Ambulation at 3 Versus 6 Hours Post-Femoral Artery Hemostasis in the Percutaneous Coronary Intervention Patient

Warfield, Karen T, Mayo Clinic, Minnesota

Objective: To investigate the (1) patient's perceived back pain, (2) overall discomfort related to bed rest, and (3) the safety and efficacy of reducing the duration of post-PCI bed rest from 6 to 3 hours.

Significance/Background: Prolonged bed rest after femoral artery sheath removal following percutaneous coronary intervention (PCI) is associated with discomfort. Previous studies have shown that reducing bed rest time after coronary angiography reduces discomfort without increasing complications, but the effect of reducing bed rest in to less than 4 hours in post-PCI patients who have received significant anticoagulation and received GP IIb/IIIa inhibitors prior to PCI has not been adequately studied.

Methods: Two hundred forty-nine patients, including those receiving GP IIb/IIIa inhibitors, undergoing PCI utilizing 5F or 6F sheaths from the femoral access site were randomized to either 3 (n = 127) or 6 hours (n = 122) of bed rest. Perceptions of back pain and over-all discomfort were measured by the McGill Pain Questionnaire-Short Form and the visual analog scale.

Findings/Outcomes: At 3 hours after hemostasis, 30% of all patients had at least 1 verbalization of pain since sheath removal and 28% required analgesics, with similar proportions in both treatment groups. Six patients developed a hematoma > 5 cm. From 3 to 6 hours after hemostasis, 21% of patients verbalized experiencing pain on 1 or more occasion, and 16% required analgesia. Patient randomized to 6 hours of bed rest experienced significantly more pain: visual analog scale (P = .005), the Pain Rating Index (P = .003) and the Present Pain Index (PPI) (P = .015). One patient (randomized to 3 hrs bed rest) had a hematoma at this point. After ambulation a hematoma >5 cm was observed in 1 patient in each of the 2 treatment groups (P > .99). Rebleeding occurred in 2 (1.6%) of the patients who had 3 hours of bed rest, compared with 1 (0.8%) of the patients with 6 hours bed rest (P > .99).

Conclusions: Bed rest time following PCI via femoral access using 5F or 6F sheaths can be safely reduced from 6 to 3 hours with improvement in patient comfort. Further studies are needed to extend these results that early ambulation may be a safe alternative to prolonged bed rest for a subset of PCI patients.

Implications: With the results of this research study a standardized practice change was implemented across the institution minimizing the length of bed rest post-PCI. Patients verbalized increased satisfaction with early mobility as well as a decrease in complaints of overall discomfort. With the earlier mobility dismissal from the hospital was also obtained sooner.

An Electronic Decision Support Rule for Identification and Automatic Ordering of Heart Failure Education

Schad S, Chua Patel C, Griebenow L, Loth A, Mayo Clinic, Rochester, Minnesota

Problem: Providing heart failure (HF) discharge instruction is 1 performance metric that is required by Centers for Medicare & Medicaid Services. These metrics are publicly reported, are tied to reimbursement, and are within the domain of Nursing. Patients with HF often have multiple co-morbidities. These complex patients may be found on multiple units throughout our hospitals. Inpatient nurses are challenged to identify these patients in efforts to provide quality patient care and prepare the patient for self-care after discharge. Despite multiple education sessions given to nurses regarding importance of HF discharge instructions, metric defects continue.

Design: A team led by clinical nurse specialists, and an Informatics Nurse Specialist, explored a systematic way to assist nurses to identify the patients with heart failure, validate diagnosis with the team, educate, and document HF discharge instructions. The team designed an electronic decision support tool (Echo and Auto-order Blaze Rules) that auto-orders required education, if the patient records indicate: (1) left ventricular ejection function <40% per echocardiogram and/or (2) diagnosis of HF on the patient problem list. The rule initiates when a nurse opens the plan of care. When HF is on the problem list, a pop up alert is presented to the nurse noting, HF education was automatically ordered. The nurse then completes and documents HF education per discretion of the nurse.

Description of Methods: Four nursing units were piloted in this quality improvement project: medical telemetry cardiology, medical oncology, vascular telemetry and a medical neurology unit. The team met with pilot units' leadership to introduce the project, answer questions and gain support. Metrics were identified and the team met weekly to review reports and validated functionality of the rule. Feedback was given to the pilot units on a weekly basis. After the 4 week pilot, nurses were electronically surveyed to gain understanding of their workflow and usability of the rule.

Findings/Outcomes: The Echo Blaze rule was triggered in 402 patients. The Auto Order Blaze Rule was triggered in 341 patients. HF discharge instructions were not completed on approximately 3 discharged patients. There was a 48% response rate to the nurse survey (n = 127). The nurses were highly satisfied with the Blaze Rules as they served as an automatic reminder to complete HF discharge instructions. One problem identified was duplication of HF education orders.

Conclusions: Nurses found the decision support rule for HF was successful in reminding them to provide HF discharge instructions when appropriate. It is 1 system enhancement to promote and improve compliance with the core measure. Heart Failure Discharge Instructions.

Implications: HF metric defects for patient discharge instructions occur over numerous nursing units. HF decision support rules are 1 method nurses can utilize in assisting with identifying HF patients when they are in the hospital with multiple comorbidities. This identification approach for the multidisciplinary team enhances the ability to meet this metric and may be transferrable in meeting similar requirements in other chronic conditions.

An Evaluation of the Use of Mock Code Skills Stations in the Neonatal Intensive Care to Increase Nursing Confidence During Code Situations

Holub PA, Rady Children's Hospital, San Diego, California

Purpose: The purpose of this project was to evaluate nurses' confidence levels during code situations by reevaluating the use of neonatal mock code skills stations, and to compare the results of last year's data to the data collected this year.

Significance: JCAHO has recommended that institutions implement team training, clinical drills, and debriefings to alleviate problems during codes. The neonatal intensive care unit (NICU) mock code committee developed a model to improve nurses' confidence during code situations. The training model that resulted in increased nursing confidence during codes in the NICU is now a hospital wide initiative to increase the number of mock codes, and establish mock code skills training.

Design: The mock code skills stations were designed to provide neonatal nurses with education related to code situations. Each skills station was designed to focus on a particular nursing responsibly during a code. The theory being that practicing these skills will increase the confidence level of the nurse during a code.

Methods: The NICU unit based mock code committee developed and facilitated the mock code skills stations. During the course of a week nurses rotated through 4 mock code skills stations, and were then signed off on a mock code competency. A pre and post Likert-like scale self-assessment questionnaire was used to determine the nurses' confidence level both before and after attending the mock code skills stations.

Outcomes: A total of 104 neonatal intensive care nurses participated in the mock code station self-assessment. The results of the pre- and post-self-assessment questions were analyzed using the Wilcoxon signed rank test. The data analysis showed that the mock code skills stations increased nurses' confidence in their skills.

Conclusions: The results of the mock code station self-assessment showed that the participants continue to feel more confident after participating in mock code skills stations. After the development of the NICU Mock code committee the number of unit based mock code has increased.

Implications: The use of mock code skills stations are a valuable training tool, and can be used to increase the confidence of nursing staff during a code. The mock code skills stations in the NICU have been utilized as the framework for hospital wide mock code training. Within the next few months we plan to incorporate high-fidelity code simulations in the NICU, and continue to measure the nurses' confidence levels. The unit CNS will use this data to assist the unit based mock code committee in reevaluating the education plan. The unit based mock code committee will continue and provide additional training for the neonatal nursing staff.

An Innovated Approach to Optimizing Adolescent Transition to Adult Healthcare

Cerns SA, Froedtert Hospital, Milwaukee, Wisconsin; Rich C, Medical College of Wisconsin, Milwaukee; McCracken C, Froedtert Hospital, Milwaukee, Wisconsin

Significance: Unique challenges exist for young adults with sickle cell disease (SCD) transitioning their healthcare from pediatric to adult care environments. Key challenges include moving from family-centered care to patient-centered care; social and financial independence; navigating a complex healthcare system and anxiety related to new healthcare providers.

Background: Pediatric to adult transition issues are well published in current literature. Targeted transition programs for young adults living with chronic disease support structured transition plans. In a large academic medical center, young adults with SCD transitioning care from a children's hospital expressed strong concerns in understanding of responsibilities, expectations, and ability to navigate an adult healthcare setting. Additionally, healthcare providers expressed challenges related to inadequate preparation for young adults being admitted to the adult hospital.

Design: An academic medical center interdisciplinary team collaborated with a children's hospital in developing a young adult transition program. The program focuses on principles of self-management, expectations and responsibilities as an adult. Other interventions included a tour of the emergency department (ED) and inpatient unit. During the tour, various disciplines share information regarding individual roles and services that can be provided to the young adult during an inpatient hospital encounter.

Outcomes: The young adults and families/significant others reported that the transition program positively impacted them. They reported less apprehension in entering an adult healthcare system, were able to verbalize their responsibilities as a patient and expressed they have a better understanding of what to expect during an inpatient stay. Adult healthcare staff had the opportunity to participate in the tours and shared significant value in the transition program as well as gratitude to build relationships and influence the outcomes of their care.

Implications: Improving clinical outcomes and the patient experiences among young adults through a targeted transition care program offers an opportunity to communication, handoff and interdisciplinary collaboration in an adult healthcare setting.

An Innovative Approach to Certification Preparation

Kitchens JL, Hull MA, Wishard Health Services, Indianapolis, Indiana

Purpose: The purpose was to implement and evaluate an institutionally-based CNS-led medical-surgical preparation course in order to prepare its medical-surgical nurses to become certified.

Significance: The CNS competencies provide a basis for a CNS-led medical-surgical preparation course. Nursing certification may have many benefits to organizations including improved nursing competence, confidence, patient care, promotion of professional growth, and reflection of knowledge and expertise in a specialty.

Design: There is no formal medical-surgical certification preparation course at the institution. This course was requested by practicing medical-surgical nurses and organizational leadership. The approach to certification preparation was innovative by being institutionally-based for its own nurses eliminating cost of tuition and travel. Magnet recognition and career ladders elevate the importance of attaining nursing certifications. Clinical nurse specialist facilitation of certification preparation courses has received little attention in the literature.

Description: Two CNSs collaborated to implement and evaluate the medical-surgical certification preparation course by: planning each preparation session, advertising, developing novel instructional materials, acquiring study resources, fostering a safe learning environment, analyzing evaluation data, disseminating findings. Topics included in the review course were: navigating certification Web sites, identifying testable material, cultivating study skills, deciphering test questions, identifying perceived barriers to studying/learning, addressing known areas of weakness, decreasing test anxiety, test taking and study tips. Participants' knowledge was assessed by administering a 10-question pretest and posttest covering certification test content. The CNS-led medical-surgical certification preparation review course was evaluated by administering a CNS-designed Certification Preparation Course Survey consisting of a presurvey (12 items) and postsurvey (16 items) to assess overall course effectiveness.

Outcomes: The medical-surgical certification preparation course included 5 sessions (1.5 hours each) over a 6-week period (n = 6 nurses). Pretest results were 38%; posttest results were 84%. The Certification Preparation Course Survey results were positive. For the survey item, "I plan to take the medical-surgical nursing certification exam," results were yes (n = 5) and maybe (n = 1). Perceived degree of anxiousness when taking a test was measured using a 4-point Likert scale (higher scores equaling more anxiety). Mean perceived anxiety scores were presurvey (3.0) and postsurvey (1.7). All participants reported learning additional content, content presented was valuable, presenters and teaching methods were effective, practice questions were beneficial, personal goals were attained, course expectations were met, and the environment was conducive for learning.

Results indicate a CNS-led medical-surgical certification preparation course was an effective approach to enhance knowledge about medical-surgical content. Clinical nurse specialists should plan to conduct additional on-site courses and recruit more nurses to participate.

Implications: Additional demographic data should be collected including the number of participants who obtain certification within 1 year. Longitudinal evaluation strategies should assess overall cost-effectiveness and participants' retention and use of knowledge.

An Innovative Preceptor Model for Newly Hired Nurses to a Medical-Surgical Unit

Rape CR, Carolinas Medical Center, Indian Trail, North Carolina

Significance: Clinical nurse specialists can be a primary resource in the development of innovative, cost-effective orientation programs. Jones (2005) reported the costs of nurse turnover ranged from about $62 000 to $67 000 per nurse. Retention rates are often lower than national benchmarks among the medical-surgical nursing population and the cost of turnover is high. One medical center case study has described the largest cost driver of turnover as the loss and necessary replacement of nurses (Waldman et al, 2010). Costs associated with an orientation program include orientees' time, preceptor's time, and educator time.

Background: A survey of vacancies and turnover rates in 2000 revealed a 21.3% turnover rate for RNs in the hospital setting, with an average vacancy rate of 14.1% in medical-surgical care units. National nursing turnover rates are averaging 15% (MacKusick and Minick, 2010). In 2009, the turnover rate in this specific nursing division was 7.8%. In addition, historically, Orientees had not been highly satisfied with the orientation process. The goals for this quality improvement initiative included decreasing the cost of orientation by 20%, increasing the overall quality of nursing care by 5%, maintaining turnover rates < 10% and to have 90% of the Orientees rate their orientation excellent or very good on a postorientation survey.

Methods: The continuous quality improvement methodology used for this project was plan, do, study, and act. A new orientation structure was implemented that included an innovative preceptor model. Historically, preceptors have 1 orientee; oversee the orientee's patients while also having their own patient load. With the new model, the preceptor has 2 orientees, oversees the patients they have, and has no patients of their own. While the orientees progressively work up their patient load, the preceptor is able to focus, educate and work with the orientees one-on-one to lay the foundation needed for the orientees to be successful. This model contains benefits for the orientee, the preceptor, and for the unit while also enhancing clinical efficiency.

Outcomes: The cost for orienting 2 newly hired nurses was reduced by >20% while turnover rates remained < 10%. Overall quality of nursing care among the division had an 11% increase from the previous year. Ninety-two percent of the newly hired nurses rated their orientation excellent or very good on the postorientation survey.

Conclusions/Interpretations: An innovative approach to precepting new nurses may help reduce costs while improving nurse satisfaction and retention rates. Having lower turnover rates and a successful orientation program may also have a positive impact on patient satisfaction with overall quality of nursing care.

Implications: This preceptor model is a new idea and a new method for orienting new nurses. This innovative approach to precepting new nurses to medical-surgical units influenced efficiency, nurse retention, overall quality of nursing care and nurse satisfaction with orientation. The CNS has the clinical expertise to explore and evaluate the impact of new models of precepting and orientation.

An Innovative Reallocation of Resources to Reduce Pressure Ulcers in the Cardiovascular Intensive Care Unit

Freeman RK, Maley K, University of Michigan, Ann Arbor

Purpose: Rates of unit acquired pressure ulcers in the cardiovascular intensive care unit (CVICU) on the monthly skin prevalence day were above the national benchmark at an average of 13.99% unit acquired pressure ulcers per month from August 2011 to March 2012. Most commonly sacral, coccyx, buttock, and heel pressure ulcers were identified in the high-risk postoperative CVICU patients. To reduce pressure ulcer rates a plan was created to reallocate resources in the CVICU to focus on turning, positioning, and mobility.

Significance: Pressure ulcers are considered a "never event" by regulatory bodies and the development of pressure ulcers has significant adverse financial and safety effects on patients and institutions. Pressure ulcers treatment costs range from $2000 to $40 000 and contribute to increased length of stay, morbidity, and mortality. Pressure ulcers also cause increased pain and suffering for patients and families

Background: Cardiovascular intensive care unit is a 24-bed ICU with high-risk cardiovascular, thoracic, vascular surgery patients. The patient population includes coronary bypass grafts, valve replacements and repairs, aortic dissections and aneurysms, heart and lung transplants, espohagectomies, mechanical circulatory support, and extracorporeal membrane oxygenation. Many patients are at high risk for pressure ulcers due to the following: age, long operating room times, moisture, friction, shear, body max index, malnutrition, vasopressor requirements, heart failure, poor perfusion, and history of pressure ulcers.

Description: The literature was researched for current evidence-based practice related to reducing pressure ulcers. After implementation of a preventative dressing preoperatively pressure ulcer rates decreased, but select high-risk patients continued to develop pressure ulcers after complex stays the CVICU. After looking at current staffing ratios and functions, it was determined that a reallocation of resource was needed. The unlicensed assistive personnel (UAP) role was transitioned to a turning, positioning, mobility and oral care team rounding the unit every 2 hours. During these rounds the UAP reposition the patient, complete a skin assessment, apply preventative products, mobilize the patient, or provide pressure point relief it the patient is in the chair. The UAP would also provide oral care and document the position change and notify the nurse if the patient exhibits any sign of skin breakdown.

Outcome: After implementation of the new UAP role in March 2012 skin prevalence day data for pressure ulcers has improved. From March to present the average number of unit pressure ulcers identified on skin day was 6.9%. Of these ulcers 1 was lip, 2 were sacral, coccyx, buttock and 0 were heel ulcers.

Conclusion: A reallocation of resources utilizing the UAP as a turning, repositioning, mobility, and oral care team can reduce unit acquired pressure ulcers. Rates of sacral, coccyx, buttock and heel pressure ulcers rates can be reduced with consistent vigilant attention to turning, repositioning, and mobility practices.

Implications: Reallocating resources of the UAP in the CVICU has improved pressure ulcer rates and allowed the UAP a focus to champion on the unit. The prevention of pressure ulcers improves patient outcomes and reduces financial impacts.

An Interdisciplinary Team Effort to Increase the Number of Stroke Patients Who Receive Dysphagia Screening

Brumfield VC, Hersey M, Tillman M, University of Texas Medical Branch, Galveston

Purpose: The purpose of this project was to increase the percentage of acute stroke patients who receive dysphagia screening prior to oral medication and nutrition.

Significance/Background: Approximately 700 000 patients are diagnosed with stroke each year. Dysphagia is a common problem in stroke patients and is associated with serious complications, prolonged length of hospital stay and increased mortality.1 Diagnosis and evaluation of dysphagia is important and involves clinical assessments. The percentage of acute stroke at UTMB who received dysphagia screening prior to oral medication and nutrition did not meet the standard of care established by the Stroke Steering committee.

Methods: An interdisciplinary team of stake holders were gathered to address this problem. This included a neurologist, speech pathology supervisor, clinical nurse specialist, and staff nurses. when we began to develop documentation for the electronic medical record (EMR) we included an information systems analyst, nursing program manager and informatics specialist. A protocol was developed guiding both physicians and nurses when to do a dysphagia screen, how to do the dysphagia screen and how to document the results. A series of education programs were implemented to train nurses from each unit and then a more focused training sessions occurred with those nurses most likely to care for acute stroke pts. Both concurrent and retrospective audits were conducted to ensure compliance with the dysphagia protocol.

Findings: Prior to the implementation of a specific dysphagia protocol, the screening compliance was approximately 37.4% (December 2010). After the implementation of the protocol it increased to 84% (December 2011). We are trying to hold our gain but as of April 2012 we are at 75%. The percentage would be higher but some nurses screened the patients and did not assure the patients were kept NPO if they failed the dysphagia screen.

Conclusions: We have not met our target goal of 85% but continue to work with IS to establish reminders when a patient fails the dysphagia screening. We also increased our education efforts to include our HUC's and PCT's asking them to help nurses be vigilant about who received diet trays.

Implications: Improving our quality of care for stroke patients helps us move 1 step closer to our goal of stroke certification. We continue to strive for excellence with a goal to prevent complications that prevent our patients from being discharged to the highest level of care possible.

The Application of Interprofessional Education Using Simulation to Foster Learning and Collaboration Between Nursing and Medical Students

Scherer Y, University at Buffalo, The State University of New York

Significance: The Institute of Medicine (IOM) notes that lack of interprofessional cooperation and ineffective communication adversely affect best practice and improved patient outcomes. The IOM report suggests that by improving interprofessional efforts which include the development and evaluation of interprofessional education (IPE) models reflecting best practice, patient errors could be greatly reduced and patient safety improved (The Institute of Medicine, 2010). The CNS as researcher and educator is in an ideal position to evaluate IPE models and implement those reflective of best practice in both academic and healthcare settings.

Design: The purpose of this quasi-experimental study was to investigate the application of interprofessional education (IPE) with an innovative teaching strategy using patient simulation to support learning and collaboration between nursing and medical students in an education setting. Most students in healthcare professions, including nursing, are taught core content, values, and skills in isolation or "professional silos" which do not foster collaboration. IPE is considered to be an educational strategy that fosters shared learning and has the added potential benefit of improving teamwork, cooperation, and collaboration in practice, leading to improved patient outcomes. A growing body of literature is supportive of simulation's role in fostering collaboration among health science students, especially in nursing and medicine. Studies using simulation as a means to foster interprofessional collaboration have been reported in the literature.

Description of Methods: A quasi-experimental pretest/posttest design using an experimental and a control group was used to study the effect of interprofessional (senior nursing students and second year medical students) compared with intraprofessional (senior nursing students) simulation on knowledge, confidence, readiness and attitudes toward interprofessional learning (as measured by the Readiness Interprofessional Learning Scale), and attitudes toward working with healthcare teams (as measured by the Attitudes Toward Health Care Teams Scale), as well as satisfaction with the simulation experience. Eighty-four nursing students and 23 medical students participated in a high-fidelity simulation, cardiac arrest scenario.

Findings/Outcomes: The findings from this study support the value of interprofessional education using simulation as an educational strategy to improve students' attitudes toward learning with students from other disciplines, as well as the importance of teamwork. These findings were supported in the Readiness Interprofessional Learning Scale pretest and posttest scores for the nursing and medical students in the experimental group. Both groups' readiness for interprofessioanl education increased. An increase in knowledge was another positive outcome of the interprofessional intervention.

Implications: The CNS needs to consider the use of simulation as a teaching strategy for nurses to promote teamwork and collaboration within an interprofessional education framework.

Bed Rest Time After Removal of Femoral Artery Sheath: Evaluation of Optimal Time in Outpatient Adult Patients Having a Diagnostic Heart Catheterization

Murphy Gardner F, East Alabama Heart and Vascular, Auburn, Alabama

Purpose: The purpose for this project focused on determining the optimal length of bed rest time following an outpatient diagnostic heart catheterization using femoral artery access in adult patients (aged 18 and older). Goals for the project included implementing a safe change in practice without increasing complications.

Significance: Cardiovascular disease remains the leading cause of death in adult men and women. Of all deaths in 2006, 1 in every 2.9 deaths (56%) was related to cardiovascular disease. Heart catheterization is considered the gold standard in diagnosing coronary artery disease and accurately identifies specific areas of coronary artery disease.

Design (Background/Rationale): Diagnostic heart catheterization continues to be the standard test for the definitive diagnosis of coronary artery disease. Because of reduced reimbursement for arterial closure devices, many facilities are returning to the standard of manual compression for hemostasis of the arterial access. With the transition to manual compression, the staff in the outpatient cardiac catheterization lab of a large 300-bed hospital observed variable bed rest times for out-patients after a diagnostic heart catheterization. The staff, lead by a clinical nurse specialist (CNS) student, developed a chart audit tool in order to evaluate complications and patient demographic information associated with the complications.

Description of Methods: Researchers conducted a retrospective chart audit of consecutive cases during 1 month. Based on a review of existing evidence including a retrospective record review, a 2-hour bed rest was implemented for patients requiring a 5F sheath. After implementing the 2-hour bed rest, the team performed a second retrospective chart audit of consecutive patients for 1 month.

Outcomes: Following the standardization in practice, the CNS-student noted an overall reduction in complications. Of the 132 patients, 9 (6.8%) experienced some form of complications. Again, some patients had more than 1 complication. Following the standardization, 2 (1.5%) patients complained of pain during bed rest, 2 (1.5%) had a hematoma prior to bed rest, 1 (0.75%) patient experienced bleeding before bed rest, and 1 (0.75%) patient had a vagal episode during their hold time. The remaining complications included 1 (0.75%) patient with a hematoma and bleeding at ambulation and 2 (1.5%) patients who had a vagal response at ambulation. Analysis of the patients with complications revealed 3 females and 6 male patients. Age ranged from 53 to 79. Weight ranged from 59.7 kg to 97.2 kg. The average weight of patients with a complication was 75.1kg (165 pounds). Six patients with complications took Aspirin and Plavix before the procedure.

Conclusions: Standardization in bed rest time resulted in a decrease in the average bed rest time from 135 minutes to 130 minutes. Average length of stay decreased from 416 minutes to 402 minutes. Complication rates remained low at 1.5% following the decrease in bed rest time.

Implications: While the average bed rest time decreased by only 5 minutes, the total number of patients with a bed rest of 1 to 2 hours increased from 77.7% to 88%. More patients ambulated safely at 2 hours without an increase in complications. Shorter bed rest time results in greater patient satisfaction with their procedure.

Bloodstream Infection: Educating Emergency Department Staff About Central Line-Associated Bloodstream Infections

Young G, Chamblee T, Children's Medical Center, Dallas, Texas

The etiology, prevention, and treatment of central line-associated bloodstream infection (CLABSI) have been critical issues for inpatient units for years. Because the Centers for Disease Control requires surveillance of central line-associated infections in inpatient areas, bedside nurses, educators and CNSs in these areas are acutely aware of terms such as catheter-associated infections, line days, bundles and biofilm. Discussions of central venous catheters during bedside rounding are common practice. Conversely, many non-inpatient areas such as emergency departments (ED), radiology or operating rooms (OR) though educated on basic care and handling of central venous catheters, have not traditionally been included in the expanded education and bundles for care. Surveillance is not required for CLABSI in non-inpatient areas, yet they still often insert and access all types of CVCs. This was the case for our pediatric emergency department. We did not have statistics linking CLABSI to the care of patients coming through our department. However, feedback from inpatient units, and patients/families who had attended our ED revealed that our practices with CVCs were not consistent. Patients/families expressed uncertainty in the expertise of the ED staff. In response to this issue, the ED CNS in collaboration with experts within the institution developed a program designed to increase ED nurse's expertise related to knowledge of CLABSI and care of CVCs. The program includes 4 hours of didactic learning, skills stations, and videos of parents relating their experiences in the ED. In addition, each nurse spends a total of 8 hours on 2 inpatient units interacting with staff, learning about CVC bundles, and caring for patients with CVCs. Twenty-one nurses have now attended the program. Written tests and audits of documentation serve to monitor knowledge and compliance. These nurses are now "clinical resource nurses" for the care of the CVC in the ED, and they serve as experts on the unit for care and trouble shooting. Feedback from ED staff and from the inpatient units has been overwhelmingly positive. Though CLABSI data cannot be tracked through the ED, we are working with infection control to explore other options. Our goal is improved patient/family experiences and plans are underway to collaborate more closely with families in the future. Hospital-associated infections decrease with use of evidence-based practices. The education and monitoring of those practices should include all areas of the hospital. Strategies for education have included collaboration between the ED and areas with expertise in the care and treatment of CVC, and the creation of "clinical resource nurses" to serve as experts for high-risk patient groups. These methods have great potential to enhance patient care and improve outcomes, as well as further develop relationships between patient care areas.

Bullying in the Workplace of Nurses

Turi SK, St Vincent Hospital, Carmel, Indiana; Ziemba-Davis M, St Vincent Hospital, Indianapolis, Indiana

Purpose: The purpose of this study was to identify the prevalence of bullying experienced by nurses and who engages in this behavior at an 800-bed quaternary care hospital located in the Midwestern United States.

Significance: There is growing evidence that unhealthy work environments contribute to medical errors, ineffective delivery of care, and conflict and stress among nurses. Documenting whether nurses experience bullying and possible variations based on demographic characteristics are the first step to addressing and stopping the behavior.

Background: Research indicates as many as 57% of nurse's world-wide have experienced bullying in the workplace. The World Health Organization defines bullying as "repeated and over time offensive behavior through vindictive cruel or malicious attempts to humiliate or undermine an individual or group of employees." As noted by The Joint Commission, quality and safe patient care depend upon a collaborative work environment free from intimidating and disruptive behaviors. While anecdotal wisdom holds that bullying among nurses is common, very few studies have actually quantified bullying among nurses in the United States.

Methods: Forty percent (n = 853) of all RNs and LPNs in the study institution anonymously completed an online questionnaire assessing the prevalence of 22 bullying behaviors and who engaged in the behavior (a nurse, physician, patient, etc). Additional questions addressed how bullying is perceived by and has affected nurses. Demographics included age, gender, education, position type, years of nursing experience, healthcare specialty/unit, and work shift. The questionnaire was based on extensive review of the literature identifying 22 behaviors previously documented as indicative of bullying. Institutional review board approval for the study was obtained.

Findings: Ninety-four percent of nurses had experienced 1 or more of the 22 bullying behaviors in the last 12 months. The average number of behaviors experienced was 8.7 (SD 5.6). The most common behavior (experienced by 77%) was having someone speak to or about you in a belittling or demeaning manner. The least common (experienced by 8%) was having someone suggest you are mentally unstable or psychologically unwell. The prevalence of bullying did not differ by demographics. In most cases, the "bullier" was another nurse. Nearly all nurses agreed that bullying negatively affects patient care. More than half reported that bullying has negatively affected them professionally and personally. Nonetheless, only 28% believed that bullying is a problem where they work.

Conclusions: This study documents that, consistent with anecdotal wisdom, bullying does occur in the workplace of nurses. Moreover, nurses themselves are the most likely to bully other nurses. The findings support existing theory that nurses inherently behave as an oppressed group and suggest that nurses believe bullying is acceptable behavior.

Implications: Clinical nurse specialists (CNSs) are charged with improving patient outcomes. The most successful do so by understanding the culture within which they work. The first author (a CNS), nurses, ethicists, and mission leaders in our organization are using this work in next steps to identify the underlying causes of bullying and enhance the work environment of nurses, thereby improving patient safety and well-being.

Burn Care Program: Building Clinical Competency for Air Force Critical Care/Emergency Nursing Fellows

Tubera D, US Army Institute of Surgical Research, San Antonio, Texas, and Savell K, US Air Force, Lackland AFB, Texas

Purpose: The purpose of this project was (1) to evaluate an educational program in conjunction with the US Army Institute of Surgical Research (USAISR) Burn Center to build clinical competency in burn care among US Air Force (AF) nurse fellows tasked to deploy overseas; and (2) to describe the multifaceted role of the clinical nurse specialist (CNS) in the implementation of the burn program.

Significance: Burn injury is a constant threat in a deployed military environment. Provision of burn care in an austere deployed environment is both challenging and demanding. It is a complex and resource intensive patient care need involving the multidisciplinary team process and requires competent burn care trained personnel to ensure optimal outcome. The CNS is uniquely positioned to use a multifaceted function in the development and implementation of an educational program to promote collaboration and facilitate learning.

Background: The critical care/emergency nursing fellowship is a year-long training program to develop an entry level Air Force (AF) critical care and emergency nurse. The nursing fellowship program is designed to identify educational elements that best prepare AF nurses for practice in the area of critical and emergency care. With nearly 100% deployment rate after fellowship completion, reports from past fellow graduates indicated they felt inadequately prepared to provide burn care in the deployed setting.

Description: Collaboration with USAISR burn unit leadership was done to establish a training agreement and education plan for the AF nursing fellows. Burn care curriculum was developed and composed of didactic class-3 hours of burn management, 2-day burn symposium; clinical hours-160 hours of supervised clinical rotation at USAISR burn center; and a competency checklist to assess and verify competency level in burn care. Nurse fellows started burn rotation towards the end of their fellowship program. The CNSs conducted daily clinical rounds to discuss patient status and evaluate nurse performance. Weekly conferences with all nursing fellows in the burn center were done to follow up on their clinical/learning experience. Continued collaboration with burn intensive care unit (ICU) wound care coordinators and CNSs provided opportunities to discuss learning needs of the nursing fellows.

Outcome: Thirty-eight competent AF critical care/trauma nurse completed the burn program; all have subsequently deployed overseas. Participants successfully completed a competency checklist of 144 burn-specific tasks.

Conclusion: Implementation of a burn care program provides increased competency in caring for burn ICU patients among AF nurse fellows. The responsible CNSs have the advanced knowledge and clinical expertise to lead the development, implementation, and evaluation of such a program. Ongoing collaboration with CNS educators in the burn center promoted the success of our burn program.

Implication for Practice: The burn injured ICU patients in the deployed setting have unique needs; preparing combat nurses with competent skills promotes optimal patient outcomes. The CNS possesses the knowledge and expertise to provide the education and assessment for nurses during predeployment training.

Can a Single Asthma Day Camp Improve Rural Children's Asthma Self-management?

Horner SD, The University of Texas at Austin

Purpose/Objectives: The purpose of this study was to examine the effects of an intervention delivered in a single asthma day camp on school-aged children's knowledge of asthma, self-reported asthma self-management behaviors, and their observed skill in using a metered dose inhaler.

Significance: Fully 9.6% of children under 17 years of age have asthma. It disproportionately affects more school-age boys than girls, and more racial/ethnic minorities than nonminorities. Because school-aged children are away from home for a large portion of the day, it is important that they learn to recognize and respond to early asthma symptoms. In rural communities where resources are limited, finding effective ways to deliver interventions or health promotion programs within the available resources is an important strategy for improving the health of underserved groups.

Design: Exploratory, descriptive study using data collected as part of a larger on-going longitudinal study testing asthma self-management interventions versus a health promotion intervention. The question of whether an asthma intervention can be delivered in a single comprehensive day camp and lead to changes in children's self-management behaviors is an important one that could potentially lead to broad dissemination across communities.

Methods: Sample inclusion criteria were children in grades 2-5 and who had a physician diagnosis of asthma. The setting is rural (non-metropolitan areas with no towns of 1300 population or larger). Children were randomly assigned to receive either asthma education in a single asthma day camp or to health promotion classes as a comparison intervention. Data were collected at the time of study enrollment (consent, assent, baseline data) and again 6 weeks after the intervention. Repeated-measures analyses of variance were run to compare the 2 groups on asthma knowledge and asthma self-management with data obtained at study enrollment and again 6 weeks after the intervention.

Findings: The sample was composed of 115 children with 78 boys (67.8%) and 37 girls (32.2%); and 60% Hispanic (H), 30% African American (AA), and 10% non-Hispanic white (W); and a mean age of 8.83 years. There were no differences between the camp and comparison group on asthma severity, asthma knowledge or asthma self-management at baseline-indicating the groups were comparable at baseline. Asthma knowledge significantly improved for both groups after the intervention (F = 18.06, P < .001). Asthma self-management behaviors did not change for the comparison group but improved significantly for the camp group (F = 5.729, P = .018). Furthermore, the children in the asthma camp significantly improved their skill in using a metered dose inhaler (F = 15.03, P < .001).

Conclusion/Implications: All of the children improved their asthma knowledge, even though the comparison group did not receive asthma education. It is possible that completing survey questions may have sensitized them to asthma information (ie, effects of repeated testing) but this did not lead to changes in behaviors for the comparison group. The significant improvements in asthma behaviors and inhaler skill of the asthma camp group, indicate that the asthma camp may be a viable means for delivering an asthma self-management intervention to school-aged children.

Caring for Adult Patients in a Pediatric Facility: Identifying Challenges and Recommendations for a Changing Healthcare Landscape

Torzone A, Chamblee T, Children's Medical Center Dallas, Texas

Objective: The purpose of this project is to appraise care needs of adult patients with chronic pediatric onset conditions requiring hospitalization in a pediatric facility.

Significance: Because of medical advancements, improved technology, and in some cases, an increase in disease prevalence, many individuals with diseases and/or conditions that were historically considered to be fatal in childhood are now surviving into adulthood. These improved patient outcomes create new challenges in healthcare. Because of the uniqueness of their condition, these adult patients often continue to seek care at pediatric hospitals. Pediatric nurses and subspecialists are not trained in the management of adult patients and their acquired comorbidities. Likewise, adult practitioners have very limited, if any, exposure to pediatric conditions. This presents a significant problem in the management of a unique patient population.

Design: There is a paucity of published literature on the care and management of the adult patient with a chronic pediatric condition requiring hospitalization. To identify content for an educational intervention, a needs assessment survey, developed by the researchers, was conducted. Based on the results, as well as, a review of the literature on the topic, an educational intervention will be developed and implemented.

Methods: The design for this project is an educational needs assessment survey followed by a 1-group pretest/posttest intervention. The population of interest is registered nurses specializing in pediatric critical care at the research site. A convenience sample will be used. The intervention will consist of information regarding the care needs of adult patients including normal parameters related to vital signs, laboratory findings, and electrocardiography, cardiac dysrhythmia management, adult comorbidities, body mechanics for lifting, informed consent/advanced directives, medication safety, emergency care algorithms, and communication strategies. The intervention will be provided in a series of four 4-hour classes. Final institutional review board approval is pending. Outcome measures include knowledge and nurse satisfaction. Knowledge will be assessed in a pretest/posttest fashion using a modified version of the Basic Knowledge Assessment Tool (BKAT-8) for adult critical care nursing. The researchers will extract specific items from the BKAT that tap into the content of interest. Reliability and validity of the modified tool will be tested prior to use in the study. Pretest/posttest nurse satisfaction will be assessed using the nurse satisfaction items on the Moorehead Employee Satisfaction Survey.

Findings: Preliminary results suggest that a practice change is needed and will likely contribute to improved patient care and improved satisfaction among nurses.

Conclusion: Adult inpatients in a pediatric facility are a low volume, high-risk population. Lack of knowledge about how to provide safe and effective care for these patients exists among pediatric nurses and providers. This knowledge gap may contribute to adverse events for patients and job dissatisfaction among pediatric nurses.

Implications: Implications of this practice innovation include identification of the care needs of a unique patient population and implementation of an educational intervention to address that need. To date, this has not been empirically tested. The study seeks to address this gap in knowledge.

An Innovative Clinical Nurse Specialist Competency Evaluation Program

Marder L, Donnelly J, Nasshan S, Toole B, Sharp Memorial Hospital, San Diego, California

Purpose/Objectives: This presentation will demonstrate how to implement an innovative annual competency program by recognizing the difference between competence and skills check offs, examining the various competency validation methods and identifying possible implementation barriers of a new competency validation program.

Significance: In today's economic healthcare climate, clinical nurse specialists must implement innovative methods to evaluate nursing competency as a means to preserve scarce education dollars.

Design (Background or Rationale): The clinical nurse specialists (CNSs) of 4 progressive care units (PCUs) in a mid-size southern California hospital decided to replace the traditional annual skills day with a modality of diverse evaluation methods to meet individual needs and learning styles. Each PCU leadership team, composed of a CNS, manager, clinical leads, and advanced clinicians, oversees the clinical competency of nursing staff. The CNS collaborated with their leadership team to select the most appropriate competency evaluation method taking unit culture into consideration. Competency evaluation methods utilized in this process were examinations, return demonstrations, evidence of daily work, case studies, on-line videos, exemplars, peer review, self-assessment, and mock events.

Description of Methods: The PCU CNSs met weekly to discuss logistics of the new competency process. The CNSs wanted to provide staff with the opportunity to choose between several methods for completing their annual competencies while on duty in the actual work environment. Each competency consisted of 3 options for completion, all of which provided an accurate reflection of current practice and autonomy in their practice. Because the competencies were to be demonstrated and completed during work hours, the specific options had to be simple yet effective for the learner. The PCU CNSs developed the specifics of the new program based on input from a needs assessment. Competencies were reviewed and case studies, reflective learning tools and clinical safety investigation rooms were created. Each nurse received an informational folder that included a section in which to document completion of competencies. A monthly schedule of competency evaluation was created and explained to nursing staff and included when each competency was to be completed. In addition to these competencies, an emergency standing orders standardized procedure "test" was administered while nursing staff were off-duty. Along with the test, a physician lecture was offered for another learning opportunity. The lecture topics were chosen from the staff self-identified needs assessment with the goal of improving the collegial relationship between physicians and nurses.

Findings/Outcomes: The new process for annual competencies produced a 600-hour reduction in education hour usage for annual competencies from 2011 to 2012. Based on the average RN rate of pay of $42.20 per hour, this program realized a cost savings of approximately $25 320.

Conclusions/Interpretations: The benefit of this innovative program is both financial and educational. Care quality is measured at the bedside. The new program allowed the nursing staff to demonstrate their competency via the method which they felt best exemplified their knowledge and skill.

Implications for Practice: Using a CNS-driven annual competency program saved education dollars for use in other areas deemed important by individual units.

Changing Vaccination Practices in a Children's Hospital

Hartman J, Cleveland Clinic, Ohio

Purpose: The Centers for Medicare & Medicare have mandated that pediatric patients be screened for high-risk conditions and immunized against pneumococcal and influenza disease prior to discharge, if indicated. The purpose of this project is to describe the implementation of a quick reference tool for pediatric nurses to order and administer the pneumococcal and influenza vaccines on inpatient pediatric units at a tertiary care hospital. The presentation will describe how an advanced practice nurse (APN), functioning as a CNS, was able to empower nursing practice by providing a tool that is quick and easy to use, while increasing professional confidence in administering the vaccine. The overall objective increased immunization rates and decrease missed opportunities, improving core measure outcomes.

Significance: The CNS role is the ideal position to effect practice change. Vaccines have been identified as one of the most important public health interventions in history. Everyday thousands of hospitalized patients from across the country could benefit from pneumococcal and influenza immunizations, yet few are actually given the vaccine.

Background: This presentation articulates how the APN functioning in the CNS role was able to promote and enable nursing to take ownership for screening, ordering and administering pneumococcal and influenza vaccines using a standardized process. Screening the patient would prove to be the most difficult part of the process. Pneumococcal vaccine was particularly anxiety producing due to the change in vaccine serotypes from 7 to 13 in the past 2 years and the addition of the Pneumovax vaccine to be administered to high-risk pediatric patients.

Description: It is an established concept that learners acquire knowledge in many different ways. There are auditory learners, visual learners and kinesthetic learners. The presentation will describe tools that are directed at visual learners, such as written directions and charts. These tools, developed by the APN allowed for rapid, accurate nursing assessment to determine whether the child is a candidate for the pneumococcal or influenza vaccine. The involvement of the CNS in reinforcing the decision prior to the actual electronic screening that is required resulted in decreased nurse anxiety and increased confidence in the implementation of the protocol.

Outcomes: Influenza season is just beginning for the 2012 influenza season. Nurse-driven pneumococcal screening, ordering and administering has taken place for the past 3 months. Results to date indicate a dramatic fall is immunization screening failures.

Conclusion: The screening, ordering and administering of vaccines is a complex process and changes from year to year. With increasing demands on nurses' time and complex patients with high acuity it is important to provide nurses with tools that will increase their understanding, decrease their anxiety and contribute to the over all well being of the patient.

Implications for CNS Basic and Continuing Education: As an educator, consultant, clinical expert and care giver clinical nurse specialists' influence outcomes by increasing quality and cost effectiveness of processes that provide support to nurses who provide direct patient care everyday. The unique articulation of the CNS role is critical to the success of the program.

Chest Tube Removal Post-Surgical Intensive Care Unit Transfer: A Practice Change for Cardiovascular Registered Nurses

Myrick J, Mayo Clinic in Florida, Jacksonville

Purpose: To instruct cardiovascular (CV) nurses in the removal of pleural and mediastinal chest tubes post-SICU transfer.

Significance: By preparing CV RNs to remove chest tubes there is the potential to change practice. In addition, it provides the opportunity to create a caring environment that may result in a positive patient experience.

Design: Cardiovascular (CV) nurses at this facility did not remove chest tubes (CTs) from coronary artery bypass graft (CABG) patients or thoracotomy patients. CTs were removed by the surgical intensive care unit (SICU) nurse prior to patient transfer to the cardiovascular unit or by the cardiothoracic surgical team (CTS). Removal by the CTS team was typically performed in the morning on their way to surgery. Often, patients were not prepared for removal via education, or analgesia. As a result, many experienced pain and anxiety that could have been avoided. One CTS surgeon suggested that CV nurses learn to remove CTs.

Description: This was a quality improvement project. Patient population included coronary artery bypass graft, heart valve, and thoracotomy patients with chest tubes in place after transfer from the surgical intensive care unit (SICU) to the cardiovascular unit. The CV clinical nurse specialist (CNS) developed a novel chest tube removal class. The 1-hour course included the following didactic elements: the history of chest tubes, thoracic anatomy and physiology, Jean Watson's Theory of Human Caring, instructions for safe chest tube removal and possible adverse events. Hands-on chest tube removal practice was simulated with the use of common drinking straws. The class concluded with a written test. Participants were required to complete a minimum of 3 observed chest tube removals by the CV CNS or CTS team before being checked off for independent removal.

Outcome: The 1-hour course was offered in January and February, 2011. Of the original 14 dayshift nurses who attended, 13 have become independent in chest tube removal. Informal survey of CV nurses indicates they felt adequately prepared to remove CTs and to create a caring environment. Patients have also responded favorably; most comments reflect that there has been little or no pain experienced during the procedure. Finally, providers have verbalized satisfaction with the new nursing skill. There have been no adverse events as a result of CV nurses removing CTs.

Interpretation/Conclusion: Data collection is still in progress; however, overall responses have been positive. The innovative chest tube removal course created by the CV CNS has allowed the CV nurses to acquire a new skill set. Furthermore, it has permitted them to create a caring environment by preparing the patient for a potentially uncomfortable procedure.

Implications for Practice: Research indicates that allowing the nurse to create a caring environment positively impacts job satisfaction and retention. This new practice change, once the domain of the SICU, has the potential to optimistically influence the nursing sphere. Likewise, patient satisfaction may be reflected in future Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores. Finally, all 3 spheres of CNS influence may be positively impacted.

A Clinical Nurse Specialist and Unit Educator Collaboration to Improve Clinical Staff Members' Resuscitation Skills

Janke E, Mahramus T, Orlando Health, Florida

Purpose: (1) Identify data that are needed to evaluate effectiveness of cardiopulmonary resuscitation practice drills on self-reported comfort with skills. (2) Describe the impact of clinical nurse specialist and unit educator collaboration on selected outcomes. (3) Illustrate the value of frequent practice drills in maintaining comfort with resuscitation skills.

Significance: Timely cardiopulmonary resuscitation efforts are imperative to improve patients' chances for survival. Research has shown that, if not utilized on a consistent basis, providers' knowledge, skills and confidence sharply decline within weeks of attending formal resuscitation training. The use of practice code drills has been reported to decrease anxiety and increase staff confidence and readiness to perform in emergency situations.

Background: The clinical nurse specialists (CNSs) collaborated with several cardiac clinical unit educators (CUEs) to develop a structured process to increase clinical staff members' resuscitation skills during cardiopulmonary arrests. All RNs and clinical technicians from 3 cardiac units were included in quarterly cardiopulmonary arrest practice drills.

Methods: All participants were given a self-evaluation form to grade (Likert scale 1-5, with 1 being the lowest and 5 the highest) their comfort with Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) skills preintervention and postintervention practice drills. Debriefing was done by the CNSs and CUEs postcode to provide feedback and to allow the participants to ask questions. Mean scores on the self-reported comfort level were compared preintervention and postintervention drill for each unit and again between each unit's quarterly scores. A tip sheet with rationales for why specific skills are necessary during resuscitation events was given to participants at the end of each session.

Outcomes: After 2 quarterly sessions an overall improvement in level of comfort was noted. First quarter predrill mean scores were 3.45 versus 4.00 postdrill. Second quarter predrill mean scores were 3.40 versus 4.14 postdrill. Participants consistently scored the following items lowest (pre-/post-): operation of the defibrillator (3.12/3.89); operation of the pacer (2.69/3.73); documentation during the code (2.94/3.61); leading a code until the Code Blue 90 team arrives (2.69/3.46); and leading a code even after the Code Blue 90 team arrives (2.63/3.44).

Conclusions: Biannual BLS and ACLS certification may not be enough to assist clinical staff with maintaining the skills necessary to resuscitation situations. Practicing code drills on a quarterly basis has demonstrated an improvement in participants' self-reported comfort with resuscitation skills.

Implications: The implementation of a structured process similar to this program may be beneficial to improve one's comfort with skills not performed on a regular basis. Practice resuscitation drills are being initiated on an outpatient chemotherapy unit and plans to include medical and surgical units in the future are being discussed. Further research is needed to determine if the results of the program have an impact on the outcomes of actual cardiopulmonary arrest situations occurring on these units.

Clinical Nurse Specialist Driven Strategies to Improve Transitions

Ventura K, Hucjs M, Hospital of the University of Pennsylvania, Philadelphia

Purpose: Identify clinical nurse specialist (CNS)-driven strategies to improve transitions from critical care to acute care to hospital discharge. Discuss CNS practices required to implement processes to improve transitions.

Significance: Increased scrutiny on hospital readmissions and focus on transitions, in addition to decreasing mortality, has become priority with the implementation of a value-based purchasing system. It is also well published that intensive care unit (ICU) readmissions are associated with increased mortality rates.

Background: Monthly review of readmission rates on a 29-bed transplant surgical unit revealed a large number of liver transplant patients being readmitted. Partnerships between the ICU CNS and acute care CNS led to further investigation and implementation of strategies to improve transitions in care for this complex patient population.

Description of Methods: Hospital and ICU readmission database was reviewed for all liver transplant recipients from July 2010 through June 2011. Descriptive analysis of readmission data conducted to explore factors associated with readmission. Case review of liver transplant patients readmitted to ICU conducted in order to identify common causes. Approximately 30% of these patients were readmitted within 30 days of discharge, a higher rate than the 20% all-cause readmission rate reported by Centers for Medicare & Medicaid Services. In addition, approximately one-third of liver transplant patients returned to the ICU during their hospitalization posttransplant.

Outcome: Clinical nurse specialists identified discrepancies between nursing and surgical provider team perspective of readiness for transfer from ICU to acute care unit including patient acuity, level of care, patient monitoring and physiologic stability. Similar differences in perspective were also revealed between the transferring ICU nurses and the receiving acute care nurses. Compromised respiratory and altered mental status were identified as the 2 areas of greatest clinical concern upon transfer and the most common reasons for transfer back to ICU. Guided by CNS, the ICU and acute care nurses partnered to create a tool to improve communication during transition from ICU to unit.

Conclusion: Increased hospital and ICU readmission rates for liver transplant population was not recognized as a problem until the CNS reviewed data and explored clinical experience. Strategies implemented in improved transitions for this complex patient population include a CNS-driven process developed in order to gather more data and identify factors specific to this patient population to prevent ICU readmission and a transition communication tool utilized by clinical nurses.

Implications for Practice: Clinical nurse specialist practice to investigate the problem, define and clarify the issues, implement and evaluate interventions is necessary to improve transitions for complex patient populations. Clinical nurse specialist ability to collectively approach an issue from the patient, nurse and systems perspectives is what guides the development of interventions appropriate to optimize outcomes.

Clinical Nurse Specialist Role in Decreasing Unplanned Device Removal in a Pediatric Intensive Care Unit

Christopher JA, Handwork C, Perebzak C, Akron Children's Hospital, Ohio

Purpose: To describe efforts by a multidisciplinary committee, led by a clinical nurse specialist (CNS), to reduce unplanned device removal (UDR) rates in a pediatric intensive care unit (PICU).

Background: The Institute of Medicine (2001) described 6 characteristics of high-quality healthcare systems, one of which is safety; another is efficient care to avoid waste. Any UDR is a patient safety risk due to the critical nature of many devices. Replacement of any accidentally removed medical device requires the use of additional resources, including personnel and equipment leading to increase cost.

Description: A longitudinal design was used to identify UDR rates in the PICU population. A medical/surgical PICU with 1500 annual admissions served as the setting. In 2009, we started to monitor UDR in our PICU. Devices monitored include endotracheal and tracheostomy tubes, nasogastric/nasoduodenal/gastric feeding tubes, central venous catheters, indwelling urinary catheters, and chest tubes. A CNS-led multidisciplinary Critical Incident Review Team (1) identified reasons for UDR, (2) monitored UDR using a standardized data collection tool, (3) conducted critical incident review of UDR in real time with nursing staff, medical staff, and the charge nurse, (4) reviewed events for the purpose of identifying/implementing improvement, and (5) provided staff education on measures to prevent UDR. In 2011, a spike in UDR rates occurred requiring implementation of performance improvement measures. In addition to real-time critical incident review, we implemented an additional level of "safety huddle" between nursing staff at change of shift. Various securement devices were trialed by staff. A guideline was created for safe moving and repositioning of patients. Parents received education on the necessity of having the nurse help with moving their child. For PICU staff awareness of UDR progress, a dry erase board was installed to display days since the last UDR event, and UDR rates were discussed at monthly PICU quality improvement meetings and monthly PICU staff meetings.

Outcome: In 2011, UDR rate spiked to 10.1/1000 device days from 2.2/1000 device days in 2010, despite improvement efforts. For the first 2 quarters of 2012, the PICU UDR rate decreased to 4.1/1000 device days.

Conclusions: Pediatric ICU critical incident reviews provide valuable information surrounding UDRs and allow for longitudinal tracking to direct improvement efforts. The multiple practice changes, guideline implementation and securement device trials, under the guidance of the CNS-led PICU Critical Incident Review Team has been instrumental in addressing patient safety and UDR in the PICU.

Implications for practice: The safety issue of UDR continues to be a problem in this PICU population. A CNS-led Critical Incident Review Team for review of UDR and implementation of education and evidence-based practices has led to a reduction in UDR rates thus far in 2012. Continued monitoring of UDR and improvement efforts are necessary to address patient safety and to conserve resources as safety and efficient care are 2 characteristics of high quality healthcare.

A Clinical Nurse Specialist's Role in Developing Strategies to Facilitate Early Transfer of Cardiothoracic Patients to the Intermediate Care Unit

Funari T, Brooke Army Medical Center, Saint Hedwig, Texas

Purpose: The purpose of this project was to enhance the care of the cardiothoracic patient population in the intermediate care unit (IMCU). The goals for this project consist of improving patient satisfaction, physician perception of nursing care, and nursing confidence by providing the nursing team with education and facilitating communication with physicians.

Significance: Coronary artery bypass graft (CABG) patients have special needs in the area of cardiac rehabilitation and with the astute clinical assessment, aggressive ambulation, and pain management they can meet their goal of wellness quickly and safely (Cebeci and Celik, 2008). It is imperative that nurses have the specialized knowledge required in order to provide the required care that will help the patients to reach their goals.

Background: Transfer of postoperative CABG patients from the ICU to IMCU has many challenges and risks. The care of complex patients requires a high level knowledge and competencies in order to progress the patient safely and timely toward discharge (St Louis and Brault, 2011). Because of the lack of expertise in caring for CABG patients, the comfort level of nursing staff at an IMCU was low. Additionally, surgeon's confidence regarding nursing care of this patient population was also low, causing surgeons to hold on to patients in the ICU much longer than then required. A workgroup was formed consisting of physician and nursing leadership, as well as, a CNS to develop a plan of action to increase the competencies of the nursing staff as well as improve communication with providers.

Methods: Forty-eight nursing and 7 physician staff were surveyed to determine their confidence level in the area of patient care and multidisciplinary communication. Twenty-seven percent of registered nurse reported confidence in caring for CABG patients and 18% reported good collaboration with providers. Six of the 7 providers rated nursing care as average but rated collaboration with nursing good. A multidisciplinary team identified that a collaborative approach to patient care and education was necessary to develop nursing competencies and decrease ICU length of stay. Methods of implementation were (1) a phased structured education plan, (2) a reservation system for CABG patients, and (3) detailed patient focused plan of care.

Outcome: A 60-day assessment revealed improvement in patient care as verbalized by physician staff and nursing staff alike; however, new interventions were needed to continue to facilitate progress. Additional interventions were warranted in the area of communication. The provider and nurse workgroup convened and a specific transfer plan was initiated to ensure the nurses had all questions answered while the surgeon is still present.

Conclusion: In conclusion, this project will conclude in December 2012. The outcome metrics will be collected through a postsurvey of nursing and physician staff, patient satisfaction surveys, patient safety reports, and length of ICU and hospital stay. Midpoint assessment revealed only positive results.

Nursing Implications: The interventions implemented in this project may enhance the clinical knowledge of the nursing staff and the communication with the cardiothoracic team. Additionally, the increased confidence providers have in nursing care may lead to decisions to decrease the length of stay in the ICU.

The Clinical Nurse Specialist's Role in Reducing Inappropriate Urinary Catheter Utilization

Niederhauser TM, Tocco S, Orlando Health, Florida

Purpose: To reduce inappropriate urinary catheter (IUC) utilization as a key process measure in decreasing the incidence of catheter-associated urinary tract infection (CAUTI).

Significance: Catheter-associated urinary tract infection is the most prevalent hospital-acquired infection. Each day that a urinary catheter is in place, the incidence of bacteruria increases by 5%. CAUTI can progress to bacteremia, sepsis, and even death. Literature suggests that IUC utilization is the leading contributor to CAUTI. It is estimated that up to 50% of urinary catheters in hospitalized patients have no valid indication for placement. Healthcare providers are often unaware of the presence of IUC which can lead to unnecessary urinary catheter days. The Center for Disease Control and Prevention (CDC) estimates that 17 to 69% of CAUTI can be prevented with the reduction of IUC utilization and appropriate infection control measures.

Background/Rationale: At a tertiary care level I trauma hospital, there is a known prevalence of IUC utilization. The CDC recommends routine evaluation of urinary catheter necessity as a key process measure in the reduction of CAUTI.

Approach: The CNS formed an interdisciplinary weekly rounding team composed of an infectious disease physician, infection preventionist, nursing leadership, and wound ostomy continence nurse. Inpatient units with high urinary catheter utilization were selected for the pilot. During rounds, the team collaborated with the patient/family, nurse, and attending physician to assess the appropriateness of each urinary catheter. The CDC criteria for urinary catheter utilization served as a guide for decision making but patient-specific risks and benefits for continued catheter utilization were also applied to challenging cases. Barriers for urinary catheter removal were also identified. Data on IUC incidence was collected and analyzed during the pilot period.

Outcomes: The average urinary catheter utilization on the pilot units was 22.71%. More than one-third (38.31%) of these urinary catheters were deemed inappropriate. The team was successful in removing more than two-thirds (68.01%) of the inappropriate urinary catheters. Data collection has continued since the pilot and will be updated at the time of the conference.

Conclusions: Clinical nurse specialist-led rounds were effective in reducing IUC utilization.

Implications: Ongoing CNS leadership is needed to overcome barriers to urinary catheter removal including: toileting challenges with morbidly obese patients, patient/family refusal, attending physician refusal, monitoring of intake and output in the debilitated female patient, management of incontinence, increase in nursing workload, and awareness of morbidity associated with urinary catheter utilization.

The Clinical Nurse Specialist's Impact on Cultural Transformation

Powers J, St Vincent Hospital, Indianapolis, Indiana

Significance: Cultural transformation may be required in some institutions to achieve advanced nursing practice, this can be very difficult to achieve and can take many years. However, it is well known that a culture of collaboration and advanced nursing practice directly affects quality patient outcomes. A safe, highly reliable organization where best patient outcomes are achieved is essential for hospitals to achieve during this turbulent time of healthcare reform. The use of advanced practice nurses is essential to achieve the best outcomes. The clinical nurse specialist role is focused on improving patient outcomes through evidence-based practice, research and empowerment of nurses at the bedside. The introduction of the clinical nurse specialist (CNS) role can have significant impact on cultural transformation at any institution.

Design: Our 800-bed hospital had historically been a paternalistic environment. Nurses were not actively involved in decision making unless in an administrative capacity. There was no evidence-based practice or nursing research and very little focus on professional development among the nursing staff.

Description of Methods: The implementation of the clinical nurse specialist role was the first step towards cultural transformation. Key initiatives were implemented and driven by CNSs to empower nurses at the bedside including: (1) development of an evidence-based practice program; (2) focus on nursing research and mentoring bedside clinicians in the practice of research; (3) development of a nursing research council; (4) intense focus on maintaining clinical visibility and interaction with nurses; (5) development of a clinical products evaluation team evaluation; (6) development of a protocol committee; (7) CNSs participate in shared governance councils; (8) implementation of specialty certification review courses.

Results: Current environment 5 years later is one in which nurses have an active voice in decisions related to patient care and care delivery processes. Nurses are empowered to make clinical decisions and maintain a collaborative relationship with physicians. We have conducted over 60 research studies with many of these having bedside nurses as the principal or coinvestigator.

Conclusion: Clinical nurse specialists (CNSs) are a key element when improving care and transforming a culture. Key factors in the success of the CNS team will be discussed in this presentation. This presentation summarizes the key strategies and initiatives that are imperative to achieve cultural transformation and the subsequent achievement of magnet designation.

Implications: The clinical nurse specialist plays a pivotal role in cultural transformation. This Advanced practice role is critical to change implementation and advancing nursing practice which leads to this cultural transformation. It is through the direct nurse mentoring and support that many key initiatives can be successfully implemented and achieved. Through evidence-based practice and research implementation, optimal patient outcomes can be achieved.

Clinical Nurse Specialists Smoothing the Transition From Hospital to Skilled Nursing Facility

McKenna Moon M, Gode A, Allina Health, Minneapolis, Minnesota

Purpose: Create an innovative CNS practice to address readmissions of high-risk hospitalized patients to an urban hospital after discharge to a skilled nursing facility (SNF).

Significance: Today hospital readmission rates are used to measure quality of care and formulate reimbursement. Poorly executed care transitions between hospital discharge and SNF have been linked to increased readmission rates, rising costs, and poor outcomes.

Background: Internal data analysis at a 649-bed urban hospital revealed that SNF readmission rates were twice as high as readmission rates from the home setting (11% compared with 4% at 30 days). In addition, SNF readmissions were highest in the first 14 days of admission to a SNF, peaking at 2-3 days after hospital discharge. No standardized process exists to determine discharge readiness in this population, or to facilitate a seamless transition from hospitals to SNFs.

Methods: An interprofessional Rapid Process Improvement Workshop (RPIW) was conducted in partnership between the hospital and one of its high use SNFs to analyze the current process of transitioning patients from hospital to SNF, and to develop a CNS-driven transitional care management program. A 90-day pilot began with the goals of improving the discharge transition process, through the use of hospital-based transition CNSs unique skill set, modern technology, and communication across organizations. All patients discharging to the partnering SNF were comprehensively assessed by a CNS prior to discharge from the hospital for clinical stability and discharge readiness. The CNS played a key role in addressing barriers to discharge, providing recommendations for an individualized plan of care at the SNF, and assuring discharge orders were clear and complete. The CNS was available for questions and clarification of discharged patients' needs for 72 hours after discharge from the hospital.

Outcomes: Metrics were defined, and baseline data were obtained prior to the start of the 90-day pilot. Outcome data are currently being obtained, and will be available after October 1, 2012. The metrics being measured include readmission rates (14- and 30-day), length of stay, patient/family experience, and staff/provider experience. The overall goal of this pilot is to reduce 14-day readmission rates by 50%.

Conclusions: In the absence of a complete data analysis, subjective reports have suggested that CNS involvement in the transition process has been instrumental in satisfying SNF regulatory requirements and improving the general clarity of orders received by the accepting facility. In addition, this innovative approach has promoted joint ownership of the patient after discharge from the hospital.

Implications: Clinical nurse specialists bring a unique perspective and skill set to patients and families transitioning across healthcare settings. This innovative approach highlights how CNSs utilize the roles of expert clinician, consultant, and change agent to influence healthcare quality and outcomes.

Clinical Nurse Specialists Team Up for Dramatic Improvement in Patient Perceptions of Pain Management in a Small Community Hospital

Lancaster S, IU Health West Hospital, Avon, Indiana; Brown S, Rehabilitation Hospital of Indiana, Indianapolis

Purpose/Significance: Clinical nurse specialists work with nurses and other disciplines to improve patient outcomes and to effect system-wide changes to improve programs of care. Two CNSs led an effort at a small community hospital to bring improved pain management to patients in our care, utilizing the 3 spheres of influence of the traditional CNS role (NACNS, 2004). Patient satisfaction with pain management scores improved from the 12th percentile in 2010 to the 92nd percentile in 2011 and are now sustaining at the 99th percentile in 2012, as measured by the NCR Picker, Value Based Purchasing metric.

Design/Methods: A replication of the Pain Resource Nurse program was rolled out by the lead CNS (a doctoral student at this time) in spring of 2010, including pharmacists and rehabilitation therapists, along with a group of registered nurses. Statistically significant improvements in Knowledge and Attitudes about Pain Management were achieved with this core group, both at the immediate posteducational measurement and at the 6 month follow-up period.

Methods: The pain resource nurse (and colleagues) team has continued to meet monthly under the leadership of the second CNS and works collaboratively to improve pain management in our facility. The pain team has spearheaded physician education on addiction and multimodal pain management, 2 pain fairs, a pain art contest, and monthly unit Pain Tidbits for staff education. Along the way, around the clock dosing for acute pain and end of life and palliative pain management were special areas of focus with educational flyers promoting evidence-based practice in these important areas. The CNS role of direct patient consulting, and encouraging and coaching of direct caregivers has resulted in increased staff ability and willingness to advocate for good pain management. Staff who have specialized skills guided imagery and other nonpharmacological pain management approaches were coached to provide peer education, which has been highly effective. Under the clinical and professional leadership of the CNS a Pharmacy Pain Consult service was advocated for and added in mid-2011. The CFO and CEO gained a better understanding as to the impact and necessity of this important addition to our collaborative pain management program through the persuasive efforts of the CNS. When the 99th percentile was achieved, concerns were raised about patient safety in the area of pain management. In response, the CNS led an effort to review Narcan use and pain medication safety through a retrospective review of all patients receiving Narcan. This CNS worked collaboratively with the hospitalist team to achieve optimum patient outcomes and safe practice.

Outcomes/Conclusions: Pain management was greatly enhanced at this small community hospital by the collaboration of 2 seasoned CNSs with a passion for improving this specific patient outcome.

Clinical Nurse Specialist Influencing Practice Through a Staff Nurse Peer Review Council

Paul D, Somerset Medical Center, Somerville, New Jersey

Purpose: Describe how the CNS can drive clinical issue analysis to improve patient outcomes.

Significance: Peer review is a necessary process to maintain control over practice. The purpose is to evaluate the quality and quantity of nursing care and to identify if there is consistency of established standards of care. The CNS as the facilitator for a council of staff nurses is in a role that can influence nursing practice and patient outcomes through the ability to lead, teach and mentor effectively.

Design (Background/Rationale): At a 350-bed hospital with a shared governance model, a peer review council (PRC) was developed using the ANA peer review principals. All RNs on the council were educated about the peer review process, chart navigation, confidentiality and providing feedback by the CNS.

Description of Methods: The PRC participates in an examination of details of a specific case or series of related cases to determine what occurred, why it may have occurred, if there was a deviation in the standard of care, trends in practice and what can be learned. The CNS identifies the cases to be reviewed prior to the monthly meeting, establishes a framework for the review and provides a safe environment for the staff to effectively evaluate the actions of peers in a nonthreatening manner. The CNS works with the staff to generate a report from the committee, forwards it to the individual or group requesting the review and provides a biannual presentation of their findings and recommendations to the Performance Improvement Council.

Finding/Outcomes: A nonpunitive review of the standard of care and nursing practice allows for identification of achievements, trends, and/or barriers which can drive practice change, policy change or identify a learning need. A highlight of review outcomes include: identifying a variance in the way nurses from shift to shift evaluate fall risk, a need for policy on use of reversal agents for sedation in the mechanically ventilated patient, development of a more formal protocol once a patient is identified as a low risk for suicide, identification of a variation in dispensing of heparin infusions from the pharmacy to name a few.

Conclusions/Interpretations: The CNS is in a unique position to mentor, support and guide staff, teaching them to be able to evaluate practice and provide objective, honest feedback. In addition staff has the opportunity to see the fruit of their labor through peer validation, change in practice, changes in policy or education sessions.

Implications: Providing mentorship and a safe environment for the staff nurse to effectively evaluate peers incorporate evidence in to practice, and to stimulate reflective practice will promote accountability and allow the staff autonomy in their practice.

Clinical Nurse Specialist Innovation: Development of a Portfolio and Interview Process to Validate Transition of New Graduate RNs Into Practice

Elgin K, Rea K, University of Virginia Health System, Charlottesville, Virginia

Purpose: The implementation of a structured process for validation of new graduate RN practice through a peer reviewed mechanism will support professional growth and development for novice clinicians within a complex acute care system. Additionally, it will provide a means for advancing peer review competencies of experienced RNs. The CNS positively impacts within the nurse sphere of influence by creating the infrastructure, coaching and guiding and evaluating the process outcomes.

Significance: Organizational guidelines and process for advancement of new graduate RN clinicians on an established career ladder do not define a panel interview process as part of validation of candidate practice. There is professional growth and development that occurs through the process of peer review and formal interview for both the candidate and peer panelists.

Design (Background/Rationale): A formalized panel review process, involving input from RN peers, supports the evolution of new graduates through the initial phases along a development continuum. Supplementing an organizational advancement process bolsters the validity of new graduate advancement and contributes to the professional practice environment.

Description of Methods: A review of new graduate advancement materials occurs by an appointed panel of peers 12 months poststart date. Materials include curriculum vitae, self-evaluation, peer reviews, and a clinical exemplar. These peers include 2 experienced nurse colleagues and a clinical nurse specialist. The candidate meets with this panel to elaborate upon submitted materials and provide clarification as deemed necessary. The panel makes a recommendation to the manager regarding advancement of the candidate based on established clinical and professional behaviors. The CNS quantifies the outcomes of the model through participant feedback, time invested, RN satisfaction, and new graduate turnover.

Findings: New graduate nurses experienced professional validation through the creation and critique of their portfolio. The experience of being interviewed by peers and clinical leaders provided positive feedback and an opportunity to articulate goals and set an expectation of future professionalism.

Conclusions: All participants believed that the creation of their portfolio and preparation for interview were positive experiences. The process of preparation was viewed differently by individuals and all recommended it to others. Educational preparation influenced how prepared new graduates felt for the process. Peer panel reviewers found the process supported their own professional development. The interview became a vehicle for positive reinforcement, strength and growth area identification and an opportunity to discuss practice and team dynamics.

Implications: Nurses benefit from a structured process for clinical validation. The CNS engages and guides their transition from novice to competent clinicians. The CNS coaches the individual and their peers through the validation process which fosters a climate of professionalism. This professional development innovation provides return on investment for all involved.

Clinical Nurse Specialist Implementation of a Transradial Cardiac Catheterization Program Through Interdisciplinary and Interdepartmental Collaboration

Faas A, St Mary's Hospital, Madison, Wisconsin

Significance: The femoral artery site for cardiac cauterizations frequently requires bed rest for several hours and the use of hemostasis devices to provide during arterial and venous line removal. Patients can experience pain and discomfort during the removal process. The risk of hematoma formation and retroperitoneal bleeds are present. Use of the radial artery as the access sites reduces the length of time for bed rest, decreases pain and discomfort, and significantly reduces the risk of hematoma formation.

Design: St Mary's Hospital Cardiac Services line rarely performed transradial cardiac catheterizations. Two of the interventionalists had performed radial artery catheterizations in the past. A program was designed and a process developed to implement a transradial cardiac catheterization program.

Description of Methods: Interdisciplinary collaboration with physicians identified an aggressive timeline. The cardiac services clinical nurse specialist (CNS) identified key catheterization laboratory and nursing unit team members who would be caring for the patient population precatheterization and postcatheterization. The CNS led the team, which identified required education elements for the new plan of care, procedures, equipment, order sets and documentation. To facilitate physicians' implementation of cases by the transradial route, the first 2 weeks of the timeline were devoted to education of the catheterization laboratory staff and the cardiac procedure unit staff. The cardiac procedure unit monitored the first 20 patients until the hemostasis device was removed. The surgical services CNS, cardiopulmonary CNS, and the cardiac services CNS devoted a second 2-week period to staff education in the surgical procedure center and intermediate cardiac care unit. After the education was complete, patients returned to the unit from which they originated for postprocedure monitoring and hemostasis device removal.

Outcomes: The transradial program launched on the designated date. The cardiac catheterization laboratory and cardiac procedure unit had been educated about the new processes and procedures. The first twenty patients were managed according to the plan and no adverse outcomes present. The transition of postcare monitoring to the surgical procedure center and the intermediate care unit was a smooth transition. Clinical nurse specialists provided one-on-one support for the Registered Nurse caring for the patient after transradial catheterization as needed. To date, no major complications have occurred.

Conclusion: Implementing a new program in a short time frame is possible with an interdisciplinary and interdepartmental approach. The short time frame did not allow for the build of the new order sets in the electronic health record, which resulted in confusion for the Registered Nurse caring for the patient preprocedure and postprocedure. Same-day discharge for patients who had undergone an intervention is not usual practice at this institution. The first transradial patient became a same-day discharge patient and the implementation plan had not addressed the process flows required for this new process.

Implications: Transradial cardiac catheterizations provide for increased patient satisfaction. Implementing a transradial program in a short time frame can be accomplished; expect on-going process changes as the program further develops.

Clinical Nurse Specialist Led Fall Program: Improving Performance Through Environment Sweeps

David CM, Shaffer B, Zellars R, VA Pittsburgh Healthcare System, Pennsylvania

Purpose: The aim of this evidence-based practice (EBP) project was to decrease patient falls and injuries by improving our facility's adherence to fall program guidelines and applying evidence-based practices that aid in fall/injury reduction.

Significance: Falls represent the most common adverse event within long-term care (LTC) facilities with 3 of 4 residents falling each year. As Medicare no longer reimburses for injurious falls that occur during a residence's stay, falls represent a significant loss in revenue. With the recognition of this problem and need to adhere to The Joint Commission's safety goal "Reduce the Risk of Falls," LTC facilities establish fall programs to guide practice and aid in the reduction of falls and injury. Program effectiveness is often limited due to staff and resident inconsistent adherence with fall program guidelines.

Background: The project influenced the organization, nurses, and residents' sphere of influence with a multidimensional intervention that ensured a safe environment, increased residents' awareness of risk, and increased staff consciousness of risk. This was accomplished by providing an avenue for continuous staff and patient education. It also created an avenue for all stakeholders to analysis issues and create plans for improvement.

Methods: The project combined several EBP concepts into 1 monthly intervention which included nonpunitive CNS and administration guided staff environment monitors, resident education using the "teach back" method, staff education, and postintervention huddles to discuss findings and corrective actions. Quarterly unit staff briefings were held to share outcomes, success, and fall event/program compliance trends. Unit staff were asked why these trends are noted and what actions can feasibly be implemented to ensure continued improvement.

Outcomes: Since the implementation, our fall rates per 1000 bed-days of care declined from 5.94 (2011 accumulative rate) to 4.75 (2012 accumulative rate). Major injury rates declines from 0.08 (2011 accumulative rate) to 0.04 (2012 accumulative rate) with a minimal estimated healthcare cost savings of $55 224.

Conclusions: Clinical nurse specialist- and administration-guided environmental monitoring that includes staff, resident education per the "teach back" method, and staff participation in creation of performance improvement plans may aid in decreasing falls, injurious falls, and costs of care related to falls by helping to ensure adherence to fall prevention guidelines and plans for improvement.

Implications: By continuously involving all spheres in fall program performance evaluation and improvement plans, sustained positive outcomes are more likely as all stakeholders are involved in the process change and the feasibility of actions.

Clinical Nurse Specialist-Led Practice Improvements in the Nursing Management of Autonomic Dysreflexia

Rovito DL, Louis Stokes VA Medical Center, Cleveland, Ohio

Significance: In 2012, the CNS assigned to the spinal cord injury (SCI) service of a large medical center designed an autonomic dysreflexia (AD) nursing template with the assistance of an electronic medical record clinical applications coordinator. The CNS trained all licensed SCI nursing staff on the inpatient SCI unit in its use and it became mandatory that AD Work Sheet data collected at bedside during AD was to be documented in the template after each episode. After the template was consistently used by staff, the CNS created an additional summary report that could locate completed AD templates in the electronic medical record for evaluation by the CNS.

Background: Autonomic dysreflexia is a potentially life-threatening condition that is characterized by sudden, severe increases in blood pressure. It occurs in patients with spinal cord injury (SCI) at or above the T6 level of the spine. Resolving an episode of AD requires timely recognition and rapid treatment. Symptoms and treatment will vary among patients and with each episode of AD, thus interventions to resolution can be complex. Nurses who work with SCI patients are often the first healthcare providers to recognize and initiate treatment when AD occurs. AD protocols are typically based on the recommended clinical practice guidelines of the Consortium for Spinal Cord Medicine and are usually articulated in institutional policies and procedures. The purpose of this CNS-led performance improvement initiative was to use consortium and local guidelines to evaluate AD documentation, to identify areas for improvement in the nursing management of AD, and then to design interventions within the nursing sphere that would drive these improvements.

Methods: Baseline data were collected between January and June 2012. There were 67 AD episodes documented in the electronic report as occurring on the inpatient SCI unit. The CNS used a simple grid to assess documentation for deviations from 8 key elements based on Consortium guidelines and local policy.

Findings: The CNS identified 2 specific items as needing improvement. Use of nitroglycerine ointment to lower blood pressure was suboptimal in 52% of the episodes, and in 96% of the episodes, there was no documentation of blood pressures that Consortium guidelines recommend to be taken for 2 hours once the AD episode ends.

Interpretation: The CNS recognized 3 interventions in the nursing sphere that could impact on improving performance in the targeted areas. First, the documentation template was altered to clearly identify the end of episode BP and an area was added for entering the follow up BPs for 2 hours. Second, redesign of the AD work sheet by the CNS provided more cueing to guide decisions related to the use of nitroglycerine ointment as well as the documentation of the final BPs. Finally, all licensed nursing staff were reeducated about AD and pharmacological management by the CNS. When daily documentation reviews revealed missed or delayed opportunities to use nitroglycerine ointment, the CNS provided one-on-one consultation with staff nurses.

Implications: Data postintervention are in the process of being collected. Data collection will end on January 1, 2013, and the impact of the CNS's targeted interventions to improve compliance with clinical practice guidelines will be determined.

The Clinical Nurse Specialist Role in the Development of a Neurosurgical Service Line at a Level 3 Trauma Center

Dewey, A, Bayhealth Medical Center, Dover, Delaware

Purpose: This session will describe the role of the clinical nurse specialist (CNS) in developing a neurosurgical service line at a level 3 trauma center serving a rural community. The CNS influence in 3 spheres, systems, patients/families, and nursing practice, assisted the multidisciplinary team to design a successful neurosurgical service line.

Significance: The CNS expertise was vital in the development phase of the new neurosurgical service line through their ability to utilize and integrate evidence-based practice, systems thinking, along with proficiency in patients/family care and nursing practice.

Background: The healthcare organization had not performed neurosurgical intervention for over ten years. Patients who had presented to the organization with a neurosurgical problem were transferred to a tertiary care center over fifty miles away for treatment.

Methods: Preliminary planning for the neurosurgical service line began as a multidisciplinary collaboration mentored by the chief neurosurgeon. The CNS assisted in designing new processes for neurosurgical patients utilizing the 3 spheres of influence. In the systems sphere, the neurosurgical patient experience was mapped out whether the patient entered through the emergency department or as an elective neurosurgical patient. The care processes were also developed from the acute inpatient hospitalization, discharge, rehabilitation and follow-up outpatient care. The CNS designed a variety of educational opportunities for the multidisciplinary team to gain insight and experience in neurosurgical care, thus exerting influence in the patient/family and nursing practice spheres. These included visitation and collegial relationships with other healthcare organizations, online education learning, equipment demonstrations, patient simulations, tracer methodology, and bedside mentorship.

Outcomes: A diverse neurosurgical patient population of over 600 received state of the art neurosurgical care over the past year near their home and support systems. The population included patients requiring neurosurgical care for mass removal, arterial-venous malformation, traumatic and nontraumatic intracranial bleeding, aneurysm clipping, and severe traumatic brain injury (TBI). Cost-effective, quality outcomes for the neurosurgical patient were achieved with the assistance of the CNS. Case exemplars include a 21-year-old man with severe TBI who is now residing at home as well as a 55-year-old woman who had severe vasospasm after a subarachnoid hemorrhage and aneurysm clipping that is now back to enjoying her family.

Conclusions: The role of the CNS in developing a new service line such as neurosurgery cannot be overstated. The effect of the CNS influence through 3 spheres, provides valuable expertise in transforming care in a level 3 trauma center in a rural community hospital.

Implications: Healthcare organizations should include the CNS as a key stakeholder when developing new service lines. The CNS practice within the 3 spheres of influence provides a variety of perspectives and innovative solutions to achieve successful outcomes.

Code Blue for First Responders Program for Lower-Acuity Settings

Rocha ED, Palomar Health, San Diego, California

Purpose: Lower-acuity settings such as behavioral health, acute rehabilitation, and labor/delivery/postpartum units typically lack the resources to respond to rapidly deteriorating patients. The purpose of this evidence-based practice project was to implement a plan for a coordinated response to code blue arrests.

Significance: Cardiac arrest is a significant cause of morbidity and mortality in the hospitalized patient. Successful resuscitation depends on early recognition and prompt intervention by knowledgeable providers. In settings where code blue arrests are infrequent, patient survival has been positively impacted by the presence of a trained, coordinated, consistent response team.

Background: With the scheduled opening of a new acute care medical facility in this suburban setting, medical/surgical, intermediate and intensive care units would be relocated leaving the remaining lower-acuity levels of care in the older facility without these resources. The loss of the code blue response team, composed of staff from these units, was a concern of both leadership and staff. A plan to address concerns, including transportation to the new facility and higher acuity level of care, was requested by leadership.

Project Description: Following leadership meetings, a group of stakeholders met to assess needs and determine the composition of a coordinated code blue response. A code blue algorithm of personnel, roles, and responsibilities was formulated. A 3-hour Code Blue for First Responders course was developed by CNSs and included the presentation of the code blue algorithm, 2 hours of hands-on skills in recognition and initiation of code blues, use of the AED, and orientation to and utilization of the crash cart to include scribing. Classes were open to any staff remaining at the older facility and were taught by CNSs from across the system. Nine classes were offered over a 2-month period prior to the opening of the new hospital.

Outcomes: A total of 135 staff attended the classes and a written evaluation was received from each participant. Eighty-three percent (83%) gave this program a "5" or "excellent" and 97% gave the instructors a "5" using a Likert scale of 1-5. Appreciation for the opportunity to network and share concerns across units was also expressed verbally to instructors in all 9 classes. Readiness testing was performed using the Code Blue for First Responders algorithm and debriefing sessions were held at both the unit and system-wide levels. Thirteen staff members attended and 100% verbalized relief at having a process in place and stated they felt better prepared to respond to code blue situations. One hundred percent (100%) verbalized the need to continue code blue drills.

Interpretation/Conclusion: The healthcare system now has a coordinated response to code blues in low acuity settings.

Implications for Practice: The Code Blue for First Responders class will continue to be offered on a routine basis. Ongoing unit-based and hospital-wide drills will be managed by the perinatal CNS and emergency department educator.

A Collaborative Team Caring for a Young Pregnant Cancer Patient

de Villers AA, Orlando Health, Clermont, Florida

Significance: Providing care to a patient who is pregnant and has a new diagnosis of Leukemia is a special complex challenge to both the oncology nurses as well as the obstetrical nurses. Nurses who work in these specialized areas possess specialized knowledge and skills unique to their population. The adult oncology clinical nurse specialist (CNS) can work with these specialized areas to facilitate collaboration that will provide support in the form of education, clinical expertise, and navigation through the healthcare system for both nurses and the patient.

Design: Cancer occurs in 1 per 1000 to 2000 pregnancies per year. The most common cancers that occur in pregnancy are cervical cancer, breast cancer, lymphoma, and melanoma. A diagnosis of Leukemia during pregnancy is very rare. The purpose of this collaboration was to provide a "bridge" for the care of the pregnant cancer patient. Collaboration of care between 2 specialized nursing fields, oncology and obstetrics, will result in safe and effective patient outcomes.

Description of Methods: The adult oncology CNS collaborated with the Winnie Palmer Hospital (WPH) women's services (high-risk obstetrics) nursing leadership to provide care for a high-risk pregnant oncology patient. The team also developed a plan of care for the pregnant cancer patient and strategies to educate the nursing staff regarding the appropriate nursing care. The oncology nursing team provided patient education and administered chemotherapy in the high-risk obstetrics unit. The adult oncology CNS assessed the patient's status daily as well as providing support and education to the high-risk obstetrics nursing staff regarding anticipated adverse effects of neutropenia, anemia, thrombocytopenia, nausea and vomiting, and others.

Findings and Outcomes: The patient was able to receive appropriate fetal surveillance, and received 2 cycles of chemotherapy during the course of hospitalization. The baby was delivered at 30 weeks' gestation via cesarean delivery. The mother was discharged and readmitted to the oncology unit. The neonatal intensive care unit's (NICU's) leadership and the adult oncology CNS arranged to have a Web camera brought to the mother's hospital room allowing the mother see her baby at anytime during her hospitalization which facilitated "bonding" between mother and baby.

Conclusions/Interpretations: Collaboration between the nurses and physicians allowed the patient to visit the WPH NICU in between doses of chemotherapy. The patient and nursing staff expressed satisfaction with the delivery of the plan of care and outcomes. Currently, the patient continues to receive treatment for leukemia and the baby was recently released from the WPH NICU.

Implications: Collaboration between nursing specialties for special complex patient populations is necessary for delivery of safe and appropriate nursing care resulting in satisfactory patient outcomes. The adult oncology CNS provided leadership for this type of clinical collaboration across specialties within a healthcare system.

A Comparative Study of 2 Methods for Turning and Positioning and the Effect on Pressure Ulcer Development

Powers J, St Vincent Hospital, Indianapolis, Indiana

Significance: Pressure ulcers occur in 3 million people in the United States. Patients must be effectively turned in order to relieve pressure that can result in skin breakdown. Multiple studies have demonstrated that appropriate turning does not get accomplished for patients as needed.

Design: The purpose of this study was to compare 2 methods for turning and positioning ICU patients and evaluate the effect on incidence of hospital-acquired pressure ulcers. Secondary aims for this study were to measure degree of turn and nurse satisfaction with turning methods.

Methods: A blocked design with a convenience sample of 60 patients was used for this study. The comparison study was completed between standard of care (SOC) involving traditional turning using pillows and a new turning and positioning device (TAP).

Findings: There was a statistically significant difference in the number of pressure ulcers between groups (6 vs 1), P = .042. There were no statistically significant differences between groups for Mobility score, Braden score, gender, age, or BMI. These factors were not identified as predictors for the development of hospital-acquired pressure ulcers. There was a significant difference in the degree of turn between groups. Patients in the SOC group required more resources for repositioning; 88% of nurses preferred the TAP system over SOC.

Conclusion: Standard of care for turning and positioning patients may be ineffective in preventing the development of pressure ulcers when compared with TAP. Standard of care also does not achieve the desired 30 degree turn and does not maintain the initial turn achieved.

Implications: Effective turning and positioning are essential to prevention of hospital-acquired pressure ulcers. Nurses are instrumental in preventing patient complications, especially hospital-acquired conditions. Through adoption of an efficient method for positioning patients, hospital-acquired pressure ulcers can be prevented.

A Comparison of 3 Burn Resuscitation Formulas: The Clinical Nurse Specialist Role

Robbins JR, US Army Institute of Surgical Research; Allen DA and Mann-Salinas E, USAISR; Serio-Melvin ML, Fort Sam Houston, Texas

Purpose: To compare and contrast 3 burn resuscitation formulas: Rule of 10, Modified Brooke, and Parkland formulas through application to a clinical case in a combat zone in Iraq. Implications within the clinical nurse specialist (CNS) spheres of influence will be discussed. With several formulas to choose from, the CNS will provide a vital role in the initiation and guidance of burn resuscitation.

Significance: During a mass casualty incident it is certain that a percentage of casualties will sustain some type of burn injury. The team is frequently challenged to identify the best mathematical formula to calculate fluids indicated in burn resuscitation while working under pressure in a crisis situation. The burn casualty often has other associated injuries that also require focused medication attention in addition to initiation of resuscitation.

Background: In the combat setting the CNS is often the only Advanced Practice Nurse on a medical team and thus is in the ideal role to guide the team in calculating fluid replacement. The Rule of 10 is a simplified method to initiate fluid resuscitation, based simply on burn size multiplied by a factor of 10 to initiate the starting infusion rate.

Description: Improvised explosive devices (IEDs) are a common threat faced by US Service Members in Iraq and Afghanistan. In fact, more Soldiers, Sailors, Airmen and Marines have died as a result of IEDs in the Iraq and Afghanistan wars than all other combat-related causes combined. During Operation Iraqi Freedom, many Soldiers would go into places where insurgents would hide IEDs. A 28-year-old 70-kg man infantry soldier was out on patrol with his squad at night when he came across something that looked peculiar. After investigating the situation, he tripped a wire and sustained 50% total body surface area (TBSA) burns after an IED blast.

Outcome: When applied to the 70 kg patient with 50% TBSA burns, the Rule of 10 closely approximates initial fluid rate of 500 mL/h that could be derived using Modified Brooke formula (438 mL/h) and provides a safe and efficient tool for rapid estimation. When compared with the Parkland formula (875 mL/h) it has a considerably lower initial fluid rate. For all formulas, titration of fluid to achieve target urinary output of 30 to 50 mL/h is expected treatment.

Interpretation/Conclusion: The CNS working with the healthcare team caring for burn patients at a non-burn center can meet American Burn Association guidelines of care and competently guide care for the patient with burns by using the Rule of 10 to begin initial fluid resuscitation.

Implication for Practice: The CNS can bridge the spheres of influence to help improve burn patients' outcomes through expert consultation, care coordination, monitoring quality indicators, and expert communication between the healthcare team and family. The CNS working at the system level can facilitate use of the Rule of 10 to improve clinicians' confidence with burn resuscitation and improve patient outcomes by decreasing risk of fluid overload.

Competence and Responsiveness in Mothers of Late Preterm Infants Compared With Mothers of Term Infants

Baker BJ, Virginia Commonwealth University Health System, Mechanicsville

Purpose: To examine maternal competence in mothers of late preterm infants, compared with mothers of term infants. The conceptual framework includes factors associated with maternal competence and responsiveness including support, self-esteem, well-being, stress, and mood. In addition infant factors of temperament and vulnerability are included.

Significance: Late preterm infants are a newly identified group of preterm infants who behave differently than term infants and present mothers with unique challenges.

Design: A nonexperimental repeated-measures design examined maternal competence and responsiveness in 2 groups of postpartum mothers. Data collection occurred during the postpartum hospitalization and again at 6 weeks postpartum. Participants were compensated with gift cards for completing and returning surveys.

Methods: Nonexperimental cross-sectional, repeated-measures design to compare maternal competence in 2 groups of postpartum mothers. Descriptive and bivariant analysis was conducted to illustrate factors predictive of maternal competence and responsiveness.

Findings: Over a 6-month period, 109 mother/infant dyads were recruited. Seventy-seven term and 32 LPI mothers completed the first survey during the postpartum hospitalization. Seventy-one mothers (52 term and 19 LPI) completed data collection at 6 weeks postpartum. Scores increased for both term and LPI mothers from postpartum to 6 weeks postpartum on scales measuring competence and responsiveness. There was no statistically significant difference between groups or between measurement times on measures of competence or responsiveness. Factors predictive of maternal competence at 6 weeks in term mothers included satisfaction with life and in LPI mothers postpartum support. Factors most predictive of responsiveness in term mothers at 6 weeks included self-esteem and for LPI mother's self-esteem, stress, and infant temperament.

Conclusions: No significant difference was appreciated between groups or within groups on scores of competence or responsiveness. However factors contributing to the development of competence and responsiveness differed between groups.

Implications: Identification of factors that support development of maternal competence and responsiveness in LPI mothers allows care providers the opportunity to better prepare mothers and families for discharge. Understanding the experience of LPI mothers further supports development of the maternal role and ultimately growth and development of the newborn and child.

Comprehensive Oral Care to Prevent Non-Ventilator-Associated Hospital-Acquired Pneumonia

Quinn B, Sutter Medical Center; Baker D, California State University School of Nursing; Parise C, Sutter Institute for Medical Research, Sacramento, California

Purpose: To apply evidence-based nursing interventions to prevent non-ventilator-associated hospital-acquired pneumonia.

Significance: Hospital-acquired pneumonia (HAP) is the second most common hospital-acquired infection in the United States and contributes to increased patient morbidity, mortality, extended lengths of stay, and costs of $40 000 to $150 000 per case. Although numerous studies have reported incidence and prevention of ventilator-associated pneumonia (VAP), nonventilator hospital-acquired pneumonia (NV-HAP) has been understudied. In a previous 2010 study, we identified 115 adults who were coded for NV-HAP and also met the Centers for Disease Control and Prevention definition for HAP. By extrapolating national HAP outcome data, this resulted in an estimated cost of $4.6 million, 1035 extra hospital days, and 23 lives in our institution.

Background: The Institute for Healthcare Improvement recommends specific interventions which reduce or prevent VAP. By applying appropriate evidence-based interventions for all patients at risk for HAP, we can prevent this common hospital-acquired infection. According to the Centers for Disease Control and Prevention, the combination of 3 events leads to the development of HAP: (1) having pathogens in the mouth and throat, (2) aspirated into the lungs, (3) in a patient with poor mechanisms of defense. By targeting modifiable risk factors, NV-HAP can be prevented. Based on our review of the literature, reducing the pathogens in the mouth and throat has the most potential for modification, so the decision was made to begin our prevention efforts with an oral healthcare campaign.

Description of Methods: We used a CNS-led, multidisciplinary approach using the Influencer Model to implement a comprehensive oral care program for every patient in the hospital. Team members included respiratory therapy, rehabilitation, pharmacy, nursing, administration, nutrition, central supply, physician, and health information expertise. We also developed an academic-community partnership with our local school of nursing. Based on the science in the literature and evidence-based guidelines, the CNS completed a gap analysis and made recommendations for interventions to address any shortfalls. We developed a new oral care protocol for all patients. We evaluated, standardized, and purchased new oral care tools and developed new patient education materials. We created audit tools and revised our documentation to better reflect recommended practice. We developed and taught mandatory oral care classes to all nursing assistants to help them understand the value of oral care. We started with 3 pilot units: telemetry, medical/surgical, and orthopedic, with a plan to spread hospital-wide.

Outcomes: Since April 2012, we have implemented a comprehensive oral care protocol, educated staff and families, and changed our oral care products. Oral care frequency has improved from a baseline of 27% of patients receiving oral care once each shift, to receiving oral care each shift 80% of the time. We have seen a 73% decrease in incidence of NV-HAP on the same 3 pilot units.

Conclusions: A CNS-led initiative, using a team approach, was successful in implementing a comprehensive oral care program and decreasing the incidence of NV-HAP on 3 pilot units.

Implications for Practice: A team approach with CNS leadership is an effective way to accomplish substantial improvement in the prevention of NV-HAP. The application of this model may be helpful to prevent NV-HAP at other institutions.

Computerized Documentation of Clinical Nurse Specialist Student Competencies: Making Clinical Outcome Evaluation Robust

Vollman KM, Poindexter KA, Michigan State University, Big Rapids

Purpose: To design a comprehensive computer-based outcome performance measurement system to document student clinical hours and achievement of adult gerontological CNS competencies within the 3 spheres.

Significance: Capturing the range of diverse competencies required of CNS students such as; change management, care of complex patient situations, product evaluations and integration of evidence into practice, makes outcome documentation of these skill sets extremely complex. The integration of a continuous computerized tracking system designed specifically for the role of the CNS provides an organized approach to monitor and assess student learning experiences. When the student, preceptor and clinical faculty are able to follow the progression of learning simultaneously, the ability to ensure robust evaluation can be achieved.

Background: Computer documentation of clinical hours and completion of skill sets is widely used in CRNA and NP graduate programs to capture type and frequency of skills performed by their students. The unique skill sets of the clinical nurse specialist are not well defined in the current tracking systems making them inefficient and cumbersome to implement into CNS graduate programs of study. A computerized tracking system specifically designed to capture the CNS competencies and evaluate student performance would provide an effective way to facilitate comprehensive clinical experiences.

Description: Using the data management platform of an existing computerized tracking system, a program was designed to specifically reflect the unique skill set of the CNS. This redesign provided students with an organized structured framework to document their clinical activities and associate them with specific CNS competencies under the appropriate sphere of influence. Time tracking is achieved when the student enters their clinical hours on the corresponding calendar. A unique feature of this system requires preceptors to validate student documentation of clinical activities and clock hours in collaboration with clinical faculty to ensure a comprehensive clinical experience.

Outcomes: (1) A continuous tracking system to document student progression and achievement of course and program outcomes; (2) preceptor, student, and faculty access to required clinical competencies strengthens the team's ability to design experiences tailored to student needs; (3) clinical evaluations include preceptor assessment and faculty evaluation of student performance readily available in pdf format; and (4) comprehensive CNS course, program, and student evaluation data required for individual and organizational record keeping and accreditation purposes.

Interpretations/Conclusions: This system demonstrated sophisticated integration of evaluation of student clinical performance and hours documentation between clinical faculty, site preceptors and the student at any point during the course. It leads to greater clarity of strengths and weaknesses to individualize learning plans to meet course outcomes.

Implications for CNS Education: Greater communication and structural links between student, preceptor and faculty. The student is required to connect each clinical activity performed with a specific competency and appropriate sphere of influence to foster greater understanding of the dynamics associated with the CNS role.

Conflict Management Styles of Advanced Practice Registered Nurses Enrolled in a Doctor of Nursing Program

Gilliland I, Cassells H, McNeill J, Munoz L, Nadeau J, University of the Incarnate Word, San Antonio, Texas

Significance: Safety in healthcare has been tied to collaborative teams. Conflict engagement is an essential precursor to collaboration which occurs within the context of professional relationships (Kriteck, 2011). Thus, effective collaborative teams require the ability to manage interpersonal conflict. Resilience, a more intrinsic trait, assists professionals to moderate their responses to interpersonal conflict and stress. Little is known about the conflict management styles of APRNs and even less about the styles of students in higher degree programs in nursing.

Study Purpose: To (1) describe the stress resiliency and conflict management styles of practicing APRNs enrolled in a DNP program, (2) examine the relationships of stress resiliency, conflict management styles, and selected demographic characteristics. Methodology Research design. A descriptive/correlational design examining 3 cohorts of students: a quasi-experimental approach without a control group and a hermeneutical phenomenological analysis of qualitative interviews.

Sample: Purposive sampling of students in the first 3 cohorts of a new DNP program.

Instruments: Three tools to collect quantitative data: a researcher-designed demographic inventory, the Thomas-Kilmann Conflict Mode Instrument, and the Stress Resiliency Profile. An interview schedule guided qualitative data collection. Interview questions used as probes were developed based on analysis of the baseline responses to the quantitative assessment.

Preliminary Findings: Analysis of this group (n = 11) revealed a mean age of 46 years (SD, 9.5 years; 34-59 years); the majority were female (7; 64%), with an average of 17 years nursing experience and a mean of 7 years as APRNs. Over half (6; 55%) self-identified as Hispanic or Asian. Fifty-five percent reported previous experience with interpersonal conflict in the workplace. Baseline scores indicated a high preference for the avoiding conflict management style and low preference for the collaborating conflict management style. Stress resiliency subscale scores indicated most students focused on their deficiencies and had low skill recognition scores suggesting a predisposition to stress. Analysis of qualitative data supported the quantitative finding that avoidance is the conflict management mode most frequently utilized and the older the APRN the more likely is the use of avoidance. Additionally, more years of experience make the APRN less likely to use compromise. Most conflicts occurred between the APRN and other professional colleagues and dealt with issues of role expectations. Lack of position power within the work system led APRNs to the use of avoidance. Unrealistic role expectations and feelings of being undervalued and unappreciated created stress for the APRNs.

Conclusion and Implications: Findings reinforce the importance of curricula that expose CNS students to interprofessional team experiences and provide tools to augment conflict management and stress resiliency. Findings suggest that conflict management should be included in all CNS and DNP programs to better prepare APRNs as leaders of interprofessional teams.

Core Competencies in Action: Defining Clinical Nurse Specialist Practice and Behaviors at the Point of Care

Hujcs M, Hospital of the University of Pennsylvania, Philadelphia

Purpose: This presentation will describe clinical nurse specialist (CNS) practice demonstrating the national CNS Core Competencies to promote patient safety, quality patient care and clinical outcomes for a neurocritical care population. Successful strategies indicative of specific components of the core competencies as measurable behaviors that define CNS practice will be discussed.

Significance: While defined core competencies exist, how these specific competencies are demonstrated or evaluated in practice has not been standardized. Establishing a methodology for examining CNS practice related to core competencies facilitates defining the unique responsibilities and contributions of the CNS as an advanced practice nurse. Incorporating the core competencies and behaviors into a peer review process further validates CNS practice.

Background: Clinical nurse specialists are essential in integrating evidence-based practices that support patient care, outcomes, appropriate resource utilization, and safety. Leading interdisciplinary teams, promoting collaboration, mentoring nurses and health professionals and sustaining cost-effective quality patient care are repeated themes within the core competencies. Demonstrating these behaviors validate core competencies at the point of care.

Description: In an urban quaternary academic medical center, CNSs utilize core competency descriptors as role accountabilities and evaluation in a peer review process. In an annual evaluation, each CNS participates in peer review based on these accountabilities. Additionally, a voluntary promotional process incorporates more detailed peer review of specific projects and outcomes. Both processes highlight the unique nature of CNS practice.

Outcome: Utilizing a model of care that promotes goal directed therapy for neurocritical care patients, CNS-led initiatives have resulted in 8 innovative, collaborative protocols defining standards of care; CNS-facilitated initiatives have resulted in standardization of 3 unique nursing practice protocols at this organization. As a result, improved population based patient outcomes have been demonstrated in glycemic control, patient temperature control, osmotherapy, cerebral salt wasting, early enteral nutrition, sedation utilization, early mobility, incontinence management, chest physiotherapy and end of life guidelines for terminal withdrawal of treatment. Sustainable change has been achieved affecting a new standard of care these patients receive. These specific examples incorporate components of the core competencies including systems leadership, collaboration, coaching, and research.

Conclusions/Interpretations: Effective strategies designed to validate CNS core competencies and behaviors facilitate successful utilization of the CNS in various clinical settings. The CNS role is recognized as a necessary link to patient, nurse, and organizational outcomes. Clinical nurse specialist practice is unique as an advanced practice nurse provider; consistent methodology, description and evaluation of practice further validate significance and necessity of the CNS.

Implications for Practice: National core competencies should be incorporated into CNS primary accountabilities, position descriptions and peer review processes. More exemplars demonstrating these competencies are needed to highlight CNS practice, educate entry level CNSs, and evaluate core competencies in action.

Creating an Innovative Statewide Evidence-Based Practice Program

Johnson K, Queens Medical Center, Honolulu, Hawaii

Significance: It is widely recognized that negative outcomes of healthcare can be a consequence of tradition-based practice. Our State Center for Nursing (Center) has a vested interest in supporting nurses in efforts to provide the highest possible quality of care to its residents. However, barriers to the provision of evidence-based practice (EBP) exist. Background/Rationale In 2009, the Center took the lead and partnered with facilities across the state to develop the only state-wide EBP program with the dual purpose of developing an EBP-competent nursing workforce and improving the quality of nursing care to the state's residents.

Methods: Translational science has outlined key elements of a successful EBP culture, such as mentors, partnerships between academic and clinical settings, EBP champions, time and resources, and administrative support. The Center offers annual 2.5-day workshops for 35 RNs who bring to the workshop an identified clinical problem. The workshop agenda is developed by Dr Titler and local faculty and covers each step of the Iowa Model. Workshop attendees, teams usually consisting of a staff nurse, an advance practice registered nurse (APRN), and a nurse manager, subsequently receive ongoing coaching and support from the Center's Project Team via an 18-month internship program as they develop, implement, and evaluate the resulting practice guidelines. Ideally, attendees return to their respective facilities and form multidisciplinary teams. The staff nurse serves as an EBP change champion and must have institutional support, resources, skills, time, cooperation, and peer buy-in. The APRN acts as the opinion leader, assisting with identifying and critiquing the literature and implementation strategies, and the nurse manager provides administrative and logistical support.

Outcomes: Across 14 healthcare institutions, over 100 nurses have been trained, 48 EBP projects initiated, and, 6 have been completed and institutionalized, 6 have been discontinued, and the remaining 36 projects are ongoing and in various stages of implementation. One project is being implemented at 4 institutions and another is being developed across 6 different units within 1 facility. Several teams have successfully disseminated their project results through national and local podium and poster presentations, Center newsletter publications, and textbooks.

Conclusions/Interpretations: The Center's focus is to empower nurses with the skills and knowledge necessary and endowed with the requisite leadership and resources to successfully change practice and improve the quality of care. What is innovative about our EBP program is that it is open to all healthcare facilities throughout the state. Faculty come from a variety of patient care and academic settings. There is a strong component of peer modeling and teaching, thus building a strong foundation for internal facility education and training as well as a change in the culture of nursing practice.

Implications for Practice: The APRN is pivotal in creating an EBP culture and encouraging enculturation of the newly developed EBP guidelines. Mentoring the EBP change champions and coaching staff nurses to address barriers to change are daily encounters. Sustainability of the state-wide EBP program is being addressed through a train-the-trainer model, a role well fitting of an APRN at the state or institutional level.

Cultivating a Safe Patient Handling Culture in a Community Hospital

Halvorson BL, Houlihan A, Riley L, Fox T, Milek C, Hargrove J, Torrance Memorial Medical Center, California

Purpose: Nurses have high rates of on-the-job injuries due to unsafe patient handling. Recent legislation requires hospitals to develop a patient protection and healthcare worker injury policy and prevention plan.

Significance: Creating a culture of safety for patients and staff can lead to reduced injury, improved patient outcomes and cost reduction.

Design: The IOWA Model for Evidence-Based Practice (EBP) and Kaizen quality improvement techniques guided a CNS co-led interdisciplinary taskforce in planning a Safe Patient Handling (SPH) program. The American Nurses Association's SPH resources served as the basis for the program content. Detailed review of the number and types of staff injuries identified high-risk situations (pulling patients up in bed, repositioning/turning, and patient transfers from sit to stand position, etc) which were occurring among various disciplines. Availability of patient lift and transfer equipment was also assessed. As a result, identified program priorities focused on: changing the culture from manual lifting to safe patient handling, incorporating a mandatory interdisciplinary house wide approach, acquiring appropriate/sufficient equipment and training staff on its use, and encouraging proper body mechanics.

Methods: The SPH program utilized a unit champion model and incorporated didactic lecture and hands-on return demonstration of equipment use. A self-learning module was also developed to complement class content. Mandatory training occurred via 2-hour small group classes taught by SPH champions, a CNS, and physical therapy staff. Instruction covered discussion of recent legislation and principles of SPH; nursing mobility assessment, care-planning and documentation; proper body mechanics; and types of patient transfer/lift equipment. Hands-on activities included patient transfer techniques using approved equipment, and patient lift operation. Knowledge mastery was measured via posttest and proficient equipment use was demonstrated by successful completion of skills competency checklists. Roll-out began in January 2012. Regular taskforce meetings and rounds continue to monitor SPH practices and address barriers and challenges to full adoption.

Findings/Outcomes: Over 120 classes were offered; 40 unit champions completed training and greater than 1000 staff attended (83%). All participants achieved at least 95% mastery of program content and over 95% demonstrated competent operation of equipment. Staff feedback was very positive reporting decreased anxiety related to equipment use. Early monitoring of practice change identified the need to distribute equipment based on acuity, increase availability of electrical outlets and lift storage space, increase accessibility to patient slings, increase completion of mobility assessments, facilitate accurate documentation via the electronic medical record, and involve additional disciplines including clinical informatics, central supply, and biomedical engineering. Early monitoring reveals a downward trend in number of employee injuries.

Conclusions/Interpretations: A CNS co-led interdisciplinary taskforce applying the EBP process and Kaizen techniques can create a foundation to facilitate successful cultural change promoting SPH.

Implications: Continued monitoring of SPH practices and inclusion of various disciplines in the process are necessary to promote full adoption and attain desired.

Outcomes: Reduced staff injuries, improved patient outcomes and cost reduction.

A Daily Goals Tool to Facilitate Indirect Nurse-Physician Communication During Morning Rounds on a Medical-Surgical Unit

Perry VL, Franks M, Rasool K, Air Force, San Antonio, Texas

Purpose: To develop a daily goals tool to facilitate indirect nurse-physician communication, at an academic institution medical-surgical unit, when the nurses are unavailable to round that will help improve communication and coordination of care between nurses and physicians about the patient's daily goals.

Significance: Daily bedside rounds are the cornerstone of communication and multidisciplinary care planning in the inpatient setting of academic institution. Although research shows standardized communication tools can help, few hospitals use them, especially in the medical-surgical units. Daily goal communication sheets, has shown to improve communication of current plan of care and provides an opportunity for clinicians to ask questions.

Design/Background: At our teaching hospital, nurse-physician rounding is difficult on our medical-surgical units due to several factors; many physician teams rounding at unpredictable times or several teams rounding simultaneously and nurses unable to coordinate round attendance, physicians spending 15 minutes or longer discussing 1 patient for teaching, or nurse is too busy. For these reasons along with several others, this made it difficult for the nurses to participate in rounds to discuss or hear the patient's plan of care for the day.

Description of Method: A laminated reusable communication tool was developed and posted outside the patient's door. The tool was used only during morning rounds. The nurses would write their nonemergent patient concerns or any information they wanted to relay to the physicians on the tool. When the physicians rounded, they would read the nurses notes and respond on the tool and also wrote the patient's goals for the day. The nurse went back to read what was written and erased the tool for the next day's use. Attending physicians, residents, and nurses completed a questionnaire before and 4 months after implementation. Responses were scored on a 5-point scale (1 = none of the time, 5 = all of the time).

Findings: Before the tool was implemented, scores for communicating patient's care for the day during rounds between nurses and physicians were 2.5 and 2.2, respectively. Scores increased by 3.8 for nurses and 3.5 for physicians. The most significant improvement was the understanding of the goals for the patient: nurses from 38% to 72% and physicians' perception of the nurses' understanding the goals from 27% to 87%. Eighty-one percent of nurses, and 62% of physicians said the tool improved communication between them. Both groups scored the tool as having a moderate positive effect on patient outcomes. Eighty-one percent of nurses and 75% of physicians wanted to continue using the tool.

Conclusion: The daily goals tool helped improved communication between nurses and physicians about the patient's goals and care when the nurses were unavailable to round. It also improved communication and coordination of care between both groups.

Implications: Utilizing a daily goals tool for rounds improves coordination and communication of care between nurses and physicians and offers a venue for the unavailable nurses to voice their concerns during physician rounds.

The Design and Implementation of an Innovative Multidisciplinary Warfarin Patient Education Program

Lake K, Catanese B, Somerset Medical Center, Somerville, New Jersey; Brunetti L, Rutgers, The State University of New Jersey, Piscataway; Dhanaliwala F, Lausin A, Somerset Medical Center, Somerville, New Jersey; Kalabalik J, Somerset Medical Center, Piscataway, New Jersey; and Doherty N, Vigdor S, Somerset Medical Center, Somerville, New Jersey

Significance: Maintaining patients on warfarin therapy is a challenge due to its narrow therapeutic index, frequent lab testing, numerous drug-drug interactions and compliance issues among patients. According to the Institute for Safe Medication Practices (ISMP), significant or fatal adverse drug events (ADEs) associated with warfarin continue to be among the most frequently reported occurrences to the FDA. The 2011 Joint Commission National Patient Safety Goal (NPSG 03.05.01) states that hospitals must "reduce the likelihood of harm associated with the use of anticoagulant therapy." One component of the NPSG is to "provide education to prescribers, staff, patients and families." Background/Rationale Upon tracking and trending medication event data in the organization, opportunities for improvement were identified for patient education regarding warfarin therapy.

Description of Methods: In 2009, an interdisciplinary committee composed of the clinical nurse specialist, pharmacy, information technology and food and nutrition convened to evaluate the current process of patient education for warfarin therapy. In a review of the literature as it pertains to best practice standards, it was identified that patients who were better educated about their warfarin therapy demonstrated better outcomes and less adverse events than those patients with little or no education. The interdisciplinary group focused on developing and implementing an organization-wide Warfarin Education Program (WEP). Initially, the program was targeted at those patients initiated on warfarin therapy and those patients who presented with an INR >5. A booklet discussing key points of warfarin therapy was written and printed in both English and Spanish, an electronic consult was built into the organization's electronic documentation for both nursing and physicians to request a pharmacy consult for warfarin counseling. A dedicated phone line (CLOT Hotline) was set up in the Pharmacy to receive warfarin counseling requests. Pharmacists and pharmacy students were scripted on the key points of warfarin education and perform consults at the patient bedside.

Outcomes: Since its inception in 2010, over 1000 patients have been counseled regarding their warfarin therapy. The volume of counseling supported the creation of an Anticoagulation Elective for students enrolled in a Doctorate of Pharmacy program at a local state university. In another study conducted by the organization regarding venous thromboembolism (VTE) readmission rates, patients who received warfarin counseling demonstrated a 30% reduction in readmission for VTE at 90 days. Conclusion Patients that receive a formal counseling session regarding their warfarin therapy have demonstrated improved clinical outcomes and less adverse events.

Implications for Practice: The current process is that prescribers and nursing staff request a warfarin consult for patients. Future initiatives could include building a trigger into the organization's electronic medical record that "auto-generates" a consult when warfarin is ordered for a patient. Counseling services to be expanded to include additional anticoagulants such as enoxaparin, heparin, dabigatran, rivaroxiban, and so on. Program to reviewed to ensure that it complies with current evidence-based practice standards and regulatory requirements.

Developing Clinical Nurse Specialist Students' Coaching Skills for Facilitating Lifestyle Change

Timmerman GM, The University of Texas at Austin, School of Nursing

Purpose: A structured clinical experience for CNS students that enhances their ability to deliver heath promotion activities designed to reduce risk behaviors and to develop students' coaching skills is described.

Significance: Lifestyle factors (eg, lack of physical activity, stress, poor dietary habits) are often etiologies for non-disease-based illnesses and also increase the risk for chronic diseases (eg, diabetes, heart disease). Thus, CNS students need to develop competencies (eg, expert coaching) to successfully facilitate lifestyle change if they are to effectively provide interventions.

Background: Traditional teaching of patients often includes giving advice (ie, lose weight, exercise more). Yet, advice giving is often ineffective and can lead to resistance. More effective, evidence-based strategies for facilitating lifestyle change are available and should be incorporated into CNS education and practice.

Description: Clinical nurse specialist students are required to separately coach 2 individuals weekly over a 6- to 8-week period to facilitate them making a lifestyle change (eg, weight management, stress management). Students improve their coaching skills by practicing motivational interviewing, choosing theory-based interventions, and providing evidence-based information. Behavioral interventions (eg, goal setting and self-monitoring), cognitive interventions (eg, cognitive reframing, positive self-talk), and educational interventions are selectively used. Through reflection students are able to evaluate the effectiveness of their delivery of interventions.

Outcomes: This clinical experience helped CNS students to improve their ability to be client-centered and to elicit active participation in the development of their coaching skills. Students developed a better understanding of the challenges involved in making lifestyle changes along with the importance of considering the problem within context of the individual's life. Students also improved in their ability to apply health promotion theories in practice, which guided their interventions. Feedback from those receiving lifestyle coaching has consistently been positive.

Conclusion: Coaching clients interested in making a lifestyle change is a useful strategy for improving CNS students' coaching skills, ability to apply theory, along with learning behavioral, cognitive and educational interventions as part of tool kit to facilitate change.

Implications: Clinical nurse specialist students can benefit from educational programs that provide students with opportunities to develop the competencies needed to deliver interventions effective in reducing risk behaviors.

Implementing a Facility-Wide Program for Feeding Tube Placement Reassessment

Perry VL, Ellis KW, Air Force, San Antonio, Texas

Purpose: To change bedside nursing practice of feeding tube placement reassessment and improve nursing knowledge of current recommendations.

Significance: Misplacement and malpositioning of feeding tubes has been reported to occur at a rate of up to 4% for adults and 21% to 43.5% in infants/children. Tube misplacement and malpositioning place the patient at increased risk of aspiration, pneumonia, feeding intolerance, and even death. Air insufflation with auscultation is no longer standard of care for nasogastric feeding tube placement reassessment. Instead, according to research, systematic reviews, and meta-analysis literature, the reassessment process should be multifactorial and include an assessment of the aspirate (volume, color/character, pH) as well as other assessment factors (patient tolerance, tube length).

Background: During the November 2011 hospital-wide nursing skills fair, it became evident that nursing staff was not aware of, nor practicing, the current recommendations. In fact, 364/365 attendees stated they currently use air insufflation to check bedside placement, and only 1/18 inpatient units had gastric pH paper available. Unit leadership reported that the point-of-care testing requirements for bedside aspirate pH testing inhibited the routine use of pH paper on the units.

Method: A standardized, evidence-based, and scenario-based training inservice was developed. Initial wave of staff training began in January 2012 and is ongoing. Training includes the acronym "TAP," which we developed to help staff recall key elements of the feeding tube assessment process: Tube, Aspirate (volume, color/character, pH), Patient. All inpatient units were provided with an initial supply of gastric pH paper and reordering information. The lab department officially waived point-of-care testing requirements. "Air bolus" option was removed from the Essentris documentation screens.

Findings/Outcomes: A pretraining/posttraining assessment questionnaire is completed at the time of training. So far, 136 nurses have been trained (n = 136). Pretraining results: 72% used air auscultation; 17% used pH; 6% used x-ray; 5% did not reassess. Posttraining results: 97% will assess the tube, aspirate (volume, color/character, pH) and patient ("TAP" process); 3% will request x-ray; 0% will use air auscultation. Sixty-one percent stated they would have previously assessed aspirate pH if pH paper had been available on their unit. Ninety-eight percent felt the TAP acronym will help them recall the assessment process.

Conclusion: Initial training results indicate that 97% of nurses demonstrated improved knowledge mastery of feeding tube placement reassessment.

Implications: Reassessment of nasogastric feeding tube placement should include assessment of the tube, aspirate, and patient; air insufflation should not be performed.

Early Recognition and Management of Severe Sepsis on Medical and Surgical Units

McNeill KP, Cole KJ, Sutter Roseville Medical Center, California; Daly MA, Sutter Health Sacramento Sierra Region, California; Petrella RL, Sacramento, California; Pifer TL, Sutter Roseville Medical Center, Roseville, California

Purpose: The purpose of this presentation is to share our organization's approach to reducing mortality through early recognition and management of medical and surgical patients with severe sepsis before it progresses to septic shock.

Significance: Evidence shows that early recognition and aggressive management of sepsis improves outcomes of hospitalized patients. However, symptoms of sepsis are easily attributed to other conditions and often not recognized until they present in a state of septic shock. National data shows a higher mortality rate for inpatients who develop severe sepsis or septic shock on a medical or surgical unit compared with those who present to the emergency department and are admitted directly to the intensive care unit.

Background: In 2010, we began collecting baseline data for our initiative to improve early identification of sepsis in inpatients. Our data showed that patients admitted to medical or surgical units who developed severe sepsis or septic shock had a mortality rate of 25.2% versus those who were admitted directly to the intensive care unit who had a mortality rate of 21.4%.

Description: In 2010, RN sepsis champions from the medical and surgical units began the work of designing and implementing processes to identify patients with severe sepsis and initiate the sepsis bundle. Sepsis champions used the PDSA model as the foundation for changing practice. A screening tool that used a step-by-step approach, beginning with infection and ending with septic shock, was designed to assist the nurse in identifying of the degree of sepsis. The rapid response team's approach was revised to include confirmation of screening results and implementation of the first elements of the sepsis bundle, including lactate level, rapid fluid bolus, and notification of the interdisciplinary team via a new Sepsis Alert. Prior to implementation, sepsis education for nurses included pathophysiology, assessment, and treatment, along with new screening and alert processes. At go-live, new flowsheets were rolled out and sepsis champions provided real-time training on their units. Ongoing monitoring included audits and data collection of all patients with severe sepsis for accurate screening, sepsis bundle compliance, and mortality. Ongoing education was based on audit findings and feedback from staff. As a result, revisions were made to the screening tool, RRT/Sepsis Alert team responsibilities and order sets, while the need for physician education was identified.

Findings/Outcomes: Bundle compliance and mortality were monitored monthly. By the end of 2011, mortality for medical and surgical patients with severe sepsis or septic shock decreased from 25.2% to 12.1%, a 50% reduction in 12 months.

Interpretation/Conclusion: Nurses are vital to the early detection and management of patients with severe sepsis. When nurses accurately assess patients, aggressive interventions can be implemented early to prevent disease progression, thus improving patient outcomes and reducing mortality.

Implications for Practice: Allowing staff to design the process ensures success and compliance. Empowering nurses to speak up for their patients improves morale and confidence in their practice-they trust themselves and their assessment skills because their findings are supported by the evidence of many studies. Together, with evidence-based assessment tools and interventions, nurses have a direct impact on improving patient outcomes.

The Evidence-Based Practice Experience!

Badalamenti SA, Stott S, Banner Thunderbird Medical Center, Glendale, Arizona

Purpose: To create a spirit of inquiry and lead teams though innovation and change in healthcare, a team of clinical nurse specialists conducted a workshop to teach evidence-based practice (EBP) principles and processes. These concepts were taught to RNs new to implementing evidence-based clinical projects on their units.

Significance: Evidence-based practice is an essential component to the healthcare system's mission, vision, and values of providing excellent patient care and positively impacting patient outcomes. This workshop was a significant step to reduce variances in EBP processes and interpretation of results.

Background: The Joint Commission acknowledges the use of EBP as an effective way to improve healthcare outcomes. Our organization is seeking Magnet recognition. The Professional Practice Department, lead by 3 clinical nurse specialists, in collaboration with the Magnet New Knowledge and Innovation committee developed a 4-day workshop to empower RNs with education, tools, and mentorship to advance their EBP unit projects.

Methods: The workshop was divided into four 4-hour sessions over a 4-month period. We used Banner Health's EBP ENSURRE Clinical Practice Model to guide the content. Mentoring between sessions facilitated progress on the projects. Time was allotted for developing PICOT questions, synthesis tables, Change Acceleration Process tools, SMART goals, and data collection methods. Nine teams were encouraged to participate in the workshop from 5 clinical areas, including NICU, maternal child health, medical-surgical, PCU, and ICU. Also, 2 clinical teams, wound and pain, participated. We used a Disney-themed approach to create an EBP "experience" for the nurses.

Outcomes: Nine clinical questions were identified with 8 developed into EBP projects. One clinical question was recognized as research. Two projects are near completion. The 6 other EBP projects are in various stages of completion. The research project team is writing the institutional review board protocol. The teams are expected to disseminate their outcomes internally, as well as encouraged to present at a national conference.

Conclusions: All 9 teams continued through the evolution of their projects. Feedback from each session was positive. One makeup session was conducted to provide the same education and training for those team members who missed previous sessions.

Implications: The success of this workshop has created a spirit of inquiry throughout the facility. The workshop will be offered throughout the 22 facilities in 7 states in a large healthcare system.

Effective Strategies to Reduce Bleeding/Vascular Complications Post-Cardiac Catheterization

Gumersell K, Stony Brook Medicine, New York

Purpose: Bleeding/vascular complications after cardiac catheterization can result in significant adverse patient outcomes associated with high financial cost. The objective was to develop successful strategies to reduce the after cardiac catheterization complication rate.

Significance: Bleeding and vascular complications related to cardiac catheterizations result in serious injury to the patient and these injuries come with economic costs. Minor bleeding complications can cost $2900 to $4300 with major bleeding complications costing $7000 to $14 000. These patients must undergo additional diagnostic imaging, additional lab costs, blood transfusions, vascular repair, an increased length of stay and delayed return to work.

Background/Rationale: Managing bleeding/vascular complications related to after cardiac catheterization can be crucial to quality patient outcomes. Establishing strategies to both prevent complications and minimize harm were essential to reduce complication rates.

Description: Opportunities were identified and an action plan was developed to include data collection on all complications, the development of a complication card and drill down documentation. Daily access rounds by the clinical nurse specialist were initiated on all after cardiac catheterization patients. Utilizing the American College of Cardiology definition of access site injury/bleeding was utilized for standardization. Ongoing education and reporting structure for complications were established. Strategies were developed to include preassessment, technique, access identification, sheath removal procedure, hematoma management, and early recognition of retroperitoneal bleed with aggressive treatment, after cardiac catheterization assessment, improved documentation, radial access and increased use of Bivalrudin.

Outcome: Strategies have been effective reducing the complication rate of 1.5% to 0.8% over 12 months.

Interpretation/Conclusion and Implications for Practice: Clinical nurse specialist-driven model has had significant reduction in post-cardiac catheterization complication rate, improving quality patient care while decreasing costs to the institution related to complications and length of stay.

Effects of a Teambuilding Class on a Progressive Care Unit's Healthy Work Environment

Leary S, San Diego VA Healthcare System, San Diego, California

Purpose: The purpose of this project was to improve the healthy work environment among staff in a progressive care unit by implementing a teambuilding class, called TeamSTEPPS.

Significance: According to The Joint Commission's Sentinel Event Database, inadequate communication was the root cause of 65% of 3811 reported sentinel events, with 75% resulting in the patient's death. In 2005, the American Association of Critical-Care Nurses prioritized a healthy work environment initiative to support and foster excellent patient care by addressing 6 components: skilled communication, authentic leadership, meaningful recognition, appropriate staffing, and true collaboration. The Joint Commission suggests that patient safety and staff satisfaction can be improved through teambuilding. TeamSTEPPS is an evidence-based teamwork system developed by the Department of Defense and Agency for Healthcare Quality and Research.

Design: The design for this evidence-based project was a descriptive, cross-sectional, nonexperimental survey design with a sample size of 33 RNs. The following PICO question was used: "Will the implementation of a teambuilding class improve the staff's perception of a HWE on the posttest assessment?"

Description of Methods: The pretest-posttest instrument used was the Healthy Work Environment Assessment Tool to anonymously survey staff. The survey consists of 18 questions with a Cronbach [alpha] of .80, used to evaluate the work environment. The CNS facilitated an interactive, 4-hour class to the progressive care unit's staff: RNs, telemetry technicians, unit clerks, pharmacists, and environmental service team members. The content included an introduction to healthy work environment and TeamSTEPPS. The components of TeamSTEPPS included leadership, situational monitoring, communication skills, and mutual support aids. Multiple teaching methods were used to facilitate communication to include lecture, scenarios, scripting, mnemonics and prompts to aid in building better communication skills.

Findings/Outcomes: The presurvey was completed by 24 RNs with an overall score of 3.4. The postsurvey was completed by 33 RNs with an overall score of 3.7. All 6 subscales showed improvement from presurvey to postsurvey assessment. Staff members unable to participate in the survey anecdotally reported increased successful use of newly acquired techniques from TeamSTEPPS classes in improving communication among caregivers.

Conclusions/Interpretations: The implementation of the teambuilding class improved the staff's perception of the healthy work environment, as evidenced by the posttest assessment and anecdotal reports.

Implications: Recommendations include clinical nurse specialists seeking to improve staffs' work environment's offer an educational, teambuilding opportunity to increase staff's perception of a healthy work environment. An increase in healthy work environment may lead to a decrease in turnover rates and increased job satisfaction and could potentially improve patient outcomes.

Effects of Health Promotion Intervention for Cancer Survivors

Meraviglia M, University of Texas at Austin

Purpose: the purpose of the study was to pilot test a theoretically-based health promotion (HP) intervention (development participant/provider support relationships, weekly HP classes for 6 weeks and telephone follow-up support for 2 months).

Significance: Many people in the United States have difficulty maintaining their health during the cancer experience because they encounter multiple barriers to acquiring or participating in health-promoting behaviors. Socioeconomic factors (eg, low income and lack of health insurance) are especially difficult to overcome and are associated with lower use of healthcare, poorer overall health, and shortened survival. Promoting healthy behaviors of low-income persons provides them with information and support to enhance their health and quality of life.

Design (Background/Rationale): Randomized controlled trial of low-income cancer survivors

Description of Methods: After giving consent to participate, people who had been diagnosed with stage 1-3 cancer at least 6 months completed a study packet assessing personal and cancer characteristics, HP behaviors, self-efficacy for engaging in HP behaviors, and outcome variables (physical health, functional health, and quality of life). Participants were randomized to either the HP intervention or control group. Data analysis examined changes over 3 time periods as well as group x time interactions using repeated-measures analysis of variance in SPSS.

Findings/Outcomes: To be included in the final sample for analysis of the intervention, participants had to complete data collection at all 3 time points and attend at least 50% of the classes. The final study sample was 35 (15 intervention, 20 control). Participants in the intervention reported the health-promotion classes were very helpful and relevant. A significant interaction effect was found for the total Self-rated Abilities Scale, suggesting that across the 2 follow-up occasions, individuals in the intervention reported on average greater levels of self-efficacy. Significant intervention effects were found for the Health Promoting Lifestyle Profile II (HPLPII). Total health-promoting behavior scores increased over time, whereas the health-promoting behavior scores for the control remained constant. A significant time x group interaction was present, which suggests that the intervention and control groups differed in terms of how their total health-promoting behavior scores changed. Significant intervention effects were found for the HPLPII subscales responsibility, physical activity, nutrition, and stress management. A time x group interaction occurred for the responsibility and physical activity subscales, suggesting that individuals in the intervention group reported greater levels of responsibility and physical activity over time. The effects of the intervention on quality of life, an outcome variable, was significant for the total Functional Assessment of Chronic Illness Therapy-General scores, but not for the subscales.

Conclusions/Interpretations: The intervention was successful in improving self-efficacy, health behaviors, and quality of life over time. The most substantial changes were in aspects of self-efficacy and performance of health behaviors.

Implications: Findings will guide further refinement of the intervention and demonstrates positive benefits for providing cancer survivors information, skills, and support they need to improve their health and quality of life.

Elicit-Provide-Elicit: Using a Motivational Interviewing Technique to Assist Patients Understanding of Fall Risk

Woodard JL, Indiana University Health, Plainfield

Purpose: The purpose of this study was to test the feasibility of use of a motivational interviewing (MI) technique used in interactions with patients around fall risk in the hospital setting. The objectives of this presentation are by then end of this discussion the learner will: (1) Understand a MI technique of elicit provide elicit (EPE). (2) Apply EPE to conversations with patients about fall risk. (3) Explore results of small study using EPE in fall risk patient conversations.

Significance: Motivational interviewing is a form of counseling that has been found to be effective in changing a wide range of health behaviors. It is a style of conversing with a patient to reveal the patient's goals, values and aspirations. A technique within MI to gain the patient's perspective of fall risk and safety in the hospital setting is the EPE technique. Information exchange begins with an open-ended question to focus the nurse's informing about fall risk. An area hospital fall prevention programs lack is the patient involvement in the process of identifying risk and goal setting to prevent falls. More importantly, no assessment to identify what this information means to the patient is practiced. Allowing patients to become a part of the hospital's fall prevention program emphasizes the patient's active involvement in their own care and motivates them to participate with the nurse to remain safe and fall free during the hospital stay.

Design (Background/Rationale): Registered nurses (RNs) completed a class to learn EPE and gain understanding of its impact on fall risk. The nurses utilized this method of EPE in their interactions with patients at risk for falling. After nurses communicated with patients, they recorded a goal set by the patient. The nurse then rated the patient's ability to maintain the goal using a goal attainment scale. Feasibility of using EPE was evaluated by the RNs using a tool developed for the study.

Description of Methods: A feasibility/usability study of EPE was conducted in the acute care setting of a Midwestern community hospital. RNs learned the pieces of EPE in regards to usability of this technique to keep patients fall free during their acute care stay. Open ended questions to elicit the patient's understanding of their own safety started the RNs conversation.

Findings/Outcomes: Five RNs participated in the study, completing 2 surveys: Feasibility/ease of use questionnaire: 4/5 not difficult at all to learn EPE; 2/5 not difficult at all to use EPE. Nurses found EPE useful; 4/5 said somewhat useful; 1/5 very useful Goal Attainment Scale: 4/5 patient's goal was to call before getting out of bed. One patient stated, "I can tell you the adverse effects of taking Ambien-it makes me dizzy." None of these patients experienced a fall. Both participating units outperformed NDNQI mean for total falls during the study period.

Conclusions/Interpretations/Implications: As EPE becomes part of the RNs normal, daily conversation about fall risk and safety, patient compliance with the interventions will occur because the patient is included in their own fall prevention plan. The platform of EPE is to inform the patient using knowledge the patient already has about the topic using open-ended questions. EPE is a skill that when perfected by RNs, has a lasting impression on the patient's ability to manage their own safety during the hospital stay.

Eliminating Elective Deliveries Less Than 39 Weeks: A Nonprofit Community Hospital's Journey

Tincher BM, Trinity Mother Frances Hospital, Whitehouse, Texas

The purpose of this poster is to share how a nonprofit community hospital dealt with significantly reducing elective deliveries less than 39 weeks' gestation. The significance of addressing this issue is to prevent iatrogenic prematurity, a cause championed by the March of Dimes. The design of this interdisciplinary team included a nurse administrator, nurse champion, nurse data abstractor and physician champion. Methodology included engaging the obstetrics/gynecology section with strong administrative support in creating a policy and process for defining acceptable reasons for medically necessary inductions and the scheduling of all elective deliveries regardless of gestational age. A proactive approval process and retrospective review of all elective deliveries ensures compliance. This hospital has reduced elective deliveries less than 39 weeks from 20% to 2% exceeding the national threshold of no more than 5% elective deliveries less than 39 weeks' gestation. The benefit to the newborn has profound implications when prematurity is prevented. Additional implications can be prevention of morbidities for the newborn and a significant savings in healthcare costs when NICU admissions are avoided. The role of the Maternal Child CNS was pivotal as she fulfilled the role of nurse champion and clinical liaison with physicians and staff during planning, implementation and fine tuning the process.

Empowering and Transforming Future Clinical Leaders

Solomon D, Klein D, Cleveland Clinic, Ohio

Purpose: The clinical nurse specialist (CNS) is in an ideal role to help transform the workplace as called for by the Institute of Medicine in The Future of Nursing: Leading Change, Advancing Health. In all 3 spheres of influence, patient, nurse, and system, the CNS can actively work in the role of a transformational leader by being an effective communicator, possessing inspirational traits, having a trustworthy character, and promoting teamwork. The CNS can empower the staff nurse to practice to the full extent of their education and training. In our presentation, we seek to reinforce the CNS voice and sense of empowerment.

Significance/Background or Rationale: In our regulatory environment, it is no longer a luxury but a necessity to push the staff nurse to perform utilizing their skills and evidence-based practice. The CNS possesses the tools to advance nursing practice by sharing their power to improve professional responsibilities. Transformational nursing leadership is required to influence and change the status quo. The roles of the transformational leader is to encourage positive self-esteem, motivate staff to function at a high level of performance and empower staff to become more involved in the hospital system through practice councils, journal clubs, and an expert to achieve improved patient outcomes.

Description: Through dynamic dialogue and interaction, 2 experienced CNSs will describe transformational leadership and empowerment in the CNS role. Many examples of how a CNS can influence and transform the staff nurse will be discussed.

Outcome: The CNS in the audience will recognize the strategies to become a transformational leader and empower nurses to be future leaders. Traditional paths are through shared governance councils, journal clubs, mentoring of clinical experts, and promotion of healthy work environments. True empowerment of staff nurses can come from the interaction between the staff nurse and the CNS.

Interpretation/Conclusion: The CNS is well positioned to be in the role of a transformational leader and empower the staff nurse to practice to the full extent of their ability.

Implications for Practice: Identification of self as a leader will encourage more CNSs to influence the future of nursing and help transform the workplace.

Enhancing Evidence Appraisal Skills Through Clinical Nurse Specialist Student-Led Journal Clubs

Huffman D, Eastland T, Hopp L, Purdue University Calumet, Hammond, Indiana; Walker J, Hammond, Indiana

Purpose/Objectives: The aim of this presentation is to describe how faculty can use a journal club assignment to develop evidence appraisal skills necessary for effective clinical nurse specialist (CNS) practice.

Significance: Clinical nurse specialists need to possess solid evidence appraisal skills. One way to help CNS students achieve these skills is through experiential learning opportunities. Leading undergraduate students in a journal club discussion is 1 way to provide this type of learning experience.

Background/Rationale: Faculty teaching CNS students recognized that journal clubs can be a valuable way to help build evidence appraisal skills. For many years, our CNS students led journal club discussions among their peers. This peer-led journal club assignment provided opportunities for critical appraisal, but group discussion was sometimes limited. Seeking to improve this learning experience, CNS faculty explored journal club opportunities with faculty teaching the baccalaureate research course.

Description of Methods: We revised the existing CNS student journal club assignment by having CNS students lead journal clubs with baccalaureate nursing students enrolled in their nursing research course. Faculty from both programs jointly select research articles to be appraised and discussed. Students appraise both qualitative and quantitative primary research reports. Depending on the articles' research design, students use either the qualitative or quantitative version of the CASP evidence appraisal tool. Journal clubs take place within small groups with faculty monitoring the discussion. Immediately following the journal club, students reassemble for faculty-led debriefing sessions.

Findings/Outcomes: This journal club experience has been positive for both CNS and baccalaureate students. For example, CNS faculty have reported improvements in critical appraisal and the quality of class discussions. Additionally, CNS students have reported increased confidence in their appraisal skills and have requested additional journal club opportunities. This experience has also prepared students to lead journal clubs in their practicum settings. What began as a pilot assignment is now fully embedded within the CNS courses and the baccalaureate research class.

Conclusions/Interpretations: Feedback from CNS and baccalaureate students has been consistently positive, and several CNS alumni have returned following graduation to participate. In addition to enhancing appraisal skills, this opportunity has allowed CNS students to further develop their leadership abilities. The faculty remain committed to this learning activity and are exploring virtual journal club opportunities for distance students.

Implications: Providing opportunities for CNS students to lead journal clubs while in their basic program can be an effective way to enhance evidence appraisal skills. In addition, this experience can assist CNS students in working with groups and serving as role models to baccalaureate nursing students.

Enhancing Self-care Practices in Heart Failure Patients

Zavertnik JE, Virginia Commonwealth University, Richmond

Purpose: The purpose of this quality improvement project was to provide an enhanced discharge education plan and home follow-up to promote self-care in heart failure patients.

Significance: Improving self-care behaviors of heart failure patients can improve healthcare outcomes. Early recognition and treatment of heart failure exacerbation can decrease hospital readmission.

Design (Background/Rationale): One hundred heart failure patients, through an ancillary services grant, were provided with resources for home self-care monitoring: a bathroom scale, a graduated drinking cup, a monthly log book for recording weight and symptoms, and a written education information. The patients were educated on how to monitor symptoms using a teach-back method. Patient agreed to be called at home weekly for 1 month.

Description of Methods: Follow-up phone calls were done by a clinical nurse specialist within 72 hours of discharge and weekly for 1 month. Data were gathered on compliance with self-care activities. Patients were asked rate the "helpfulness" of the teaching and home follow-up.

Findings/Outcomes: Patients in the project did adhere to weight and symptom monitoring and notification of provider of worsening heart failure. Patients thought the project was "very helpful." The staff nurses involved in the project verbalized an increase satisfaction in being able to provide patients with resources to practice self-care behaviors. Discharge education commenced earlier in the patient's hospitalization.

Conclusions/Interpretations: By providing the resources needed to monitor signs and symptoms of worsening heart failure, the project improved patient's self-care management in terms of being able to recognize a change in their condition and take appropriate action.

Implications for Practice: Nurse-led initiates can enhance self-care practices of heart failure patients. Using limited financial means, nurses can make an impact on the healthcare outcomes of the heart failure population.

Entry-Into-Practice: The New Kids on the Block

Falder K, Selimos A, Children's Medical Center Dallas, Texas

Purpose: The purpose of this presentation is to describe the successful orientation of 2 novice CNSs entering into a growing practice within 2 established specialty units (gastroenterology and cardiac) at a large metro children's medical center.

Significance: The concept of the clinical nurse specialist has fluctuated over the past 60 years and has been steadily reemerging since the late 1990s. The recent expansion of CNS utilization over the past decade has increased the need for successful orientation programs and continued support from CNS colleagues after completion of orientation.

Background: There are many documented challenges for the new CNS entering into practice throughout literature. In addition to the currently documented challenges, the novice CNS now faces new hurdles with the economical changes in healthcare. Despite a formal education, the realities of a novice CNS establishing a new role can be challenging. The success of the new CNS is highly influenced by the existence of a formalized orientation and the support of an established CNS network within the institution. This presentation was guided by the From Limbo to Legitimacy Model.

Methods: The formal CNS orientation is a 3-month process to include socialization into the institution and specialty unit. The process consists of formal meetings with key stakeholders led by the CNS manager. Members of the multidisciplinary team, key stakeholders, and CNS team members are shadowed throughout the 3-month period. An advanced practice competency checklist is completed, and SMART goals are also established with the CNS manager based on priorities of the unit. The new CNS is immediately integrated into select committees and councils for socialization into the system. Monthly meetings occur with the CNS manager, unit manager, and director to discuss current and future projects. The entire CNS team also meets regularly on a monthly basis where a mentor-mentee relationship is established. Project selection is crucial for the new CNS to focus on achievable projects in order to avoid over commitment and improve likelihood of success. Each specialty CNS (gastrointestinal and cardiac) conducted a needs assessment through direct observation, meetings with key stakeholders, quality data, and results from the patient/family satisfaction survey. Results from the assessments led to project selection.

Outcomes: Successful completion of the orientation process and integration into the system resulted in appropriate project selection for the novice CNS.

Conclusions: The existence of an established CNS group and formal orientation process enabled 2 novice CNSs to successfully integrate into the system and begin new roles.

Implications: The next generation of clinical nurse specialists can greatly benefit from the knowledge obtained after this entry-into-practice experience. If a similar orientation process is replicated, it can improve the probability of success for not only the novice CNS, but also the experienced CNS and the entire organization.

Every Second Counts: Innovations to Increase Early Defibrillation Rates

Borak M, Bednar V, Beschorner J, Francisco MA, Li S, Lowder E, Maroney M, Pakieser-Reed K, Stokas MA, Barnes MR, University of Chicago Medicine, Illinois

Purpose: To increase timely utilization of automated external defibrillators (AEDs) by medical-surgical staff nurses.

Significance: In-hospital cardiac arrest occurs about twice as often as out-of-hospital cardiac arrest and is associated with poor survival rates. American Heart Association recommendations for cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia call for early defibrillation, manually or with an AED within 2 minutes. Of the cardiac arrests that occurred in medical-surgical areas in our institution in 2011, utilization of the defibrillator in AED mode occurred in only 15% of the cases prior to resuscitation team arrival. Registered nurses, as first responders, must be prepared to perform early defibrillation on medical-surgical inpatients in cardiac arrest.

Design: The AED has primarily been used outside the hospital for timely defibrillation. Early defibrillation programs using AEDs are being established in hospitals. While our institution initiated a number of programs to increase usage of AEDs since 2010, minimal improvement in clinical practice occurred. Thus, an innovative approach was instituted.

Methods: The innovative approach included: *Employment of a designated resuscitation nurse, who facilitates quality improvement resuscitation efforts, monitors resuscitation data, supports staff education and disseminates results. *Provision of high-fidelity simulation-based education program (30 minutes) as part of annual nursing competencies (n = 356). The program included review of unit-specific cardiac arrest statistics, reinforcement of basic life support principles including demonstration of AED use, and emphasis on defibrillation within 2 minutes. Additionally, each nurse responded to a cardiac arrest simulation utilizing a high-fidelity manikin. Performance was evaluated by recognition and activation of emergency assistance, initiating compressions, placement of the AED, and defibrillation. Remediation occurred until all nurses successfully performed these tasks within 2 minutes. *Implementation of ongoing sustainability efforts: Inclusion of clinical nurse specialists, clinical nurse educators and the resuscitation nurse as clinical support to cardiac arrest events, monthly review of unit-specific cardiac arrest data with nurses, interdisciplinary monthly cardiac arrest case discussion, and monthly education of new nursing employees.

Outcomes: All nurses and managers in groups of 2 to 3 completed the simulation event. While the majority of the groups successfully completed the simulation in 1 attempt, 35% of the groups required remediation to successfully complete the competency within the 2-minute time frame. Evaluations indicated that 93% of the staff felt they learned a great extent from the simulation. Analysis of cardiac arrest event data revealed the utilization of the defibrillator by nurses prior to the resuscitation team arrival in 2012 has increased almost 3-fold, compared with 2011 (57% vs 15%). Our preliminary data suggest that early defibrillation by nurses contributes to early return of spontaneous circulation in multiple events.

Conclusions: High-fidelity simulation education, increased clinical support, and a designated individual coordinating ongoing resuscitation efforts resulted in increased timely defibrillation of cardiac arrest patients.

Implications: Our approach can serve as a model for other institutions challenged to improve early defibrillation rates.

Facilitating Self Care in CNS students

Cadman SJ, Regis College, Hollis, New Hampshire

Purpose/Objectives: The purpose of this presentation is to share strategies on promoting self-care practices in CNS students. Significance CNSs in practice facilitate the development of nursing caring practices through role modeling, coaching and mentoring but CNS students may not understand that caring practice begins with self-care. Many CNS students have ongoing stress from the competing demands of clinical practicum hours, course assignments and regular work hours and fail to adopt self-care strategies that promote wellness and successful completion of CNS course work.

Design/Background/Rationale: CNS faculty investigated self-care behaviors in CNS students and found opportunities for growth. Using data from course evaluations, illness/absence records and a review of the literature, a CNS self-care bundle' was developed and added to the curriculum. The purpose of the bundle is to facilitate understanding and the adoption of self-care practices within the CNS cohort and includes: Setting intention, facilitating presence, development and evaluation of a personalized self-care plan, connection and sharing sessions with past CNS graduates, in-class experience with complementary therapies for stress relief, coaching by CNS faculty in self-care practices throughout nine months course work.

Methods/Description: CNS faculty coach students in adoption of self-care practices and help students navigate transitions and anticipate possible challenges to the implementation. Past graduates share proactive strategies that assisted in successful completion of the CNS program. Through discussion, support exercises and coaching, students are empowered to create their own optimal healing self-care plan. Faculty facilitate student experience with complementary therapies designed to reduce stress.

Findings/Outcomes: Since implementation of the self-care bundle in the CNS curriculum in 2009, on time graduations and data from evaluations support the usefulness of a self-care plan for CNS students.

Conclusions: The use of a self-care bundle provides CNS students with a proactive strategy for health promotion and wellness. Future research is needed to evaluate the impact on CNS practice.

Implications for Practice: Implications Facilitating the adoption of self-care practices in CNS students has the potential to positively impact the health and wellness of the CNS throughout their professional life.

Facilitating the Transfer of Expert Knowledge and Practice in Complex Stoma Care Using the 3 C's: Consulting, Collaborating, and Coaching

Trevellini AC, St Francis Heart Center, Roslyn, New York

Objectives: Learner will identify 1 example of how the CNS utilized consulting, collaborating, and coaching to teach patients complex stoma care.

Background: Skin irritation and leakage are reported as common problems contributing to decreased adherence of ostomy appliances. This domino effect negatively impacts the ostomy patient's overall quality of life. Problem identification and timely intervention facilitates discharge, prevents readmission, and improves quality of life for the ostomy patient.

Description: A 300+-bed acute care heart center experienced an expansion of general surgery cases. With expansion came an increase in fecal/urinary diversions. Cases were complicated, often requiring complex stoma care interventions not easily communicated in writing. The CNS collaborated with the clinical nurse to identify complex stoma care needs of postsurgical patients. The CNS group was challenged to establish innovative approaches to consistently communicate interventions to nursing staff and patient/family. The CNS consulted the CWOCN Specialist to establish individualized plans for each patient. This lead to a project focused on creation of individualized photographic tutorials as clinically efficacious coaching tools used to promote continuity/consistency among caregivers while improving patient satisfaction. With patient consent digital photographs were taken to illustrate stoma care. The photographic tutorials were organized in PowerPoint format, step-by-step digital photographs and bulleted directions of care. Plan was devised, stoma care photographed, and color copies of tutorial provided to the patient and interdisciplinary team.

Outcome: This creative and innovative approach to communicating complex stoma care proved a valuable coaching tool. Collaboration of the CNS, CWOCN, clinical RN, care manager, and patient/family optimized clinical outcomes for the ostomy patient. The evidence-based tutorials were developed through consultation with CWOCN and proved instrumental in preventing hospital readmission, decreasing length of stay, and facilitated transfer to rehabilitation and home health agencies. Through consultation, collaboration, and coaching the CNS lead clinical project positively impacted the ostomate and family/caregiver progress towards independent stoma care.

Interpretation/Conclusion: As consultants the CNS and CWOCN Specialist utilized their advanced knowledge to develop and implement teaching strategies which facilitate focused problem solving. Collaborating with other member of the healthcare team provides an avenue of communicating complex stoma care and resolving clinical concerns. The CNS and CWOCN act as a coach to other healthcare team members, patients and family by utilizing the digital photography of step-by -step individualized tutorials.

Implications for Practice: Through consultation, collaboration, and coaching the CNS and CWOCN established a practical tool for communicating complex stoma care. The tutorials have been utilized as teaching tools for advanced stoma care in a didactic setting. The CNS and CWOCN plan to produce additional tutorials for complex stoma cases. The tutorials will be utilized in patient and healthcare provider education.

Family Caregivers Advocating for Older Adults in the Healthcare System: What Strategies Work?

Messecar DC, Oregon Health and Sciences University, Portland

Purpose: Describe the strategies that family caregivers report using to make sure the needs of older adults are met by the healthcare system.

Significance: Caregiver advocacy can make a huge impact on the likelihood of receiving quality care. However, it is not well known what types of advocacy caregivers engage in and or how effective their strategies are in obtaining needed services, equipment, and care. Information from the caregiver's perspective is needed about what advocacy strategies they have tried and how well these strategies work.

Background: Nine focus group interviews with 43 caregivers were conducted to describe caregivers' experiences with advocating for older adults in the healthcare delivery system.

Methods: Nvivo 8 was used to analyze the interview data. Charmaz (2006) approach to coding data was used to organize and categorize the findings.

Findings/Outcomes: Caregivers used several strategies to advocate for the needs of older adults in the healthcare system. These strategies included: being pushy and not easily dissuaded; not easily giving up and insisting on being heard; being present during encounters (doctor's visits, at the bedside in the hospital); and learning how to be persuasive on the phone and in person. About being pushy and not easily dissuaded, 1 son said "it's[horizontal ellipsis] a matter of how pushy you choose to be, because[horizontal ellipsis] you may or may not get the services you need[horizontal ellipsis] [the first time you ask]." When caregivers talked about not easily giving up, they described being persistent even after initially being refused. They often did this by reframing the issue with either the provider or some other intermediary for the healthcare system. For example, several caregivers would call back at a later time, ask to speak to someone else, or go in person say, if they had been brushed off on the phone. One daughter said: "it was something you just have to keep after." Being present when the older adult was being seen by the provider or in some way interacting with the system also was very helpful. As 1 son said, "a lot of times the doctors, when they're talking to seniors, they never directly talk to that person[horizontal ellipsis]." Learning how to be persuasive was another skill that was critical, especially with third-party payers like insurance companies.

Conclusions: The strategies that caregivers found most useful involved being both insistent and persistent, but many lacked the confidence to this.

Implications: Nurses should act as coaches to help family caregivers master the strategies that other caregivers have reported worked for them in getting the needs of the older adult met. Since many lack the confidence to use these strategies, role playing and other simulation techniques can be used by the nurse to help the caregiver practice these strategies. Caregivers might also write out what they plan to say in a script to prepare for a difficult healthcare system encounter. Follow-up and feedback can be used to further build the caregiver's skills using these strategies.

Five Years Later: Has an Evidence-Based Protocol Improved Care for the Adult Sickle Cell Population?

Humphries LA, Texas Health Southwest Fort Worth

Purpose: To evaluate the effectiveness of a Sickle Cell Protocol we implemented at our community hospital in September of 2007.

Significance: Adults with sickle cell disease have a difficult time finding consistent care, primary physicians who understand their condition and often use the emergency rooms to seek care for their condition. Pain is usually the chief complaint for patients experiencing sickle cell crisis. Once admitted to the hospital the sickle cell patient often encounters varying attitudes, inconsistent treatment, and high lengths of stay.

Background: The average length of stay for the adult sickle cell population at our hospital was 12.78 days in 2007. Staff, physicians and patients were frustrated with inconsistent care and treatment. Texas Health Southwest Hospital developed a task force in 2007, facilitated by the clinical nurse specialist to explore best practice, and develop an evidence-based protocol to address treatment and early and aggressive pain management intervention.

Description: The protocol consists of a 5-day length of stay plan of care with an emphasis on quick and aggressive pain management, rapid identification and management of secondary complications, and team approaches to ensure continuity and consistency of care. The clinical nurse specialist facilitated the task force, developed the protocol, and follows each sickle cell patient throughout their stay and any repeat visits as well. The CNS tracks data. The CNS facilitated a citywide taskforce, which resulted in the opening of a Sickle Cell Clinic in 2010 at the county hospital. Hospitals throughout the city are able to refer patients to the clinic for consistent follow-up care. In addition, the adolescents transitioning for the children's hospital are referred to the clinic to continue care as an adult.

Outcome: Our hospital lengths of stay and variable direct costs immediately improved and 5 years later we continue to keep our average length of stay below 5 days. The opening of the Sickle Cell Clinic has provided a place to refer the patients who do not have primary care physicians or need consistent follow-up care. A Sickle Cell Symposium is held annually for the past 4 years to raise awareness in the medical community on best practice for sickle cell management.

Interpretation/Conclusion: There was a slight increase in length of stay for 2012 as of August. The main reason for this rise is believed to be the closing of the only other hospital that serviced Southwest Tarrant County in March 2010. Our hospital has had new patients who are not familiar with the protocol. In addition, new hospitalists, who are the primary admitters for the inpatient side, must be oriented to the protocol and may cause some delay in early pain management.

Implications for Practice: Developing guidelines for the adult sickle cell population has proven to be effective for delivering consistent quality care. Management of sickle cell patients continues long after the patient is discharged. Referral to a sickle cell clinic has helped provide continuity of care.

Four Dimensions: Strategies for Working With The Client Who Has Chronic Pain

Laskowski C, Brien Center, Pittsfield, Massachusetts

Purpose: This theoretical presentation is based on the author's research relating to "difficult" client behavior. The paper was developed to summarize and expand upon theories derived from previous qualitative research done by the author.

Significance: Chronic nonmalignant pain is a problem across most clinical areas and across all client groups. Not only does chronic pain create a financial burden (in terms of tests, treatments, absenteeism, presenteeism), but it also evokes caregiving fatigue.

Design: Qualitative research done with CNSs working with the "difficult" patient and qualitative research done with individuals experiencing symptomatic hepatitis C form the background for this theory-based paper.

Methods: Grounded theory built on previous research done by the author and review of literature.

Findings/Outcomes: As Heidegger (1996) observed, using the analogy of the hammer, our attention is drawn to the times when we hit our thumb rather than the nail. We have much to learn from those times of discomfort, confusion, and pain. This learning can be guided by a 4-dimensional framework: looking at (assessment), looking with (empathy), looking in (self-reflection), and looking around (context). Looking at, the dimension most of us are quite familiar with, can be influenced by cognitive and affective errors. Cognitive errors include Groopman's (2007) discussion of confirmation error and vertical line thinking, and Croskerry's (2003) "zebra retreat." Affective errors easily occur when we particularly like a client (see, eg, Radner, 2000) or dislike a client. Looking With allows us to engage clients on levels that are profound and healing-both for ourselves and our clients. The Jungian archetype of wounded healer speaks to this complicated process (Laskowski and Pellicore, 2002). Looking in involves self-reflection. "What am I feeling when I speak with this client?" "What, about this interaction is 'pushing my buttons'?" Looking around, a dimension often missed in our clinical settings and in our clinical practice, has to do with paying attention to where our clients are "coming from." Social support, emotional distress, feedback loops, and identifying "who is the real patient" can only be recognized if we take the time to look around. Often, inviting family members to join in for the appointment can be enlightening (Rolland, 1995).

Conclusions: The clinician can expand her/his understanding of and treatment of the client while cultivating self-care and duly diligent practice by using techniques related to each dimension. For example-looking at: speak out loud about your questions and considerations regarding treatment. Looking with: "move in" when you have a strong desire to "move out." Looking in: find at least 2 colleagues who you can speak with, honestly and openly, about your insecurities. Looking around: if possible, make a home visit when you are confounded by a certain client's presentation.

Implications: Using these 4 dimensions when working with individuals who have chronic pain can promote higher quality outcomes. In addition, these have the potential to allow for a richer, satisfying practice.

Initiating an Early Mobilization Program in an Intensive Care Unit: A Multidiciplinary Approach

Young S, The Johns Hopkins Hospital, Baltimore, Maryland

The TRiP (Translating Research into Practice) methodology was used in a surgical intensive care unit (ICU) to implement an early mobility program using a multidisciplinary approach. The clinical nurse specialist (CNS) collaborated with a multidisciplinary team to introduce the evidence that early mobilization in a medical ICU decreased ICU and hospital length of stay, maintained preadmission functional status, and was cost effective. Initiating the same program in a surgical ICU was attempted to see if it was feasible and safe. A secondary program goal, in addition to seeing if we could duplicate the MICU (medical intensive care unit) outcomes, was to improve patient outcomes by preventing delirium, ventilator-associated pneumonia, and pressure ulcers. A multidisciplinary team was created to identify barriers to implementation and solutions to those barriers. Baseline performance was measured. Pilot tests were developed to measure outcomes and monitor any improvements. Key stakeholders from frontline staff to executives were targeted to engage, educate, execute, and evaluate the program. The barriers included a lack of leadership support, resources such as equipment, staff, and time, knowledge education deficits by multidisciplinary team members, nonstandardized documentation, nonstandardized sedation and delirium protocols, and lastly safety, pain, and physiological instability. The results of a pilot test exhibited that the program was not only feasible but safe. The bedside tools used to assist in the process were guidelines. The information was used as a reference, but much of the improvements were due to a change in the culture of the unit. The CNS, as an advanced practice nurse, is the expert clinician and change agent that is best qualified to lead in this culture change by role modeling, collaborating, and engaging the team to find sustainable solutions. Ongoing efforts continue as we evaluate our program and expand to a second surgical ICU.

Giving and Receiving Constructive Feedback: The Role of Preceptors in Developing This Skill

Altmiller G, La Salle University, Philadelphia, Pennsylvania

Significance: Constructive feedback is essential for personal and professional growth. Developing skill to provide as well as receive constructive feedback should be part of every clinical nurse specialist's education. It is an integral part of continuous quality improvement, it supports teamwork and collaboration as a communication technique, and it is essential in maintaining patient safety in the clinical environment.

Background/Rationale: The perception of feedback can interfere with professionals giving and receiving it which can have negative effects on patient outcomes. The consequences of not providing feedback are missed opportunities for self-improvement as well as missed opportunities for improved patient care.

Description of Methods: Delivering and receiving feedback effectively are learned skills that need to be developed early on in one's education and be practiced regularly. Faculty, particularly preceptors, can role model this skill and influence the perception of feedback to be viewed as an opportunity so that students can learn to appreciate its value in maintaining patient safety and high quality care in clinical practice. During this presentation, the use of constructive feedback to support the Quality and Safety Education for Nurses (QSEN) competencies for graduate education will be discussed. Challenges to giving and receiving feedback will be identified and participants will learn strategies to deliver constructive feedback effectively.

Outcomes/Findings: Patient safety is supported when processes are in place that allow for feedback and colleagues are comfortable with their skill set to deliver and receive it effectively.

Conclusions/Interpretations: Faculty have the potential to influence the perception of feedback, that is, for it to be viewed and valued as an opportunity for self-improvement, optimal patient safety, and high quality care.

Implications: Preceptors of clinical nurse specialist students are in a unique position to model this skill as a means to maintain patient safety and support quality improvement.

High-Fidelity Simulation Improves Provider Confidence During Advanced Cardiac Life Support Resuscitation Scenarios Even Among Highly Experienced Staff

Zavotsky K, Robert Wood Johnson University Hospital, New Brunswick, New Jersey

Purpose: The purpose of the study was to test the hypothesis that providers undergoing high-fidelity simulation of cardiopulmonary arrest scenarios will express greater confidence.

Significance: Advanced Cardiac Life Support (ACLS) resuscitation requires rapid assessment and intervention. Some skills like patient assessment, quality cardiopulmonary resuscitation, defibrillation, and medication administration require provider confidence to be performed quickly and correctly. It is unclear, however, whether high-fidelity simulation can improve confidence with a multidisciplinary group of providers with high levels of clinical experience.

Design: This was a quantitative, longitudinal, quasi-experimental, prospective cohort.

Methods: The study conducted at an urban level I trauma center from January to October 2011 with a convenience sample of registered nurse (RN) and license practical nurses, nurse practitioners, resident physicians, and physician assistants who agreed to participate in 2/4 high-fidelity simulation (Laerdal 3G) sessions of cardiopulmonary arrest scenarios about 3 months apart. Demographics were recorded. Providers completed a validated pretest and posttest 5-point Likert scale confidence measurement tool before and after each session that ranged from not at all confident (1) to very confident (5) in recognizing signs and symptoms of, appropriately intervening in, and evaluating intervention effectiveness in cardiac and respiratory arrests. Descriptive stats, paired t tests, and analysis of variance were used for data analysis. Sensitivity testing evaluated subjects who completed their second session at 6 months rather than 3 months.

Findings: Sixty-five subjects completed consent, 39 completed 1 session and 23 completed at least 2 sessions. Ninety-two percent were RNs, median clinical experience was 11-15 years, and 56% were from an intensive care unit.

Conclusions: Provider confidence increased significantly with a single session despite the highly experienced sample. There was a trend for further increased confidence with an additional session and the increased confidence was maintained for at least 3 to 6 months given the normal sensitivity analysis.

Implications: This research will provide a basis for future research to determine what impact caregiver confidence has on patient and quality outcomes. The results strongly suggest that utilization of high-fidelity simulation even with experienced nurses in the hospital contributes to increased caregiver confidence and may help to improve outcomes and should be integrated into our education and training practices.

Home Telemental Health: Provides the Right Care, at the Right time, at the Right Place

Harris-Cobbinah DA, Department of Veterans Affairs, New York Harbor Health Care, Bronx, New York; Arden K, Department of Veterans Affairs, New York, New York

Purpose: To provide current information to health clinicians regarding expanded provisions of patient care beyond mental health institutional settings by the use of health informatics, disease management, and Telehealth technologies.

Significance: In 2008, the Veterans Health Administration (VHA) added a subdivision, Telemental Health to their Care Coordination/Home Telehealth department. This subdivision was created to ensure that eligible veterans with a mental health diagnosis have access to a comprehensive and integrated high-quality healthcare continuum that addresses both medical and mental health needs of veterans in urban and rural communities utilizing home monitoring devices and case management. The telemental staff utilizes informatics technologies and telecommunication modalities to augment care provided by both VHA and non-VHA medical and mental health providers. This ensures appropriate continuity of care throughout the course of enrollment.

Design: A chart review of patients enrolled in the program more than 12 months was conducted. The review consisted of the most used mental health diagnosis, the percentage of patients who have a medical diagnosis and mental health diagnosis, the percentage of psychiatric and medical admissions, inpatient admissions, and the length of stay of the inpatient admissions.

Description of Methods: Veterans are referred to the program by self-referral or medical/mental health providers. Accepted veterans are expected to complete daily self-report protocols via telehealth monitors/cell phone systems. If a high-risk behavior or symptom is alerted, a telemental health coordinator will contact the patient for further interventions. These interventions include patient education, provider notification, crisis intervention, referrals to VHA/non-VHA community services.

Findings/Outcomes: There was a significant decrease in hospital admissions and length of stay. Hemoglobin A_1c and blood pressure readings improved. There has also been marked improvement in compliance with clinic appointments and medication regimes.

Conclusions/Interpretations/Implications: Telemental health services facilitate access to care and improve the health of mental health patients with specific intent of providing the right care, in the right place, at the right time. This expanded care improves chronic disease management, patient satisfaction, increase access to services and reduce resource utilization, thus decreasing healthcare costs. VHA health professionals emphasize that home telehealth does not replace traditional homecare but can help veterans understand and manage their medical and mental health conditions at home. Proper management of these chronic conditions can delay the need for institutional care and maintain independence for an extended time.

Hospital-Based Postdischarge Community Case Management by Clinical Nurse Specialists in Rural Texas

Baldwin KM, Black D, Hammond S, Texas Health Resources, Cleburne, Texas

Significance: Chronic disease is a national epidemic. Annual cost for heart disease and stroke is $432 billion; diabetes, $174 billion; and lung disease, $154 billion. Clinical nurse specialists (CNSs) are uniquely qualified to manage chronic diseases across the continuum of care.

Design (Background and Rationale): In 2011, Texas ranked 44th of 50 states for health and was classified as weak to very weak for overall healthcare performance in cardiovascular, diabetes, and respiratory care. Johnson County is a poor, rural county with an average per capita income of 81.3% of the state average. Of the 221 Texas County responding in 2012, Johnson County ranked 126th in health behaviors, access to and quality of clinical care, socioeconomic factors, and physical environment. The county, a designated health professional shortage area, has only 1 hospital, no county health department clinic and only 1 sporadically opened free clinic staffed by volunteers. Over 1 quarter of county residents have no health insurance. One of the ways to minimize preventable hospital or emergency department (ED) visits is through better outpatient disease management. In the last quarter of 2011, we implemented a community case management nurse (CCMN) program to reduce preventable readmissions. We targeted uninsured adults with chronic diseases, who were below the age of 65 and frequently admitted. The CCMN, a CNS with prescriptive authority, works 20 hours per week. She currently monitors at-risk patients via telephone for at least 30 days following discharge.

Findings/Outcomes: The CCMN has used several interventions resulted in continuity of care and improved outpatient disease management. They include helping patients obtain disability certifications, writing prescriptions for needed medications, making mental health referrals, referring to support groups, providing physician referrals, scheduling clinic visits, obtaining diabetic supplies, and appropriately triaging patients to the ED. The results of this program have been decreased morbidity and mortality, decreased hospital admissions, and appropriate referrals for our patients. We have received 1 national nursing award for our program. And, our CEO has approved program expansion.

Conclusions/Interpretations: Telephonic monitoring of at-risk patients at home for 30 days after discharge has decreased readmissions to the ED and hospital. The program has been so successful that our 15-hospital system is now discussing implementing it in other facilities. Because sometimes more than a telephone conversation is needed, we are collaborating with a local university to add real-time virtual visits using android technology. We have also discussed our program with the county EMS physician director. She volunteered the services of county EMS ambulances and paramedics for in-home visits to assess any patients the CCMN deems appropriate for such services. We are also collaborating with the free clinic to increase hours of service there for physical examinations.

Implications for Practice: Our program shows that CNSs with prescriptive authority can impact treatment of rural dwelling patients with chronic disease, both in the hospital and after discharge. The integration of real time virtual visits should improve care and help to build a case for telenursing.

Prewarming of Maternity Patients Undergoing Cesarean Section

Stott S, Banner Health, Phoenix, Arizona

Purpose: The goal of the project was to increase the average patient temperature on admission to both postanesthesia care unit (PACU) and postpartum to meet SCIP criteria of greater than 36[degrees]C through the use of forced air warming.

Significance: The surgical site infection rate at a Level III facility was 2.07% prior to implementing the prewarming protocol. This infection rate dropped to 1.35% after the protocol was implemented.

Background Nationally, 3% of postoperative patients develop surgical site infections. Mild hypothermia suppresses the immune response and increases the incidence of infection. Patient warming and thermal control leads to reduced costs, increased patient satisfaction, and improved outcomes. In the past, warmed cotton blankets have been used to provide comfort and increase body temperature. However, research shows that warmed cotton blankets maintains body heat, but are ineffective at restoring core body temperature. The SCIP benchmark for patient temperature on admission to PACU and Postpartum is 36[degrees]C. Prior to the project the average patient temperature on admission to PACU did not meet this SCIP benchmark. The average patient temperature was 35.8[degrees]C on admission to PACU and 35.9[degrees]C on admission to Postpartum.

Methods: The prewarming protocol calls for the patients to be prewarmed in preoperation for 30 minutes prior to schedule cesarean sections by a forced air warming device.

Outcomes: After implementation of the protocol, the average patient temperature on admission to the PACU was 36.1[degrees]C and 36.3[degrees]C to postpartum. Both of these measures are above the SCIP benchmark and meet the SCIP criteria. Subsequently, the surgical site infection rate dropped to 1.35% after the protocol was implemented.

Conclusions: Prewarming of cesarean patients by forced-air warming increases patient temperatures on admission to the PACU and reduces surgical site infection rates.

Implications: To meet SCIP criteria, decrease infection rates, and improve patient satisfaction, this protocol is being implemented throughout a large multifacility healthcare system as a standard of care for scheduled cesarean section patients.

Hourly Rounding: Improving Patient Satisfaction in the Emergency Department

Ignacio A, Torrance Memorial Medical Center, California; Castillo E, Pacific Hospital of Long Beach, California

Purpose: Improve patient satisfaction in the emergency department (ED) through hourly rounding.

Significance: The ED generates 42% of all hospital admissions nationally. Although this department is an important revenue source for hospitals, it has one of the lowest satisfaction ratings from patients compared with all hospital departments (Press Ganey, 2010). Research indicates that the largest number of complaints about ED care focus around patient treatment, communication, poor staff attitudes, and delay in treatments. These are also causes of patients leaving without being seen. Studies have documented that staff providing information regarding patients' health status and treatments, how well patients are informed about delays, prompt pain control methods, and the attitudes of healthcare providers significantly impact ED patient satisfaction.

Background/Rationale: According to Press Ganey results 2011-2012, the top 3 common themes of patient dissatisfaction in this ED include patients not being updated on the plan of care, pain not adequately addressed or managed, and treatment delays not being explained. Patients who come to the ED are in their most vulnerable time of need. They are scared and anxious, in pain, and uncertain of what might happen next. Research indicates that hourly rounding is one of the best interventions that ED staff can provide to reduce patient anxiety and help control their pain. Explanation of treatment delays will keep them in the ED and not leave without being seen.

Description of Methods: A formalized process of hourly rounding in the ED was developed by the CNS in collaboration with the ED staff, nurse manager, and director. A 1-hour class on patient rounding was provided to the staff during skills fair and multiple in-services were conducted. Documentation of ED rounding was provided by a rounding log which was reviewed by the nurse manager, supervisor, and ED CNS for compliance and accountability. ED technicians rounded during even hours and the ED RNs rounded during odd hours. Pain, explanation of plan of care, and delays in treatments were addressed during roundings.

Outcomes: Patient satisfaction scores in the ED increased 3 months after implementation of hourly rounding. Patient satisfaction scores based on how well the nurses explained patient treatments increased from 80% to 85.8% and reasons for the delays in treatments improved from 64.9% to 73.3%. Patient satisfaction on how well their pain was controlled increased from 75.3% to 82.8%. Patients leaving without being seen were reduced from 4.2% to 3%.

Conclusions: Hourly rounding improved patient satisfaction results and reduced the number of patients who left without being seen in the ED.

Implications: Developing a structured format of hourly rounding, monitoring through the use of rounding log to hardwire the practice, and incorporating it in the ED policy and procedures will improve patient care management and satisfaction.

How to Help Patients Manage Weight: Do You Have a Tool Box of Weight Management Strategies?

Timmerman GM, The University of Texas at Austin, School of Nursing

Purpose: The purpose is to provide CNSs with information about effective weight management strategies that can be shared directly with patients and also with nurses who work with patients who would benefit from these strategies.

Significance: Excess weight is a major problem, impacting the majority of adults. Obesity and weight gain increase the risk for many chronic lifestyle diseases. Interventions that can facilitate weight management, both weight loss and preventing weight gain, can improve overall health outcomes.

Background: Only recently have researchers begun to focus on the influence of the environment on food consumption, yielding possible strategies that can be used for weight management. A calorie deficit is required for weight loss. Although food diaries that track caloric intake can be very effective for those who use them, many individuals are unwilling to put forth that amount of effort. Wansink (2006) proposes that we "reengineer" our food environment to minimize the effort required to reduce calories.

Description: Based on work with participants in the Mindful Restaurant Eating intervention, there were lessons learned about the importance of presenting participants with a variety of strategies that they could choose related to weight management. Many evidence-based weight management strategies are available such as eating mindfully, eating vegetables first, eating fruit before snacking, using replacement meals, eating a hot breakfast, using 10-inch plates, making tempting foods inconvenient to access, monitoring hunger and fullness cues, and avoiding sugar filled drinks. Participants were taught how to set their own goals and individualize strategies to deal with their barriers.

Outcome: Different weight management strategies were acceptable to some but not others, supporting the idea of partnering with patients and facilitating individuals in choosing strategies that best fit their lifestyle. Individualized weekly goal setting was perceived as one of the most useful strategies.

Conclusion: By empowering patients to choose strategies that impact weight management, some of which could easily be implemented, nurses may be able to encourage success for those patients who are reluctant to make substantive changes. Even small caloric reductions over time could prevent additional weight gain or possibly weight loss.

Implications: Clinical nurse specialists need to help nurses develop an efficient way to provide a tool box full of evidence-based, specific weight management strategies that patients can choose to try. Providing more guidance than just eat less and avoid fatty foods is needed to improve patient outcomes. (Wansink B. Mindless Eating. New York: Bantum Books; 2006.) Mindful Restaurant Eating intervention was funded by the North and Central Texas Clinical and Translational Science Initiative (5UL1RR024982-03).

Idea to Innovation: Understanding Clinical Nurse Specialist Practices Through a Tracking Tool

Colwill JP, Albert NM, O'Rourke CP, Cleveland Clinic, Ohio

Purpose: The purposes of this study were to quantify how CNSs spend time (work roles), determine if work roles were associated with personal characteristics and goals and examine associations of time spent in work roles and in quality initiatives over time.

Significance: Clinical nurse specialist work roles are broad in scope and difficult to quantify. Healthcare leaders may not understand the impact CNSs have on performance measure improvement over time. Clinical nurse specialists should use quantifiable methods to demonstrate work roles and their impact on clients, nursing practice and organizations and systems.

Design: This prospective, single-center, correlational study used a convenience sample, investigator-developed Role Tracker Tool (software) and a 1-page survey to document CNS characteristics, work roles, quality initiatives (QIs), and unit-based quality scores at baseline and monthly for 5 months.

Methods: Clinical nurse specialist subjects recorded their perceptions of current work roles and QI priorities every month, and minutes spent in each role every month and transmitted data electronically to the principal investigator. Descriptive statistics were used to summarize CNS characteristics and Kruskal-Wallis rank sum test and Spearman's rank correlational statistics were used to measure associations between characteristics and work roles. Tests for differences of average time spent in a role were completed using a Welch 2-sample t test and analysis of variance. Hierarchical linear models were used to determine if relationships existed over time between work roles, priority ranking of work roles and nursing characteristics.

Findings: Fourteen CNSs participated; mean age was 43.15 (SD, 10.11) years and mean time as a CNS was 5.57 (SD, 7.87) years. For 6 work roles, CNSs ranked quality as the most important, followed by clinical work and research work ranked 4 of 6 options. Mean (SD) time spent over the 5 month period was highest for clinical work (2251 minutes/month/CNS +/- 1216 minutes) and lowest for professional self-development (550 minutes/month/CNS +/- 500 minutes). Amount of time spent in specific roles varied by specialty, certification status, years as a CNS, and other characteristics, even after controlling characteristics that were significantly associated with work roles. For all work roles but quality, CNS role priority rankings were associated with time spent (all P <= .02); however clinical and consulting roles were not based on CNS priorities. Clinical nurse specialists' baseline work role priority rankings were not associated with most characteristics. Of 9 QI focuses, mean (SD) time spent was highest for heart failure, even though only 2 CNSs were involved (2227 minutes/month/CNS) followed by venous thromboembolism (1215 minutes/month/CNS) and pressure ulcer (460.4 minutes/month/CNS). Time spent on QIs was associated with QI outcomes for 6 quality focuses (all P <= .03).

Conclusions: Clinical nurse specialist work role priorities and QI focuses varied over time. Amount of time spent in work roles were associated with CNS characteristics.

Implications for Practice: Clinical nurse specialist work can be captured and communicated to enhance the understanding of their unique role and contributions in the healthcare matrix.

The Impact of a Clinical Nurse Specialist Initiative to Change Practice Through a New Paradigm for Competency Assessment

Marzlin KM, Aultman Hospital, Uniontown, Ohio

Purpose: The purpose was to assess the impact of a new approach to competency on the adherence to evidence-based cardiac monitoring practices; and to evaluate the impact on nurse confidence and engagement in these practices.

Significance: Cardiac monitoring contributes to patient safety by identifying conduction abnormalities, silent ischemia, and prolonged QTinterval. Evidence demonstrates patient outcomes are improved through accurate cardiac monitoring. The historical approach to competency assessment in nursing has been the clinical skills checklist. This approach does not assess the translation of the science behind the practice, or the required critical thinking and decision making skills. Therefore, a new paradigm is needed.

Design: The following components were integrated into the new competency paradigm (a) professional portfolio, (b) self-assessment of adherence to practice expectations, (c) direct observation of clinical practice, (d) review of unit based quality improvement data, (e) case studies, and (f) nurse choice of reflective exemplar, peer review statement, evidence-based article review, or achievement of critical care certification. Evidence-based cardiac monitoring indicators were assessed preintervention and postintervention. Nurse perceptions were assessed after intervention.

Methods: Monitoring indicators were assessed preintervention and postintervention: (a) lead placement, (b) ST segment alarms, (c) documentation of type of BBB, (d) measurement of QTc interval, (e) documentation/reporting of clinically significant arrhythmias. Pre and post percents were compared using 2-sided Pearson [chi]² tests, with the exception that Fisher exact test was used when the expected cell number was less than 5. A postintervention survey was done to assess the achievement of nurse satisfaction and engagement. Analysis of the nurse survey data included the frequency distributions, calculation of medians and interquartile ranges for each question.

Outcomes: The improvement for the accuracy for V lead placement was 27.1%; P <= .001. The improvement for the accuracy for limb lead placement was 20.41%; P = .004. Accurate identification of type of bundle branch block showed an improvement of 52.5%; P = .003. The accurate assessment to QTc interval showed an improvement of 22.45%; P <= .001. The posting of clinically significant arrhythmias showed an improvement of 38.5%; P = .005. Additionally, the nurse survey showed agreement with increased confidence regarding competency (85%) as well as increased engagement in the cardiac monitoring process (77%).

Interpretation: Improvement in several evidence-based cardiac monitoring indicators showed statistical significance with trends towards improvement in the other indicators that did not meet statistical significance. This change in clinical practice occurred in conjunction with an increase in nurse engagement and satisfaction with a new paradigm in competency assessment.

Implications: This project demonstrates that a comprehensive competency assessment program integrating the assessment of real time clinical practice has the potential to improve adherence to evidence-based standards of practice. It also brings to light the scope of knowledge and skill required for competence at the point of care. The results of the nurse survey demonstrate that the majority of nurses welcome the acknowledgement of the complexity of their practice and embrace a process that calls for accountable care.

Impact of Day of Surgery Activity on Meeting Criteria for Discharge in Knee Replacement Patients

Ryzner D, Northwest Community Hospital, Arlington Heights, Illinois; Ogilvie MA, Northwest Community Hospital, Rolling Meadows, Illinois

Purpose: Explore whether day of surgery (DOS) activity results in total knee replacement (TKR) patients being able to meet criteria for discharge from the hospital sooner than patients who remained in bed on DOS and do not have any activity.

Objectives: (1) Name 2 benefits of early mobilization after TKR surgery and (2) describe 2 criteria used to determine readiness for discharge after TKR surgery.

Significance: DOS activity for TKR patients has been shown to increase muscle strength, decrease risk of postoperative complications, increase range of motion, and improve length of stay (LOS).

Background: Total knee replacement surgery is a common, successful intervention that greatly improves function, relieves pain, and improves quality of life. Early rehabilitation after surgery helps increase joint range of motion and muscle strength, enabling patients to achieve maximum benefit from TKR. Risk of complications like deep vein thrombosis, pulmonary embolism, and pulmonary infection are decreased when patients are mobilized early. A randomized controlled trial (Labraca, Castro-Sanchez, Mataran-Penarrocha et al, 2011) demonstrated that early mobilization decreased hospital LOS and reduced the number of rehabilitation sessions needed to achieve autonomy with normal gait and balance for patients. Morris, Benetti, Marro, and Rosenthal (2010) implemented Clinical Practice Guidelines (CPG) that included dangling the patient on DOS. Collaboration among care providers for CPG implementation showed enhanced benefits of early activity and reduced LOS.

Hypothesis: If TKR patients have activity such as dangle or out of bed on DOS, then they will be ready for discharge sooner than patients who remain in bed on DOS.

Description of Methods: Nonexperimental correlational, retrospective design. Institutional review board approval obtained. Researchers used a convenience sample of 1 orthopedic surgeon's TKR patients. Patients all receive continuous femoral nerve block. Group 1 (n = 60) consisted of patients before the enhancement of physical therapy (PT) evaluation and treatment on DOS. Group 1 patient activity on DOS was performed only by nursing staff. Group 2 patients (n = 87) received PT evaluation and treatment on DOS. Literature review was conducted. Criteria from a PT perspective were established to indicate readiness for hospital discharge. Two discharge criteria of 'needing no to minimal assistance' and 'ambulate 50 feet' were selected. Collaboration between PT, nursing, and surgeons for the DOS activity initiative was vital.

Findings/Outcomes: Patients with DOS activity met discharge criteria sooner than patients who remained in bed (statistically significant P = .003). Though not statistically significant, a secondary finding showed lower mean for last pain score documented at discharge for patients who had DOS activity versus patients who remained in bed (mean, 1.93 vs 2.41, P = .095).

Conclusions/Interpretations: Hypothesis is supported. Patients with any activity on DOS met criteria for discharge sooner than those who remained in bed. A limitation is that 1 surgeon's patients were studied to eliminate variables in surgical technique and differences in pain management. This small study is not generalizable.

Implications: Further research to examine most efficient use of nursing and therapy resources for optimal benefit of TKR patients. Research on other multimodal pain management techniques and time to meet discharge criteria could be considered.

Implementation of the Humpty Dumpty Falls Scale: A Quality Improvement Project

Close JF, Palomar Health, San Diego, California

Purpose/Objectives: To implement a pediatric-specific fall risk screening tool to be used for all pediatric patients (14 years and younger) in the Palomar Health System.

Significance: Patient safety is a priority in healthcare. The Joint Commission (TJC) and the Institute of Medicine have placed a great emphasis on patient safety and decreasing adverse events during hospitalization. The hospital environment places patients at increased risk for falls related to physiologic factors, medications and the use of equipment. TJC recommends that hospitals have a method to identify children at risk for harm from falls as well as a screening process to determine which children are at risk. Efforts should be made to assess and protect this population.

Background: The Morse Fall Risk Screening tool was being used for all patients at Palomar Health. A group led by the geriatric CNS designated to manage fall prevention and CNSs from the emergency departments (EDs), birth center and pediatric unit met with staff nurses to look at the health system's process for identifying pediatric patients at risk for falling. Falls data for our system did not show any pediatric patient falls. Our team suspected that pediatric falls were not being reported, which is consistent with the literature.

Description: The Humpty Dumpty Falls Scale (HDFS) is a screening tool designed by an interdisciplinary team of nurses from Miami Children's Hospital in Miami, Florida. There are 2 scales, inpatient and outpatient. The tool is broken down into age, gender, diagnosis, cognitive impairment, environmental factors, response to surgery/sedation/anesthesia and medication usage. A score is given in each of those sections. A total score of 12 or above is considered at high-risk and warrants implementing a protocol to protect the patient. The EDs, birth centers, NICUs, and pediatric unit all planned to implement the inpatient tool. Pediatric and NICU nurses were given a pretest regarding pediatric falls, and then education was provided about falls and the HDFS. After a posttest was given, the HDFS tool was piloted. Following education in both the EDs, the HDFS was implemented.

Outcomes: The HDFS was found to be an innovative tool for improvement in clinical practice. It has also heightened awareness of the need for fall risk screening in the pediatric population.

Interpretation/Conclusion: All patients at Palomar Health are screened for fall risk using an age appropriate tool. Implementation of the HDFS tool has led to the appropriate screening for pediatric patients, which in turn improves patient safety.

Implications for Practice: The HDFS tool has allowed our nurses to screen this population and implement safety precautions to protect our patients from falls. All patients 14 years or younger are screened in the ED using the HDFS. Those at risk are identified to allow heightened awareness about safety precautions.

Implementing a Mobility Program on an Inpatient Medicine Unit

Wood W, Tschannen D, Grunawalt J, University of Michigan Hospitals and Health Centers, Ann Arbor

Purpose/Objectives: To decrease the negative effects of bed rest and improve patient outcomes through implementing a mobility program on a medical inpatient unit.

Significance: Research has shown that immobility or bed rest has negative effects on the human body, including muscle weakness, atrophy, pneumonias, constipation, and pressure ulcer formation. (1) Cardiorespiratory and muscular decline has also been found in patients with short-term hospitalizations who presented with mild disease severity. (2) Although the adverse effects associated with bed rest/immobility and the benefits of ambulation/mobility have been reported, patients still spend a large amount of their hospital stay in the bed or chair. Current evidence related to implementation of mobility programs has primarily focused on patients in intensive care units, with the exception of 1 study conducted by Markey D. and Brown R. (3) This evidence-based translation project describes how an early mobility project impacted patient outcomes on a general medicine unit.

Design: This project utilized a descriptive design. Data were entered and analyzed using the Statistical Package for Social Sciences (Chicago, Illinois) version 17.0 for Windows software. Computations for frequencies, percentages, means, ranges, and standard deviations were completed. Analyses focused on determining if increasing mobility of adult patients admitted on a medicine unit decreased the unit fall rates, incidence of pressure ulcers, length of stay, and readmission rates.

Methods: The interdisciplinary team consisting of nursing staff, nurse aides, unit physical and occupational therapists, leadership, and a school of nursing representative, developed mobility guidelines and interventions for the program. Patients who were ambulatory (eg, tier 2) were assisted to ambulate 3 times a day, while nonambulatory patients (tier 1) participated in active or passive ROM 3 times a day. The unit manager assigned 2 nurse aides to function as "mobility aides." Their responsibilities were to perform activities with patients after receiving direction from the patients RN and unit therapists. Patients and their family members were given a handout describing the program and families were encouraged to assist.

Findings: A total of 534 patients were admitted to the unit during the project timeframe (3 months). Of those patients, 96% (n = 521) of them participated in the mobility program during their stay. Approximately 69% (n = 373) were identified as at risk for falls. In terms of tier levels: 80% ambulated independently or with assistance (tier 2), 11% received ROM (tier 2), and 5% varied between the tiers (.eg participated in tiers 1 and 2). In terms of mobility compliance to the protocol, 58% of patients participated in mobility exercises at least 3 times each day during their stay, while 88% of the patients participated in at least 2 mobility exercises each day. In comparing patient outcome data, 3 months prior to implementation to 3 months postimplementation, there has been a decrease in readmission rates and falls. Pressure ulcer incidence and length of stay have remained relatively consistent.

Conclusions/Implications for Practice: The mobility program has shown positive outcomes; decreased unplanned readmissions, falls, and increasing patients' activity during their hospital stay. This program can be replicated on other medicine units.

Implementing a Pediatric Early Warning System in a Community Hospital Setting

Somberg CM, Northwestern Lake Forest Hospital, Deerfield, Illinois

Purpose/Objectives: Purpose is to influence the phenomena of patient safety in an inpatient pediatric community hospital setting. Objective was to determine if there was a difference in the number of pediatric code blue calls and emergency intubations between preimplementation and postimplementation of Pediatric Early Warning System (PEWS) and a Pediatric Rapid Response Team.

Significance: A Pediatric Rapid Response Team and PEWS provide a tool to identify pediatric patients who may be at risk for deteriorating condition and arrest. The system quickly provides the resources to assess, stabilize, and facilitate transfer of the patient to a higher level of care. The CNS can lead development of Pediatric Rapid Response Team and PEWS implementation, within the limited resources of a community hospital setting, influencing patient outcomes by decreasing occurrence of pediatric code blue calls/emergency intubations providing early recognition of physiological deterioration.

Design: The evidence has shown a decrease in the number of code blues of hospitalized children after initiating Pediatric Rapid Response Teams and PEWS, impacting patient safety outcomes. PEWS scoring was developed using the literature, along with the regional children's hospital protocols, tailoring the tool to meet a community hospital's requirements. Relationship-based Care model (Creative Health Care Management, 2004) provided nurses with a framework for the change in practice. The Promoting Action on Research Implementation in Health Services (PARIHS) (Rycroft-Malone, 2004) was used to guide the implementation process.

Description of Methods: Developing a Rapid Response Team and implementing PEWS was targeted for an inpatient pediatric department within a community hospital. Specific PEWS scorecard and an action plan were developed to reflect a community hospital's patient population and resources. The PEWS scoring tool was built into the electronic medical record. Nurses document PEWS scores on all patients within 1 hour of vital signs and assessments. Nurses follow standardized PEWS scoring and action algorithms. PEWS scores trigger specific nursing interventions.

Findings/Outcomes: Outcomes consist of no emergency intubation or code blue calls since inception of the pediatric rapid response team and PEWS scorecard on April 15, 2012. A rapid response team monitoring tool tracks all rapid response team calls. PEWS scores serve as a trending tool for patient improvement and deterioration.

Conclusions/Interpretations: Overall, the implementation of PEWS and Pediatric Rapid Response Team influenced code blue and emergency intubation rates impacting patient safety.

Implications: The implementation of this practice change had positive effects on patients, nurses, and the organization. The CNS influences direct patient care outcomes, nursing to intervene with a standardized evidence-based protocol and the system by impacting the patient safety culture within the institution.

Implementing a Progressive Mobility Program in the Surgical Intensive Care Unit

Fitzpatrick ER, Thomas Jefferson University Hospital, Glenside, Pennsylvania

Purpose: To implement a new evidence-based standard of care for progressive mobility for surgical intensive care patients.

Significance: Immobility, deconditioning, and weakness are common in critically ill patients and contribute to prolonged hospitalization and complications. Implementing a progressive mobility program in the earliest days of hospitalization results in better patient outcomes and shorter hospital stays. This practice will optimize recovery in intubated and nonintubated surgical ICU patients through increased physical activity and range of motion exercises begun immediately postoperatively.

Design: Based on the current literature implementing a progressive mobility program has the promise of improving patient outcomes and we sought to provide our patients similar effects. Among patients (on and off ventilators) in early and progressive mobility programs, 83% survived to hospital discharge with a medical ambulation distance of 200 ft. with adverse effects occurring in less than 1% (Bailey et al, 2007). There were fewer ventilator days, shorter hospital and unit length of stay, and fewer immobility-related complications (Thomsen, 2008). Survival to discharge was higher and capacity for ambulation and strengthening exercises was greater (Thomsen, 2008). Return to independent functional status was faster (Schweikert et al, 2009).

Methods: Sample: Patients older than 18 years admitted to the surgical intensive care unit and possessing baseline functional independence. Patients excluded are those with known/suspected unstable spine, an open abdominal wall, hemodynamically unstable, or those with an unstable airway (airway edema, difficult intubation).

Methods: To determine a patient's appropriateness for early and progressive mobility the nursing staff performed daily assessments using a checklist which defines criteria for patients' involvement in/progression through increased levels of activity. Activity performed (or discontinued) was also documented. Data were collected for surgical patients housed in units with 25-bed total capacity. Average daily census was approximately 18 patients during this time. Occasionally, medical patients are housed on the unit. These patients were not included in data collection. Data were collected relative to effective participation in the program as well as to length of stay data. Additional data review is currently being performed on the rates of ventilator-associated pneumonia as well as pressure ulcer rates before and after the implementation of the program.

Findings: To be identified.

Conclusions: To be identified.

Implications: The American Association of Critical-Care Nurses has identified the prevention of complications in critically ill patients as an important research priority for our profession. Complications after surgery and trauma have negative implications for the outcomes of critically ill patients. Pneumonia, deep vein thrombosis and even pressure ulcers can threaten the life of our patients, and at the very least can prolong the ICU and hospital lengths of stay. It is imperative that critical care nurses develop and use the evidence to enable them to institute strategies for preventing complications in this population. Nursing assessment and implementation of progressive mobility in the critically ill surgical patient will have an impact on the occurrence of complications in the critically ill surgical patient.

Improving Care for Older Adults Through Education of Nurses as Adult Gerontology Clinical Nurse Specialists

Murray DM, Curry-Lourenco K, Fowler C, Sharp P, Old Dominion University, Norfolk, Virginia

Significance: This presentation will describe the transition from a Nurse Educator program to an Adult Gerontology Clinical Nurse Specialist (CNS)/Educator Program that prepares graduate nurses to address the healthcare needs of underserved geriatric populations. The goal of the transition is to increase the number and distribution of culturally diverse CNS providers from minority and disadvantaged backgrounds. The CNS graduates will be prepared to serve as educators, researchers, expert clinicians, collaborators, and consultants providing patient-centered care to improve health outcomes for older adults. The program is delivered through Web-based didactic courses, clinical practicum experiences, standardized patient scenarios, interprofessional care conferences, and a teaching internship.

Background: The specific goals of this transition were (1) to recruit, retain, and graduate nurses from underrepresented minorities and underserved regions of Virginia as Adult Gerontology CNS/Educators; (2) to educate nurses to function in the Adult Gerontology CNS/Educator role as an interdisciplinary team member in acute, long-term and community-based care settings that provide healthcare services for older adults; and (3) to enhance the capability of the Adult Gerontology CNS/Educator to provide instruction on issues of aging and care of older persons using knowledge of adult learning theory and evidence-based teaching/learning best practices.

Methods: The courses were developed and implemented by the CNS curriculum committee consisting of the project director, CNS program and practicum coordinators, nurse educator coordinator, and gerontology content coordinator. An array of geriatric healthcare professionals from the HRSA-funded Virginia Geriatric Education Center will serve as consultants.

Outcomes: Courses began in the fall semester of 2012. There are 13 part-time students enrolled for 2012-2013. Ten students are completing the master of science curriculum. Three students hold a master of science and are completing the Adult-Gerontology CNS/Educator post-master's degree certificate curriculum.

Conclusions: The project focuses on educating nurses who will be able to practice as Adult Gerontology CNS/Educators within rural and underserved populations. Second, students recruited to participate in this distance program will come from many of the rural areas of Virginia considered Health Professional Shortage Areas. This access to quality distance education is aimed at increasing the likelihood that graduates will remain in their communities and contribute to efforts to enhance healthcare services and promote quality outcomes for older adults.

Implications: This program will prepare the graduate to assume a teaching role in clinical or academic settings, thus fulfilling a critical need for nurses with knowledge of gerontology and formal graduate education in teaching/learning methods who are able to serve in faculty positions.

Improving Care One SCIP at a Time: Overcoming Barriers to Postoperative Urinary Catheter Removal in Thoracic Surgery Patients With Epidural Infusions

Craig S, University of Virginia Health System, Barboursville; Nigro K, and Morton S, UVA Health System, Charlottesville

Purpose: Achieve improved adherence to postoperative urinary catheter removal in thoracic surgery patients with epidural infusions.

Background and Significance: Epidural catheter placement is common following open thoracic surgeries. Traditionally, urinary catheters are left in place for the duration of epidural use to prevent postoperative urinary retention (POUR). However, the risk of urinary tract infection (UTI) increases each day the urinary catheter remains in place. A literature review identified the risk of POUR as low following urinary catheter removal and continued epidural use. When urinary retention is present the incidence of UTI with an in-out catheterization is less than the risk of UTI with an indwelling catheter. The Joint Commission Surgical Care Improvement Project (SCIP) monitors several surgical core measures including adherence to postoperative urinary catheter removal no later than day 2 unless documented medical necessity. The sample thoracic surgery nursing unit did not consistently meet SCIP measures related to urinary catheter removal by day 2. An interdisciplinary group identified thoracic patients with epidurals as a significant portion of the failures to meet SCIP. Nursing barriers to adherence included nurses were not convinced that this was safe practice for patients, nurses and providers were unfamiliar with the institution's bladder scan algorithm to avoid catheter reinsertion, increased time and labor associated with early removal, and catheters were removed early but nursing documentation was incomplete in the new electronic medical record system.

Methods: A workgroup analyzed nursing barriers to adherence to postoperative urinary catheter removal. The workgroup created a comprehensive education module for unit nursing staff. The module reviewed the literature related to epidurals and urinary catheter removal, SCIP and the significance of early urinary catheter removal, interventions to prevent urinary catheter reinsertion, the institution's bladder scan algorithm, and correct nursing documentation in the electronic medical record. The ten minute module was presented one-on-one in a standardized method by the core RN workgroup to each member of the unit nursing staff over a 1-month period. Nurses were given a short quiz and required to demonstrate documentation at the end of the teaching session to highlight major points. Chart reviews followed the education intervention to monitor adherence to urinary catheter removal day 2 and remediation was provided to staff.

Outcomes: Nursing staff resistance towards early postoperative urinary catheter removal in epidural patients has decreased. Adherence to early postoperative urinary catheter removal and utilization of the institution's bladder scan algorithm has increased. Device utilization, UTI rates, SCIP data show a downward trend since completing the education module for all thoracic surgery postoperative nursing staff.

Conclusions and Implications for Practice: Postoperative day 2 urinary catheter removal in thoracic surgery patients with epidural infusions represented a significant practice and culture change on the postoperative thoracic surgery nursing unit. Unit level needs assessment and analysis is a crucial step in implementing national and institutional practice changes at the unit or patient population-specific level.

Improving Neurologic Function After Cardiac Arrest Through Therapeutic Hypothermia

Ignacio A, Torrance Memorial Medical Center, California; Castillo E, Pacific Hospital of Long Beach, California

Purpose: Improve outcomes in patients after resuscitation from out-of-hospital cardiac arrest.

Significance: Post-cardiac arrest patients have a high mortality rate and poor neurologic outcomes in spite of standard postresuscitation care and intensive critical care monitoring. Of 164 000 cardiac arrests occurring in the United States annually, 65% to 95% dies. Those who survive have suffered adverse health outcomes. The post-cardiac arrest patient often has limited physical abilities and physiologic instability.

Background/Rationale: The American Heart Association recommends initiation of therapeutic hypothermia to patients who remain comatose after resuscitation from sudden witnessed out-of-hospital cardiac arrest. Therapeutic hypothermia is an intervention that cools the postarrest patient to a temperature of 32[degrees]C to 34[degrees]C with iced saline or other surface cooling measures after the return of spontaneous circulation and maintained at that temperature for 18-24 hours. Research has shown that patients in the hypothermia group were more likely to survive to hospital discharge compared with standard postresuscitation care. Therapeutic hypothermia has been shown to improve neurologic outcomes and decrease mortality following cardiac arrest.

Methods: A policy and protocol was developed by the CNS in collaboration with the ED and ICU nursing staff, ED physicians, respiratory therapy, physical therapy, pharmacy, and clinical informatics, which outlined the approach for instituting immediate hypothermia in patients remaining comatose following out-of-hospital cardiac arrest. The goal was to start therapeutic hypothermia within 6 hours after return of spontaneous circulation and to keep the patient's temperature at 33[degrees]C for a period of 18 to 24 hours. Staff was educated about the protocol, and a therapeutic hypothermia kit was provided to the ED and ICU which contain the protocol and supplies to initiate hypothermia.

Outcomes: Findings were based on mortality rate and neurologic outcomes. Modified Rankin Scale (MRS) was used to measure neurologic outcomes. An MRS score of 2 or lower indicates a good functional outcome. There were 17 patients who met the criteria for therapeutic hypothermia since the program started in 2011. Eight patients survived with good neurologic outcomes (MRS score of 1-2), 7 expired and 2 were discharged with neurologic deficit (MRS score of 3 and above). Results showed that there was a 47% survival rate among patients treated with therapeutic hypothermia with good neurologic function. This supports the findings revealed by previous studies which showed a 47% to 49% survival rate among out-of-hospital cardiac arrest patients treated with therapeutic hypothermia.

Conclusions: Results suggest therapeutic hypothermia decreases mortality rate and improves neurologic outcomes.

Implications for Practice: Based