative health practitioner were hired as a consultant to develop a comprehensive 8-hour training course aimed at "training the trainers." Two integrative health practitioners provided 60- to 90-minute classes to more than 90 staff members.
Description of Methods: Several 1- to 1.5-hour workshops were then led by a professional Integrative Health Practitioner starting in early 2010. The workshops had a didactic and practical component and were designed so that attendees receive adequate training to return to their clinical areas and begin using these techniques with patients.
Findings/Outcomes: Preassessment results revealed 80% of the participants felt their professional environment discouraged the use of touch to communicate support to patients or family members; 70% felt time pressure was an obstacle to the use of touch to communicate support to patients or family members, while 60% believed patients or family members would appreciate receiving touch as an expression of support. Seventy percent of the participants felt they did not have an adequate understanding of how to use touch as support. Post assessment results showed 90% of the participants felt confident to use touch effectively to communicate support.
Conclusions: Thirty-day participant focus groups showed increased understanding of how touch can be used in a therapeutic way to improve patient outcomes and practical application of touch in everyday nursing practice.
Implications: Evidence-based innovation that can directly impact providers and patients at the point of care exemplifies patient-driven care as it is a mechanism to demonstrate to women veterans that we value their opinion and are striving to meet their needs.
High-fidelity Simulation as a Teaching Strategy for Oncology Nursing Education: Implications for Education and Practice
Tanya L. Trotter, MSN, RN, CNS, The Ohio State University Comprehensive Cancer Center-The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
Purpose/Objectives: To equip the nurse to recognize, assess and manage the acutely decompensating patient.
Significance: Review of unit specific quality data identified failure to recognize increased oxygen requirement and mental status changes as early warning signs of acutely decompensating patient. Needed to asses, develop, implement and evaluate education plan to address registered nurse (RN) learning needs.
Design/Background Rationale: Use of simulation in nursing education helps to improve self-confidence and clinical judgment in addition to enhancing problem solving abilities, opportunities for unlimited practice of rare, critical events in a safe, controlled environment without risk to patients.
Description of Methods: Five-phase education plan utilizing high fidelity simulation:
* Phase I (assessment): created simulation scenario with data from chart of actual thoracic surgery patient cared for on 9 James. Scenario implemented in Ohio State University College of Nursing simulation laboratory. Groups of 2 to 3 RNs managed the "patient." Registered nurses were given presimulation and postsimulation surveys, evaluated by nurse manager, CNS, and educators for (a)appropriate response to changes in patient's condition, (b) communicating up the chain of command, (c) correct use of equipment, (d) obtaining and following appropriate orders, and (e) calling for additional resources as needed (ERT, code blue). After each session, debriefing occurred. Interventions for the remaining phases were designed based on the specific learning needs identified during phase I.
* Phase II (implementation): 10 unit-specific skills stations with both didactic and hands-on return demonstrations.
* Phase III (implementation): 8-hour didactic course. Topics: failure to rescue and nursing assessment, respiratory distress and ABG interpretation, failure to rescue case study focusing on the thoracic patient, legal aspects of documentation, preparing for code blue, second simulation exercise.
* Phase IV (implementation): 4-hour education: "care of the Thoracic Patient and pain management.
* Phase V (evaluation): 120 days after plan complete, third simulation exercise to evaluate knowledge and skill attainment.
Findings/Outcomes: "This is how we should be learning." "Case scenarios encouraged critical thinking." "Can we do more simulations, perhaps at least quarterly to help maintain comfort with less-frequent events?"
Conclusions: Simulation can provide nurses with realistic, hands-on practice with any patient care condition or scenario.
Implications: Simulation is helpful to assess, address, and evaluate unit-specific learning needs.
Hyperbilirubinemia in Newborn: A CNS-Led Evidence-Based Practice Initiative to Reduce Risks and Hospital Readmissions
Marianne Allen, MN, RNC-OB Pinnacle Heath System, Harrisburg, Pennsylvania
Purpose/Objectives: A 3-year review of newborn readmissions identified hyperbilirubinemia as the predominant diagnosis. Our objective was to improve care/processes to reduce newborn risks and prevent readmissions.
Significance: Risks of severe outcomes including neurological damage and/or death have made evidence-based initiatives addressing hyperbilirubinemia a priority.
Design/Background Rationale: Iowa Model of Evidence-Based Practice to Promote Quality Care Current practice included screening all newborns at 24 hours of age, repeated prior to discharge; phototherapy based on risk factors, symptoms, bilirubin, and age/hours, 1 to 2 days postdischarge follow-up for moderate-high risk infants. Additional standards included increased frequency of feedings, phototherapy using super-blue bulbs in open crib or bilibed for effective therapy, neutral thermal environment, and parent education.
Description of Methods: A CNS-led interdisciplinary team recommended and implemented evidence-based practice changes to improve outcomes and decrease readmissions.
Findings/Outcomes: The initial team of CNS, nurse-managers, and outcomes management team conducted retrospective medical record reviews of birth and readmission data and identified improvement opportunities in breastfeeding support, home phototherapy equipment availability, and home health follow-up. Findings were presented to third party payer performance initiative members and pediatricians. The team was expanded to include physicians, nurses, lactation consultants, social work, home health, and DME providers who identified issues/barriers and made recommendations. The CNS and nursing team guided implementation and reassessed outcomes. Education preceded implementation of evidence-based practice changes.
Conclusions: This CNS-led initiative has improved practice in the 3 spheres of influence: client, staff, and organization through innovative interventions:
* improved bilirubin evaluation/trending/interventions,
* hyperbilirubinemia risk screening tool, and
* priority for intensive lactation consultant support for at-risk newborns within 24 hours of birth and postdischarge.
Home phototherapy equipment on nursing unit through DME consignment for distribution facilitates discharge and continuity of treatment. In 1 month, none of the 17 newborns having home phototherapy were readmitted. Home health referral network: follow-up assessment, phototherapy, and breast-feeding support. Comparison of preintervention and postintervention: Risk factors, gestational age, feeding method, birth discharge and readmission bilirubin levels, and home health referrals. Effectiveness of practice changes: Comparison of readmission rates preintervention and postintervention.
Implications: A CNS-led interdisciplinary collaboration effectively provides seamless care for at-risk newborns to improve outcomes and reduce readmissions for hyperbilirubinemia.
Immersive Learning: An Innovative Certification Review Model
Amelia Ross, MSN, RN, Wake Forest University Baptist Medical Center, Winston Salem, North Carolina
Purpose/Objectives: The purpose of the program was to develop an immersive critical care nursing certification review course to increase the number certified in our region.
Significance: Immersive learning refers to highly interactive education that includes Web-based education, simulation, and virtual learning. Today's adult learners have experience with hands-on education in addition to e-learning. As a tertiary, university medical center with a high-fidelity simulation center and learning management system, we collaborated with community hospitals to provide an opportunity in immersive learning.
Design/Background Rationale: The benefits of certification are well known. The clinical nurse specialist (CNS) identified the need to incorporate innovative methods to elicit critical thinking skills among critical care nurses for certification preparation.
Description of Methods: The program blended learning environments of interactive Web-based modules and problem-based case scenarios using high-fidelity simulation with didactic debriefing sessions. The sessions provided opportunities for assessment of strengths and weaknesses, questions and answers, review of evidence-based practice, and practice test questions. The CNS, as project leader, educator and mentor, participated in the e-learning modules to be an observable influence for and garner understanding of the experience along with the learners.
Findings/Outcomes: Twenty-nine of 40 nurses completed the program. A validated knowledge assessment test was administered prior to and at completion of the program. Improvement in the test scores was demonstrated (pretest: mean, 79; median, 81; posttest: mean, 84; median, 86). Evaluations reported positive feedback with suggestions for improvement. Applications for the certification examination were submitted with examination results due by year end.
Conclusions: Immersive learning is an option for incorporating multiple approaches to elicit critical thinking skills and reinforce evidence-based practice in preparation for certification. Through the spheres of influence, the CNS provided resource information and acted as a change agent to influence and improve patient outcomes and promote clinical excellence.
Implications: Acquisition of knowledge is an ongoing process that does not end with degree or certification proclamation, but is a lifelong opportunity. The CNS must participate in self-reflection, scholarly study, and innovative immersive learning technology to maintain skills as an effective educator.
Impact of the CNS Role Competency of Collaboration, Consultation and Mentoring on Nurse-Sensitive Quality Outcomes
Jennifer Colwill, MSN, RN, CCNS, PCCN, Cleveland Clinic, Cleveland, Ohio
Purpose/Objectives: An upward trend in the incidence of unit-acquired pressure ulcers (UAPUs) was noted on the cardiovascular step-down units above National Database of Nursing Quality Indicators (NDNQI) benchmarks in the last quarter of 2008. The aim of this project was to reduce UAPU below NDNQI benchmarks by leveraging the bedside nurse unit expert role.
Significance: The Centers for Medicare & Medicaid Services no longer reimburse hospitals for hospital-acquired pressure ulcers. Pressure ulcer development is often preventable and is linked to increased length of stay, morbidity and even mortality. The economic impact of reduced reimbursement from hospital-acquired pressure ulcer is a priority for hospital administrators nationwide. Effective and functional translation of the unit bedside expert nurse role in practice may be a decisive factor in impacting outcomes.
Design/Background Rationale: The skin care resource nurse (SCRN) is a specially trained unit-based bedside resource nurse. The unique role of SCRN was utilized in a quality improvement project to reduce the incidence of UAPU. The CNS maximized unit expert role through collaboration, mentoring, and expert consultation in a process improvement process, educational fairs, and initiatives to engage nursing staff in actively reducing UAPUs below NDNQI benchmarks. Patients admitted or transferred to the unit were assessed head to toe for pressure related skinproblems by the primary bedside RN and the SCRN within 24 hours. If pressure ulcers were identified, assessment and a plan for treatment/prevention per NDNQI guidelines were implemented. The SCRN and CNS met routinely to discuss trends, role development, and problem solve.
Description of Methods: Patients admitted or transferred to the unit were assessed head to toe for pressure-related skin problems by the primary bedside RN and the SCRN within 24 hours. If pressure ulcers were identified, assessment and a plan for treatment/prevention per NDNQI guidelines were implemented. This year, SCRNs were encouraged to set an achievable target to work towards based on 2009 prevalence. When weekly prevalence of PU was sent out the CNS encouraged discussion and feedback regarding targets and actual prevalence.
Findings/Outcomes: Incidence of UAPUs has been lowered under NDNQI benchmarks for adult step-down areas starting in first half of 2009 to the second quarter of 2010.
Conclusions: The unit expert bedside nurse role application and unit staff engagement in quality initiatives can be maximized through CNS collaboration, mentoring, and consultation, with positive outcomes.
Implications: Clinical nurse specialists positively impact quality outcomes through process improvement and practice change.
Implementation of a Suicide Protocol in Critical Care
Tammy Maclay, MS, RN, CCRN, CEN, Chambersburg Hospital, Chambersburg, Pennsylvania
Purpose/Objectives: My aim was to provide a consistent process, that is, standard, for assessing and treating each intentional overdose patient.
Significance: Having a consistent protocol for treatment of the suicidal patient is essential.
Design/Background Rationale: Our critical care unit did not have a consistent process for managing the intentional overdose patient, each individual nurse did what he or she felt was appropriate.
Description of Methods: A review of the literature was conducted, an inquiry of other VHA hospitals was done, and collaboration with our inpatient Behavioral Health Unit and Emergency Department was also done. After the above things were done, an interdisciplinary protocol was developed, as well as documentation for our electronic medical record. The protocol addresses routine assessment of patient's suicidal risk using a suicide risk assessment (standardized tool), routine behavioral assessment, and securing of the patient's environment (includes removing patient's belongings and cataloging of these belongings on admission, removal of telephones and other equipment with cords, removal of all sharp or hazardous objects, special instructions to dietary for safe food delivery). The patient's room is searched at the beginning of each shift for potentially dangerous articles. Patient is assigned a staff member to be with them, at arm's length, at all times. A psychiatric consult is part of the protocol based on the Suicide Risk Assessment Score. Once we had everything ready to go our unit-based practice committee developed a video to educate staff members on the new process.
Findings/Outcomes: Random audits have been done to assess staff compliance in using the protocol. Because this protocol is fairly new to us, the numbers of audits are low-7 of 9 were compliant with the new process.
Conclusions: Implementation of a suicide protocol in critical care provides consistency in the assessment and care of this patient population. This protocol helps ensure that these patients are kept safe from any further self-harm while under our care. Last, having this protocol helps ensure compliance with The Joint Commission standards related to care and safety of this patient population.
Implications: Use of a consistent protocol for the suicidal patient helps ensure the safety of these patients and also assures compliance with The Joint Commission related to care and safety of these patients.
Implementation of an Evidence-Based Aspiration Pneumonia Prevention Protocol
David O'Brien, MSN, RN; and Ilia Echevarria, MSN, RN, CHES, CCRN, Pennsylvania Hospital, Philadelphia
Purpose/Objectives: The primary purpose for this project was to develop an Aspiration Risk Assessment tool, which would promote the early identification of those nonventilated patients at high risk for aspiration in medical-surgical settings.
Significance: Aspiration pneumonia, a pulmonary infectious process, is associated with significantly high morbidity and mortality rates, accompanied by high health care costs. Baseline data collection indicated an increased trend among patients experiencing aspiration occurrences in the medical-surgical setting. These occurrences further led to longer hospital stays, as patients were routinely intubated and transferred to the intensive care unit.
Design/Background Rationale: The Aspiration Pneumonia Risk Assessment Screening Tool was developed after an extensive literature review and is a major component of the intervention model. While the purpose of the assessment tool was to identify patients at risk for aspiration, the intent of the accompanying intervention protocol was to promote the implementation of strategies to reduce the risks identified via the risk assessment.
Description of Methods: Under the direction of the CNS in collaboration with infection prevention, speech pathology, and the unit nursing leadership, the tool was piloted on a neurosurgery/orthopedic medical-surgical unit concurrent with education about program objectives, risk assessments and functional assessments, feeding/positioning techniques, and interdisciplinary resources. The pilot commenced in the first quarter of 2009 with the Aspiration Pneumonia Risk Assessment completed on each patient admission/transfer and was piloted over 4 months.
Findings/Outcomes: Interdisciplinary partnership in the development of a risk assessment tool and its inherent nursing interventions to prevent aspiration pneumonia has proven to be an effective technique in promoting a safe patient environment.
Conclusions: Since implementation of the Aspiration Risk Assessment Tool on the trial unit, there have been no aspiration pneumonia events on the unit for the trial period; the program has now been accepted as routine nursing practice and has accounted for zero infections for the entire 18 months after implementation.
Implications: With vast supporting evidence that sustains the detrimental effects of aspiration pneumonia to both the patient and the health care organization, efforts to prevent occurrences are timely warranted. For this project, the development of an evidenced-based screening tool and care protocol was utilized to identify high aspiration risk patients and implement appropriate preventative interventions.
Implementation of an Oral Care Program in a Critical Care Unit to Decrease the Incidence of Ventilator-Acquired Pneumonia
Tammy Maclay, MS, RN, CCRN, CEN, Chambersburg Hospital, Chambersburg, Pennsylvania
Purpose/Objectives: To determine if following a "ventilator bundle" would decrease our hospital's incidence of ventilator-acquired pneumonia (VAP).
Significance: Can a hospital's VAP rate be decreased by following a "ventilator bundle"?
Design/Background Rationale: In spring 2007, our rural, 250-bed, nonprofit hospital made the decision to join an initiative known as "transforming the ICU." In this initiative, we would be looking at a "ventilator bundle," items that had been identified as best practice for the ventilator patient.
Description of Methods: The items in the bundle include weaning assessment, head of bed (HOB) elevation, deep vein thrombosis (DVT) prophylaxis, peptic ulcer disease (PUD) prophylaxis, appropriate sedation, and oral care. Every day, excluding weekends and holidays, all ventilator patients are looked at for compliance with items in the bundle.
Findings/Outcomes: We identified early on that we did not have issues with compliance with weaning assessment, HOB elevation, DVT prophylaxis, PUD prophylaxis, and sedation. From the very beginning, these items were all 90% or greater with compliance. Where we were really lacking was with our oral care. All of the following had to be complete for oral care to be compliant: assess gums/teeth/mucous membranes daily, deep oropharyngeal suctioning every 12 hours, teeth brushed twice daily, oral care and suctioning every 4 hours, and mucous membranes moistened every 4 hours. Our initial compliance was only 11% and was less than 60% for at least the first 6 months. We have done many things to improve this-signs at the bedside, signs on our bedside computers, electronic charting specific to what needs to be done, purchased oral care kits with everything in them to ensure compliance, provide frequent feedback on how we're doing, and numerous education sessions in various formats. Most months we are above 80% compliant. In 2008, we had zero VAP patients, 4 patients in 2009, and 1 case so far in 2010. What we have discovered in chart review was that all but one of the VAP cases were a reintubation.
Conclusions: Despite compliance with the ventilator bundle, we are still seeing occasional cases of VAP, but what is interesting is that 80% (4 of 5) were patients who were reintubated.
Implications: We are now focusing on an oral care program just prior to extubation and for the first 24 hours after extubation.
Improving Patient Safety With Evidence-Based Fall Protocol: An Implementation Project
Marsha Henn, MSN, RN; and Kaye Petta, RN, APRN-CNS BC, Faith Regional Health Services, Norfolk, Nebraska
Purpose/Objectives: The purpose of this project was to implement an evidence-based fall protocol including the intervention of scheduled toileting for the adult patient at risk to fall in the hospital setting. The clinical nurse specialist's influence on 2 of the 3 spheres of CNS practice included the client and nursing staff.
Significance: Patient falls are the No. 1 accidental injury in the hospital setting. Falls occur in the hospital setting at a rate of 2.3 to 7 falls per 1000 patient-days and 30% of falls result in injury accounting for an additional $4000 in health care costs per individual fall.
Design/Background Rationale: Fall rates and injuries resulting from falls have been associated with the quality of nursing care it he hospital setting. Patient falls is problematic for 1 hospital. In comparing the hospitals falls rates per 1000 patient-days with the American Nurses Association's National Database of Nursing Quality Indicators, the hospital's mean fall rate was well above the national mean. Meta-analysis of studies on falls shows that using multifaceted interventions to prevent falls yields the best results to fall prevention in the hospital setting. There is increasing evidence that multifactorial interventions including scheduled toileting can prevent falls in hospitalized adults.
Description of Methods: After mandatory education, nursing staff implemented fall protocol for adult patients scoring at risk to fall using the Morse fall risk tool. The implementation of the evidence-based practice project began September 17-November 17, 2009.
Findings/Outcomes: The number of patient falls decreased by 50% when comparing falls using the fall protocol to no fall protocol. The fall protocol was documented as being used for 91% of the 291 patients at risk to fall.
Conclusions: The clinical nurse specialist as mentor for applying multifactorial evidence-based fall protocol was proven to be effective in preventing falls for at-risk adult patients in the hospital setting.
Implications: Consideration for implementing a minimum set of evidence-based fall prevention interventions for at-risk patients under the guidance of the clinical nurse specialist can impact fall rates and raise the quality and safety of patient care in the hospital setting.
Incorporating Emerging Standards for Clinical Nurse Specialist in a CNS Online Curriculum
Margaret Doheny, PhD, RN; Kathleen Adamle; Carol Sedlak; and Ann Jacobson, College of Nursing, Kent State University, Ohio
Purpose/Objectives: The faculty undertook a major clinical nurse specialist (CNS) program curriculum revision that led to an online asynchronous format for delivery of didactic course content that focused on the 3 spheres of CNS influence to meet recent expansions in educational, regulatory, and certification standards.
Significance: Evolving changes in health care systems demand responsive curricula to prepare CNSs to meet societal, organizational, and patient care needs. A framework for CNS education and practice addresses these developments within the 3 spheres of influence, to prepare graduates to function as CNSs in health care agencies within specified locales.
Design/Background Rationale: The College of Nursing has had a well-recognized clinical nurse specialist program since 1980. Review of trends in advanced practice nursing certification, and education, along with increased emphasis on quality, safety, and evidence-based nursing practice supported a need for substantial curriculum revision.
Description of Methods: To inform the curriculum revision process, a needs assessment was conducted. Using surveys, interviews, and focus groups, CNS program faculty sought feedback and consultation from nursing leadership in the area's health care agencies, formal and informal CNS groups, and program graduates. After summarizing this information from stakeholders, faculty reviewed the Licensure, Accreditation, Certification and Education Model, American Association of Colleges of Nursing Essentials of Master's Education and the Doctorate of Nursing Practice Essentials, and documents of the National Association of Clinical Nurse Specialists, American Nurses' Association, Ohio Board of Nursing, and certifying organizations (eg, American Nurses Credentialing Center).
Findings/Outcomes: The clinical course sequence of the revised curriculum was launched in spring, 2009 and the first class graduated May 2010. Student and faculty evaluations are strongly positive and very supportive of the online format. Plans for an evaluation of long-term outcome data are being developed.
Conclusions: To prepare CNSs for practice in today's health care system, CNS curricula must be responsive to professional, national, and regional health needs while balancing student needs and demographics.
Implications: This curriculum revision is an exemplar for basic CNS education and demonstrates the curriculum development and evaluation process.
Innovations in Conflict Management
Sally Cadman, MS, ACNS-BC, CCRN, Regis College, Hollis, New Hampshire
Purpose/Objectives: The purpose of this poster presentation is to review the design and use of an innovative reflective conflict tool by clinical nurse specialist (CNS) students.
Significance: Effective management of conflict situations is an essential skill for today's clinical nurse specialist. The CNS acts as role model, change agent and mentor to nursing staff in the resolution of conflict situations. Frequently, CNS students lack the comprehensive management skills to effectively navigate the conflict situation.
Design/Background Rationale: To assist CNS students in the development of conflict resolution skills, a reflective conflict tool was designed after a comprehensive review of the literature. The tool acts as a catalyst for the discussion of conflict situation and provides insights into possible actions. The tool helps the student identify the type and characteristics of the conflict, ethical issues, management strategies, and possible actions.
Description of Methods: The tool was informally piloted by graduate students and found to be easy to use and helpful in identifying possible actions steps. The tool facilitates personal and professional growth by asking the student to reflect and explore the conflict situation from different viewpoints. Themes found in the conflict situation are explored in post-clinical conferences.
Findings/Outcomes: Although the tool was designed for use by CNS students, it has broader usefulness by nurses in leadership roles.
Conclusions: This reflective conflict tool can provide the CNS with a holistic tool for resolving conflict situations.
Implications: The tool can be used throughout the professional life of the CNS and has the potential to improve health and safety outcomes for patients, families, and staff.
Innovative Use of Electronic Health Record Reports by Clinical Nurse Specialists
Suzanne Purvis, MSN, RN, GCNS-BC; and Maria Brenny-Fitzpatrick, MSN, FNP-C, University of Wisconsin Hospital and Clinics, Madison
Purpose/Objectives: To demonstrate how clinical nurse specialists (CNSs) can use information pulled from the electronic health record (EHR) in innovative ways to improve nursing care of vulnerable older adults.
Significance: Computerized reports can be used to facilitate the use of nursing practice guidelines and evidence-based clinical tools such as the confusion assessment method and to increase use of nursing plans of care. The reports can also provide real-time key indicators such as albumin, activity level, delirium assessment, last fall, use of restraints, and so on, which can be used to facilitate identification of older adult patients in need of CNS and/or geriatric team consultation.
Design/Background Rationale: As the number of older adults increases, the need will grow for easier access to evidence-based practice nursing interventions for the older population. Clinical nurse specialist are the experts in evaluating research and will also need to find innovative ways to bring the evidence-based practice pertinent to the care of older adults to the bedside nurse.
Description of Methods: Clinical information from various parts of the EHR is pulled into computer-generated reports that focus on identifying older adult patients with specific high risk indicators. The specific clinical information pulled into the reports and examples of how the reports are used will be presented. Four reports are described including new hospital admissions over the age of 65 years; current hospitalized patients with dementia/delirium; current hospitalized patients on cholinesterase inhibitors; and a comprehensive report of all current hospitalized patients over the age of 65 years focusing on specific geriatric indicators identified in the literature.
Findings/Outcomes: The benefit of these 4 reports and the real-time reporting is that the APNs can utilize the data from the reports almost instantaneously in their roles of clinical expert, consultant, educator, and leader.
Conclusions: This poster presents a few innovative ways to use the EHR to facilitate use of computer-generated reports in the daily practice of CNS caring for older adults. More research still needs to be done regarding the impact of the EHR on nursing indicators such as number of falls, delirium, and use of restraints.
Implications: There are important changes occurring within health care that will continue to impact nursing and especially CNS practice. These include the continued development of new evidence to improve care of the older adult, new systems to improve use of EHR, and a growing number of older adults in the acute health care setting.
Location Variables Affecting Accuracy of Blood Pressure Monitoring Using a Noninvasive Cuff System
Catherine Draus, MSN, RN, ACNS-BC, CCRN, CNS; Mary Kravutske; Marilyn St Amand; and Colleen Dougan, Henry Ford Hospital, Detroit, Michigan
Purpose/Objectives: The purpose of this study is to determine variables that affect the accuracy of a blood pressure (BP) reading using a noninvasive blood pressure monitoring system, when obtained on the right versus left arms, and upper versus lower arms.
Significance: Nurses are often unable to obtain a BP from the upper arm and rely on a BP taken from another location.
Design/Background Rationale: Studies have shown that many variables affect the accuracy of a BP reading, including body size and positioning, type of device, size of blood pressure cuff, and location/placement of the blood pressure cuff. However, when it comes to determining accuracy of a blood pressure obtained from the arm versus other locations, there are few data in the literature. What studies do exist have been done utilizing advanced equipment not utilized in the daily care of the patient.
Description of Methods: Data collectors, using a convenience sampling, with the patient as their own control, obtained blood pressure readings utilizing a noninvasive blood pressure cuff. The blood pressure was obtained from 1 of 2 methods: right versus left arm, or upper versus lower arm. This 1-time obtainment of measurement occurred during normal assessment times and was recorded on a data collection tool. Prior to study start, institutional review board approval was obtained, and each data collector underwent interrater reliability testing.
Findings/Outcomes: There was a sample size of 117 subjects per group (total, 234). Pearson correlation analysis was used to assess the relationships between location of blood pressure obtained and systolic or diastolic readings. The 2 sites, right versus left (0.86, 0.65), and upper versus lower (0.51, 0.69), are positively correlated. There was more deviation in the upper and lower arm measurements, with this being affected by female sex (P = .001), but not by age or body mass index.
Conclusions: Should an alternate site be needed for BP measurement, right versus left has greater consistency than upper versus lower. The limb and location should be documented when recording a blood pressure reading.
Implications: Nurses need to consider the implications of obtaining a blood pressure reading utilizing a different location than the "normal" upper arm.
Obstructive Sleep Apnea: A Patient Safety Initiative
Erica Thibault, Evergreen, Colorado
Purpose/Objectives: The purpose of this patient safety initiative was to develop, implement, and evaluate an OSA protocol. Those patients who are identified as high risk for OSA are placed on the OSA pathway.
Significance: Obstructive sleep apnea (OSA) is a major risk factor for the hospitalized patient receiving opiates and sedation. Obstructive sleep apnea affects 2% to 26% of the general population in the United States and is associated with a higher incidence of motor vehicle accidents. A recent study reported that patients with severe OSA have a 40% increased risk of mortality than those who do not have OSA. The 2 facilities involved in this safety initiative did not have a formal process to identify and treat those with OSA.
Design/Background Rationale: A multidisciplinary clinical effectiveness team was formed in 2007 to implement an OSA screening tool and develop a clinical pathway for this high-risk population.
Description of Methods: After a comprehensive literature search, the STOP tool was selected as a screening tool for OSA. The STOP tool consists of a series of 4 questions designed to identify those at risk for OSA. The questions are related to snoring, daytime tiredness, observed apneas, and history of high blood pressure. When adding 4 more questions to the screening including body mass index, age, neck size, and sex, the STOP tool is more than 90% sensitive in detecting OSA in those with moderate to severe OSA. The team then developed an algorithm to direct the patient's plan of care.
Findings/Outcomes: Results from April to July 2009: 1532 patients screened positive (high risk) for OSA at a level I trauma center, and 465 patients screened positive at the community hospital.
Conclusions: Since the implementation of this safety initiative, cardiac arrests were reduced significantly, and rapid response calls increased secondary to increased monitoring and awareness.
Implications: Since the implementation of the OSA screening initiative at our 2 hospitals, all facilities within an 11-hospital system have adopted this patient safety initiative.
Professional Development for Advanced Practice Nurses: An Innovative Model
Gail Mueller, MSN, RN-BC, ACNS-BC; and Molly Hespenheide, Akron General Medical Center, Ohio
Purpose/Objectives: The Advanced Practice Nurse (APN) Professional Development Program was created to recognize excellence in practice. This innovative model recognizes APNs excelling in professional clinical roles.
Significance: A clinical ladder program existed for staff nurses at the institution. However, there was a lack of a meaningful method to recognize the professional development of the APN.
Design/Background Rationale: Clinical ladder programs have traditionally been used for staff RNs. Through review of the literature, a meaningful process for recognizing professional development in advanced practice was not identified.
Description of Methods: A subcommittee of APNs was formed. Program development began with assessment of the current RN Clinical Ladder Program at the institution followed by a thorough literature review aimed at exploring clinical ladder programs for both RNs and APNs. In evaluation of existing clinical ladder programs, drawbacks included a focus on documentation of tasks and performance review, time consuming paperwork, and the lack of a meaningful process and outcome. Therefore, the APN Professional Development Program was created. The program is based on a new model encompassing relationship-based care (RBC), APN Standards of Professional Performance, and the American Nurses Credentialing Center (ANCC) Forces of Magnetism. A crosswalk was created demonstrating convergence of the theories. Portfolio submission and eligibility criteria were established.
Findings/Outcomes: The outcome was development of a meaningful process in which the APN presents a professional portfolio unique to one's own professional growth, guided by the crosswalk description. This is an innovative program to recognize APN professional development and is usable by APNs from diverse backgrounds.
Conclusions: The professional development program offers recognition to APNs who demonstrate clinical and professional excellence using RBC Model of Practice, Magnet Forces, and the APN Professional Nursing Standards. In addition, the program provides the APN a meaningful process of evaluation through use of a professional portfolio. The project is currently in the pilot process.
Implications: Institution of an APN Professional development Program provides opportunity to recognize excellence in practice in all specialties of advanced practice nursing, promoting visibility of APN practice while providing incentive in clinical roles. Patients, families, and staff benefit from ongoing APN professional growth.
Program to Enhance Asthma Management Among Rural Families of School-aged Children Who Have Asthma
Sharon Horner, PhD, RN, FAAN; Sharon Brown; and Lynn Rew, The University of Texas at Austin.
Purpose/Objectives: To evaluate the effect of a family asthma management educational intervention on children's and parents' asthma management and children's health outcome.
Significance: Asthma is the most common chronic illness in childhood (8.7% of all children) and the leading cause of childhood disability; it is the third leading hospital diagnosis for children. Most asthma self-management studies have been conducted with urban children, while only 2 studies were conducted with rural children.
Design/Background Rationale: A 12-month community-based randomized control trial was conducted with 183 children (108 boys, 75 girls), mean age of 8.78, and 46% Mexican American, 30% white, 22% African American.
Description of Methods: The treatment group received the Asthma Plan for Kids curriculum at their schools; parents received an individualized home visit. The control group received a basic health promotion intervention at their schools. Baseline data were compared with 12-month data to examine the effectiveness of the intervention in improving (a) child health outcomes (ED visits, hospitalizations, absenteeism, quality of life [QOL]); (b) asthma severity, (c) MDI skills, and (d) family asthma management.
Findings/Outcomes: Repeated-measures analysis of variance showed significantly greater improvements in the treatment groups' child self-management (F = 3.88, P = .02), MDI skill (F = 13.00, P < .001), asthma severity (F = 9.82, P = .002), and parental asthma management (F = 4.14, P = .02), than did the control group. All of the children demonstrated significant improvements in their quality of life scores (P < .001) and decreased absenteeism by 24% (F = 11.46, P = .001). Hospitalizations were reduced by nearly half in both groups, but ED visits did not change over the year.
Conclusions: The improvements in family asthma management and children's MDI skills contributed to a significant decrease in children's asthma severity. Other studies have also found improvements in control group outcomes, such as the improvement in hospitalizations and absenteeism found in this project, and attribute this to participants becoming sensitized to health issues through the action of completing project surveys.
Implications: Results indicate that a nurse-designed program can be delivered effectively in schools, thereby reaching families who may be underserved or missed by other venues.
Psychiatric/Mental Health Clinical Nurse Specialists (PMHCNS): Helping to Overcome Mental Illness Stigma Through Research
Nancy Mann, MS, RN, PNHCNS-BC, WellSpan Health, York Hospital, Pennsylvania; and Carla Strassle, York College of Pennsylvania, York
Purpose/Objectives: The purpose of this research study was to investigate the prevalence of mental illness stigma among different nursing specialties to identify the potential ways psychiatric/mental health clinical nurse specialists (PMHCNSs) can impact clients, staff, and system.
Significance: The literature on mental illness stigma demonstrates that individuals diagnosed with psychological disorders are subjected to a range of negative thoughts, feelings, and behaviors by others, including nurses. These views of mental illness and the patients who are so diagnosed have implications for treatment and health care. The PMHCNSs have an opportunity to impact these views through consultation and support across specialties.
Design/Background Rationale: The Mental Illness Stigma Scale (MISS, Day, 2003; Day, Edgren, and Eshleman, 2007) was sent electronically to 3480 health care providers and staff of a community health system as part of a larger data collection project.
Description of Methods: Analyses of variance were conducted on 7 dependent variables from the MISS: relationship disruption, hygiene, treatability, anxiety, visibility, recovery, and professional efficacy. The independent variable of nursing specialty had 11 levels: behavioral health, cardiovascular, care management, emergency, medical, neurosciences, oncology, surgical, women and children, outpatient, and "other."
Findings/Outcomes: There were 685 nurses (48%) who responded to the survey. Behavioral Health nurses reported significantly less anxiety around people with mental illness than nurses from all other specialties except care management. Behavioral health nurses reported significantly more positive views about treating mental illness than surgical nurses, but less positive views than oncology nurses. There were no significant differences between specialties for the remaining MISS scales.
Conclusions: Although some nursing lines show differences in certain types of mental illness stigma, no specialty is without stigma.
Implications: An understanding of the presence of stigma towards persons who have mental illness can impact the interventions that the PMHCNS can provide. Given the results of this study, the availability of a Behavioral Health PMHCNS as a consultant within behavioral health as well as other specialties can help to reduce stigma, ensure proper treatment, and facilitate appropriate follow-up.
Reducing 30-Day Heart Failure Readmission Rates
Jennifer Kitchens, MSN, RN, CVRN; and Rhenita Cain, BSN, RN, CCM, Wishard Health Services, Indianapolis, Indiana
Purpose/Objectives: The goal was to reduce 30-day heart failure (HF) readmission rates at a large county hospital by implementing targeted multidisciplinary interventions.
Significance: Heart failure in the United States yearly affects 5 million patients with 550 000 new cases including 6.5 million hospital days and 53 000 deaths. Heart failure is the leading cause of hospitalization in older adults and the most common Medicare diagnosis-related group. There are more Medicare dollars spent for diagnosis and treatment of HF than any other diagnosis, with a yearly cost of 29.6 billion.
Design/Background Rationale: In the third quarter of 2009 (3Q09), it was determined that HF readmission rates needed to be reduced based on comparative data for jurisdiction, state and national 80th percentile for 30-day HF readmissions according to the Short-Term Acute Care Program for Evaluating Payment Patterns Electronic Report.
Description of Methods: Several targeted strategies were identified as key to reducing 30-day HF readmission rates. Multidisciplinary interventions implemented included membership in local patient safety coalition HF group, initiating monthly nursing and multidisciplinary team meetings, implementing transitions of care model for case management, ensuring patients had timely follow-up appointments and phone calls, standardizing patient teaching materials across inpatient and outpatient areas, implementing the "teach-back" method throughout the health care team, collaborating with the home care liaison, enforcing "hand-off" communication across the continuum of care, and increasing medication reconciliation at multiple points throughout the system.
Findings/Outcomes: From 3Q09 to the first quarter of 2010 (1Q10), 30-day HF readmission rates were reduced. For the fourth quarter of 2009 and 1Q10, HF readmission rates were below the comparative data for jurisdiction, state and national 80th percentile for 30-day HF readmissions.
Conclusions: Utilizing a multidisciplinary approach was a successful strategy for reducing 30-day HF readmission rates at a large county hospital.
Implications: New processes and programs are needed to sustain reduction in 30-day HF readmission rates. Future plans include continuation of comprehensive cardiac care including initiation of a HF clinic and cardiopulmonary rehabilitation.
Skin Rounds: The CNS as Interdisciplinary Skin Team Expert
Kathleen L. Dunn, MS, RN, CRRN, CNS-BC, SCI Center, VA San Diego Healthcare System, California
Purpose/Objectives: To describe the development of an inpatient interdisciplinary skin team and team rounding process and the key role of the CNS in this innovation.
Significance: The CNS is in a key position to lead an interdisciplinary team in the management of complex wounds to both improve patient care and educate team members about wound management. With both the Joint Commission and Medicare paying much more attention to pressure ulcers in hospital settings, this model can be used in a wide variety of settings and specialty areas.
Design/Background Rationale: With the implementation of a VHA-wide pressure ulcer prevention and management directive in 2006, this unit was challenged to develop different ways to provide and coordinate care for patients with complex wounds. The CNS played an integral role in development of the team, methods for conducting skin rounds, and documentation of both evaluation and recommendations for wound management.
Description of Methods: Steering committee development, clinical rounding, electronic documentation, interdisciplinary collaboration.
Findings/Outcomes: Since implementation in 2007, weekly skin rounds have evolved into the primary venue for decision making regarding wound management for the patients on the SCI unit. Plastic surgery staff now regularly attend the rounds to participate in decision making about surgical interventions and outcomes. Professional students (nursing, medicine, dietary, physical therapy, occupational therapy, etc) are assigned to the rounds as part of their learning experiences. The CNS has worked with the different disciplines to identify team roles, follow-up procedures, and documentation methods to assure that all team members are part of the decision-making process and that interventions are evidence-based.
Conclusions: The CNSs in a variety of settings can use this model to develop interdisciplinary wound care models in a variety of specialty areas. The CNS is in a key position to develop the collaborative process as well as educate team members about evidence-based wound care and improve patient care.
Implications: This model has applicability to a variety of settings and specialties, as well as for other clinical problems that require an interdisciplinary approach to management and collaboration between disciplines.
Staff Nursing Satisfaction With a Clinical Nurse Specialist Facilitated Journal Club to Enhance Evidence-Based Practice
Jennifer Kitchens, MSN, RN, CVRN, Wishard Health Services, Indianapolis, Indiana
Purpose/Objectives: The purpose was to assess nurses' satisfaction with a clinical nurse specialist (CNS) facilitated Journal Club (JC) approach to enhancing knowledge and confidence with doing evidence-based practice (EBP) on 3 medical-surgical units at a county hospital.
Significance: Clinical nurse specialist competencies provide the basis for a CNS-facilitated JC as a method to increase nurses' knowledge of EBP. The literature lacks information reflecting satisfaction with JCs as a method to enhance nurses' EBP knowledge indicating a need for further assessment of JC interventions to enhance EBP.
Design/Background Rationale: The Academic Center for EBP Readiness Inventory was completed by 201 nurses of 236 approached to participate to assess knowledge and confidence in using an EBP approach. Scores reflected modest knowledge and confidence scores (43.85% [SD, 13.30%]) (3.34/6 [SD, 1.24/6]), respectively. Of the participants, 30% were 19 to 35 years, 32% were 36 to 50 years, and 19% were 51 years or older. Thirty 2% had 0 to 10 years of nursing experience, 26% had 11 to 20 years of experience, and 22% had 21 or more years of experience.
Description of Methods: The CNS facilitated the JC by surveying for best time, maintaining consistent time and location, advertising, selecting relevant/staff suggested topics, distributing articles prior, utilizing JC facilitator document, inviting guest speakers and multidisciplinary staff, and mentoring staff nurse leaders. A literature-based 10-item JC satisfaction survey was developed by CNS and administered 1 year after JC implementation. A 4-point Likert Scale was used, with 1 = strongly disagree to 4 = strongly agree (higher scores equaling higher satisfaction).
Findings/Outcomes: Mean attendance was 5 per JC. A total of 15/19 medical-surgical nurses participated in JC survey. The mean satisfaction score was 3.18. For item 5, "I feel my overall knowledge about EBP and research has increased by attending Journal Clubs," the mean score was 3.26.
Conclusions: Results indicate medical-surgical nurses' satisfaction with a CNS facilitated JC approach to enhancing knowledge and confidence with using EBP. Clinical nurse specialists should continue to use this approach and increase the number of JCs throughout the hospital.
Implications: Recommendations are to revise survey instrument to include items to assess self-efficacy and application of EBP in clinical setting and continue to periodically assess nurses' satisfaction with JC process.
The CNS's Role in Advancing Practices: Removal of Chest Tubes and Transthoracic Pacing Wires in the Stable Post-Open Heart Surgery by ICU Staff Nurses
Alexandra Cox, MSN, RN, CNS-CC, CCRN, Northeast Baptist Hospital, New Braunfels, Texas
Purpose/Objectives: (1) Discuss the CNS's role in the collaboration and implementation of removal of chest tubes and transthoracic pacing wires by critical care staff nurses in the open-heart-surgery patient, (2) evaluate the outcomes in relation to (a) staying within or below the reported levels of adverse outcomes as compared to the APN/physician removal and (b) reported patient, family, staff, and physician satisfaction when removed by the ICU staff nurse.
Significance: Removal of chest tubes and temporary pacing wires has traditionally been a practice performed only by physicians or APNs. With an increased need for ICU bed space and an interest by staff nurses in advancing their skills, a collaborative implementation of such a program was established.
Design/Background Rationale: Over a year's time and a collaborative effort between nurses, 3 cardiothoracic physicians, and ICU staff and using AACN guidelines for assisting with removal of and administration lead to the development of a policy and procedure followed by formal theoretical and skill competency validation by the physicians and CNS. A total of 6 hand-selected seasoned nurses were chosen by the CNS/ICU educator, ICU director, and the CV surgeons to remove the chest tubes themselves.
Description of Methods: Over a predetermined 90-day period, an observational study was done on a total of 17 patients. After the initial 3 validations by the CV surgeons, the skill was assessed/assisted by the CNS as needed. Staff, administrative, and physician discussions assessed for satisfaction of the program. Families and patients were interviewed to assess for positive outcomes and satisfaction.
Findings/Outcomes: No complications occurred after removal of chest tubes or pacing wires. The goals of patient, family, and physician outcomes were met. Of interest was increased staff satisfaction in not only ascertaining new skills but increased collaboration and rounding with the physicians occurred.
Conclusions: With CNS guidance, successful evidence-based outcomes can be achieved while increasing the staff's competency.
Implications: This small study shows promise in chest tube and temporary pacing wire removal by trained ICU staff in the post-open-heart patient while maintaining optimal patient outcomes; however, more studies with bigger patient samples are encouraged.
The Effects of Silver Containing Alginate Primary Dressings Compared to Alginate Primary Dressings on the Healing of Chronic Venous Leg Ulcers
Kimberly Hall, MSN, RN, CWCN, Christianburg, Virginia
Purpose/Objectives: Chronic venous insufficiency is a complex disease that can result in multiple complications, the most common being venous leg ulcers. The exact progression from venous insufficiency to venous ulcers is still unclear.
Significance: Research exists to show the benefits of each of the 2 types of dressings when used to heal venous stasis ulcers, but very little research has been done comparing the 2 types of dressings. Data analysis of the results enables practitioners who specialize in the treatment of wounds to make an educated decision when choosing between the 2 types of dressings that were evaluated by enabling them to understand the effects on healing wounds and efficiency.
Design/Background Rationale: A quasi-experimental, equivalent concurrent comparison group study was conducted to compare the effects on wound healing when using alginate primary dressings versus silver containing alginate primary dressings when treating chronic venous stasis ulcers.
Description of Methods: There were 8 total participants in the study, 5 males and 3 females (n = 8). The average age of participants was 60 years old. P < 0.01 significant level was used to calculate the t tests. There was no statistically significant difference between the 2 comparison groups. Statistical results did not support a superior comparison group, but when evaluating the mean scores of the participants on a weekly basis, there was a quicker reduction in the mean scores for the participants who received alginate dressings.
Findings/Outcomes: Based on the size of the study, a statistically significant result could not be determined. According to the results of this study, both comparison groups made progress toward healing the venous ulcer(s).
Conclusions: The results of the study encourages researchers and practitioners specializing in wound care to expand focus areas of research studies to provide better, more efficient care to this patient population.
Implications: Although the results of the study did not determine a superior dressing, the need for ongoing research gives the CNS a prime opportunity to be the leading practitioner in the development of advanced wound care because of the clinical expertise, familiarization with public policy, knowledge of nursing theory, and experience in case management and educator roles for patients, families, and nurses.
The Role of the Clinical Nurse Specialist in Innovation Implementation
Catherine S. Brennan, MS, RN, CNS, Sparrow Hospital, Lansing, Michigan
Purpose/Objectives: Clinical nurse specialists (CNSs) are in a unique position to move clinical practice forward. The purpose of this presentation is to analyze the role of the medical-surgical CNS in implementing proven evidence-based strategies, in the context of a fall prevention program.
Significance: To initiate a comprehensive response to a problem, the CNS is the logical point person for coordinated innovation implementation. The CNS must use clinical expertise in determining and advocating the changes required to safeguard against nursing never events. Clinical nurse specialists need to be aware of current evidence, communicate that evidence to both nursing and nonnursing personnel, and then orchestrate the implementation of safe, cost-effective innovations.
Design/Background Rationale: Evaluation of the hospital NDNQI falls data revealed opportunities for improvement. As a CNS, it was necessary to facilitate the changes needed to ensure safe practice. The CNS held a summit attended by nurses, physicians, and administrative and support staff to determine the roadblocks to successful patient care. Following the summit, the CNS facilitated subgroups to focus on assessment, intervention, data collection, education, and administrative issues. The CNS remains the conduit between the subgroups to maintain forward progress on the project.
Description of Methods: The falls prevention program in a large acute care hospital needed updating to reflect the recent evidence-based strategies found in the literature. A review of fall data, assessment, documentation, and evaluation was completed. The literature review revealed 2 validated and nationally recognized fall risk assessment tools. A pilot program using one of the validated tools was implemented in 4 hospital units. The CNS and the Fall Prevention Committee assessed the pilot and determined a second pilot would be useful. An additional pilot was developed using the second validated tool and is currently in progress on 2 units in the hospital.
Findings/Outcomes: Evaluation of the tools is ongoing. Outcome review and data analysis continue.
Conclusions: Fall prevention is a nursing sensitive indicator of performance. The CNS plays an integral role in facilitating quality care.
Implications: Entry-level CNSs would benefit from a template to use with nurse managers, educators, and clinicians when implementing innovative practice changes.
Using Computer-Based Learning as a Method of Establishing Competency in the Care of High-Risk, Low-Volume Nursing Care
Janice Kulisek, MS, BC-RN, APRN-BC; Rebecca Coffey; and Esther Chipps, The Ohio State University Medical Center, Columbus
Purpose/Objectives: The purpose of this study was to determine the effectiveness of computer-based learning (CBL) as a method of establishing competency among burn nurses.
Significance: A repeated-measures analysis of variance was used to analyze the data. Our findings demonstrated a significant increase in test scores between time 1 and time 2 (P = .004) and from time 1 to time 3 (P = .04).
Design/Background Rationale: A quasi-experimental study, 1-group pretest/posttest design was used. A convenience sample (n = 14) of nurses working in 2 burn care areas (surgical intensive care unit and burn unit) was recruited, and the study took place over 7 months.
Description of Methods: As part of routine orientation/staff education, each nurse in this burn center undergoes an 8-hour didactic course in burn care. The experimental intervention, from November 2008 to June 2009, included 2 CBL modules developed by the burn nurse practitioner and burn clinical nurse specialist. Volunteer registered nurses completed the pretest (time 1), posttest immediately after completing the CBL (time 2), and second posttest 6 months after completing the CBL (time 3). We collected demographical data on education level, time from burn orientation, years of burn experience, number of clinical experiences related to burn care, and number of burn classes.
Findings/Outcomes: Although test scores increased over time, scores were still lower than the expected passing rate of 80%.
Conclusions: Computer-based learning may not be the ideal method for complex clinical skills such as in burn care. For complex clinical skills, consideration should be given to utilizing CBL in tandem with clinical demonstration as a method of competency testing.
Implications: Despite the advantages associated with CBL, those testing for competency should be aware of the issues related to its efficacy and question its use as the sole means of testing clinical knowledge and/or skills in any area of practice. A larger study should be conducted to validate this method of testing for competency in all areas of clinical practice.