Creating a Healthy Work Environment With Collaborative Team Meetings

Chapman J, St. Onge C; Maine Medical Center; Me

Purpose: 2004 NDNQI staff satisfaction survey showed nurses on the cardiac surgical step-down unit and cardiac surgical ICU rated job satisfaction lower than the national average. In an effort to improve the working environment, an informal weekly mee ting was developed to facilitate communication amongst the cardiothoracic nursing, physician, and physician assistant leadership and key nursing staff. Description: This process has allowed for open discussion of pressing issues brought forward by the interdisciplinary team that affect the continuum of the patient’s stay. Plans of action are developed that allow for immediate changes in practice as well as the development of a process for continued quality improvement. Evaluation occurs at a designated time, and changes to the plan are made, if necessary. Role out of the plan occurs simultaneously in both units with all members of the interdisciplinary team. Resolution of problems has occurred in a timely fashion. The plan, do, check, act approach has been rewarding. This informal meeting optimizes a true collaborative approach, skilled open communication, effective decision making, and meaningful recognition of staff. All of this leads to clinical excellence, optimal patient outcomes, and staff satisfaction, which promote a healthy work environment. The staff recognizes their power to influence positive change by participating in this process. Sample topics have been patient chart review, patient satisfaction results, protocols, time out process, and nurse physician documentation and communication. Evaluation/Outcomes: Immediate response to issues with a plan and resolution has allowed consistency in practice across the cardiac thoracic continuum of care. This process has played an instrumental role in leading to clinical excellence and an increase in staff satisfaction which was evidenced by 2005 NDNQI resurvey results in both units.

Triad of Communication-Patient, Physician, Nurse—Improving the Physician Nurse-Physician Collaboration

Barelick P, Duffy M, Grove S, Penrod J, Rhoads R, Shaffer N; Conemaugh Memorial Medical Center; Pa

Purpose: Physicians had expressed concern that frequently novice nurses are not consistently communicating pertinent data about a patient in crisis when calling the physician with a change in condition. This program was developed to help nursing staff understand the requirements of effective communication. Understanding that the physician is dependent on information provided by the nurse in his absence, critical thinking was emphasized. Description: As a result of the peer review process at our facility this communication deficit between the disciplines was discovered. Education became the solution to the deficit detected. This program was developed to promote a healthy work environment between the physician and the nurse. The effective communication goal would serve as an advantage for the staff, nurses, patients, and the physician. A committee of 6 RNs met over several weeks to develop a PowerPoint presentation regarding the topic discussed. The target audience was to be staff RNs hospital-wide. Because this was a required program, a whimsical character was chosen to represent the body systems involved in our critical thinking assessments. Real body system examples were presented and audience participation was encouraged with each body system scenario. Evaluation/Outcomes: This program was evaluated by 65% of the staff that attended the program: 60% found the inservice to be beneficial, 10% felt that the inservice was not beneficial, an additional 17% of the participants gave the program positive reviews. Based on the majority of comments being a positive, the triad program has been recommended to become a part of the orientation class presented at the hospital. The orientation class is centered on an audience of RNs and graduate nurses that are new to the facility.

Braking the Silence: Helping to Halt Unsafe, Unhealthy Practices Through “Silence Kills” Awareness

Jay L; Seton Medical Center; Tex

Purpose: The longstanding practice of ignoring, tolerating, and even silently condoning unhealthy practices has led to many detrimental patient outcomes, as well as nurse dissatisfaction and high turnover rates. Our awareness of these matters was heightened through study of the Vitalsmarts Industry Watch research presented through their “Silence Kills” telecast in which collaboration with AACN, JCAHO and other entities brought compelling data before us. We became engaged in an effort to educate staff regarding this research which spanned over 1700 responses and revealed alarming statistics. An awareness of the facts, along with commitment to alleviate the situation, was our purpose. Description: After recovering from our own sense of shock and appallment at the research findings, we prepared for our staff a powerpoint overview of the “Silence Kills” research and publications. We emphasized the “seven crucial conversations” that must be mastered to transform unhealthy environments, according to the authors. Also included in our program were interactive exercises in awareness and improvement of unit and individual responses to unsafe and inappropriate behaviors. Evaluation/Outcomes: After taking part in the education, nurses were surveyed and their responses showed that 90% had previously been unaware of the extent of the problems; 80% had been minimally (at best) involved in speaking out on the issues; and over 70% had not really considered it their problem even though they considered themselves strong patient advocates. More than 80% reported changed viewpoints since taking part in the awareness education, and a new surge of commitment to quality in practice environment is replacing the previous level of apathy. The rampant silence has been “braked,” or at least slowed down.

Stop Moral Distress and Helplessness, Fight Back With the 4 A’s

Correll-Yoder N, Neal T; Queen of the Valley Hospital; Calif

Purpose: To provide the staff of a progressive care unit with tools, strategies and resources to recognize, validate and then decrease feelings of moral distress. Description: Staff on a 26-bed telemetry/step-down unit (progressive care) were surveyed on their feelings of moral distress and their ability to cope with ethical situations. Based on the data education sessions were provided focusing on the recognition and development of appropriate strategies for managing feelings of moral distress using the AACN’s Four A’s of Moral Distress Tool. Staff were assisted in identifying and developing current available resources on the unit to combat moral distress such as unit representation on the systemic-issues ethics committee, the bioethics referral process, unit-based ethics expert and active rounding and bedside consultation by the CNS on patients/situations driving moral distress. Evaluation/Outcomes: Progressive care staff found the content very validating of their feelings and the dilemmas they commonly faced. Staff began slowly to voice more concerns by identifying and communicating ethical issues on the unit. Staff communicated concerns and situations driving moral distress to the CNS and participated in small system changes on the unit. Moral distress survey results improved relating to staff ’s ability to cope and better manage ethical situations on the unit.

Transforming a Critical Care Unit Through the Use of AACN Practice Alerts

Cox L, McAdams K; Memorial Medical Center; Pa

Purpose: Optimal patient outcomes are best achieved through a multidisciplinary, evidence-based approach to care. Finding a way to communicate evidence-based practice initiatives to all members of the healthcare team was a challenge. As part of our post-NTI euphoria, we decided to meet this challenge through the use of AACN Practice Alerts. Description: A bulletin board designated the Practice Alert Board was placed in a common hallway between both of our critical care units. This location was selected because of the heavy traffic flow of healthcare workers from all service lines. The Practice Alert Board contains information on the expected clinical behaviors and the supporting evidence as outlined in the AACN Practice Alert. Pictures of various members of our multidisciplinary team are used to draw attention to the board. Evaluation/ Outcomes: Since the Practice Alert Board debuted, personnel from all disciplines have been observed reading the information displayed. The first Practice Alert selected was prevention of ventilator-associated pneumonia (VAP). The VAP Practice Alert was chosen because our unit’s compliance to head of bed (HOB) elevation was consistently less than 50%. In the month following the initiation of the Practice Alert Board, our compliance with HOB elevation dramatically improved to 77%. The current Practice Alert Board focuses on family presence during cardiac arrest. Displaying this information has generated spirited discussions between various disciplines and has prompted the development of hospital wide guidelines for family presence during cardiac arrest. Through the use of AACN Practice Alerts we have successfully “engaged and transformed” our critical care units.

Operationalizing Evidence-Based Practice: Taking It Off the Page and to the Bedside

Schmitz T, Hooker S, Megwa J; The Methodist Hospital; Tex

Purpose: Nursing is making significant progress toward a practice based on research and science. Often, however, clinicians and managers struggle or fail in implementing new processes or practices even though they have a strong evidence base. An understanding of barriers and specific strategies helps to bring evidence-based practice to reality. Description: In working to implement new protocols in our unit, we encountered numerous barriers to quick and easy progress. These included conflicting evidence, variation in levels of evidence, underestimating the time needed for adoption, logistical barriers, and competing priorities. Through collaboration and effective communications, we used a variety of strategies to enhance the adoption and incorporation of evidence-based practice. These included teaching and reteaching, use of focus groups, incorporating teaching and monitoring in multidisciplinary rounds, and continual reassessment and modification. Some of our most powerful strategies were using stories and anecdotes, making it easy to do the right thing and hard to do the wrong thing, and always considering the “WIFM” (what’s in it for me) factor. Evaluation/Outcomes: Recognizing the barriers and using the strategies described above has enabled us to implement an oral care protocol, a glucose control protocol, and components of a ventilator “bundle” in our unit. These techniques have decreased our frustration and increased our satisfaction as we move evidence-based practice from the page to the bedside.

Developing a Nursing Research Program: Quest for Magnet Recognition in a Community Hospital

Brown D; Hoag Memorial Hospital Presbyterian; Calif

Purpose: As a staff nurse driven Nursing Research Council (NRC) in a shared governance structure, our focus has been on research utilization and dissemination of evidence-based practices. Seeking Magnet designation, our goals evolved to include embracing the conduct of nursing research. We desired to put the infrastructure in place to encourage nurses to conduct clinical research. Description: The Iowa Model of Evidence-based Practice was adapted to mentor staff in developing evidence-based practice projects. When existing studies are insufficient to guide practice, research may be needed to generate new knowledge. A packet entitled, How to Submit a Nursing Research Proposal, was developed and placed on the hospital Intranet to guide and support the approval of nursing research. This packet includes the policy and procedure for review and approval of nursing research proposals, the nursing research proposal form to be submitted by the principal investigator, the NRC proposal review and approval form, instructions for applying to our Institutional Review Board, and a tool for critiquing a research article. Advanced practice nurses and master’s prepared staff nurses with research experience mentor staff in the development of research skills. Resources available for nursing research include a university nursing professor advisor, a biostatistician for statistical and data questions, and the hospital director of clinical research for funding. In addition, the hospital librarian is available to assist with literature searches and staff have been educated in unit based on-line access to Ovid and ProQuest databases. Evaluation/Outcomes: Currently, we have 6 ongoing nursing research projects, and one completed exploratory nursing research study. Administration has justified a fulltime position for a PhD nurse researcher to coordinate our projects. Great strides have been made in the past year culminating in a very positive Magnet interview.

Improving Hand Hygiene Compliance: “Germie” Coming to a Hospital Near You

Buska L, Gray T, Flores R, Boquiren M; Sharp-Grossmont Hospital; Calif

Purpose: Hand hygiene is the single most effective means to prevent, control, and reduce the incidences of hospital-acquired infections. As part of the 2005 National Patient Safety goals to reduce the risk of health care associated infections, members of the PCU Quality Council implemented an innovative program in their unit to raise awareness and compliance of hand washing by caregivers. During the last 2 quarters of 2004, hand hygiene compliance was at a low 11%–33%. The goal of this program is to increase hand hygiene compliance and reduce healthcare related infections. Description: Members of the 5th PCU Quality Council started the program by educating the staff about the importance of hand hygiene. In-services at the staff meetings were given regarding several topics such as: (1) relationship of hand hygiene and hospital-acquired infections, (2) soap vs. hand gel, (3) length of hand washing, and (4) increasing the staff ’s awareness of several hot spots where “germie” can reside. An innovative hand hygiene jingle called “I’m going to wash these germs right out of my hands” was developed. If sung properly while washing your hands, the song will meet the 15 seconds hand washing hygiene standard. The song and “germie hot spots” were posted on sinks and workstations through out the unit as visual reminders. Monthly audits were done to monitor staff ’s compliance with the new program. Staffs that were observed to demonstrate proper hand washing techniques were given a “handshake” letter with a coupon for a beverage or an ice cream, while staff that were noncompliant were given a “hand-slap” letter reminding them about the importance of handwashing. Evaluation/Outcomes: Since the implementation of the program, hand washing compliance for the nurse’s aides went from 15% to 85% compliance, and the nurses’ hand washing compliance went from 13% to 87%. The innovation was presented at the hospital collaborative leadership day to other units.

“Novice To Expert…In Critical Care” Utilizing the Benner Model To Promote New Grad Retention

Lepman D; Hoag Memorial Hospital Presbyterian; Calif

Purpose: Recruiting new graduates and keeping them is a top priority for nurse managers across the country. In our efforts to recruit new graduates it became evident that keeping them requires as much thought and strategy as initially hiring them. Description: Using a model that examines the various stages that new graduates experience as they matriculate into critical care is a powerful tool that can help your unit succeed. Role clarity, defining expectations and understanding the new graduate in this setting is exceedingly important to their success and the overall success of staff retention and nurse satisfaction. Patricia Benner’s Model, “Novice to Expert” is an evidence-based approach providing valuable insight into how new graduates develop during orientation and continued “mentorship” at the bedside. Four attributes: Focus, Salience, Temporal Focus and Problem Solving, as identified by JoAnn Grif Alspach, serve as criteria to measure the progress of the new graduate nurse. These 4 attributes together with Benner’s “Novice to Expert” Model, create a pathway by which the development and evaluation of the new graduate may be objectively measured and clearly communicated. Evaluation/Outcomes: Between January and June of 2005, 15 new graduates have been hired into our Cardiac Critical Care Department. Beginning in May of 2005, the above principles have been presented in 6 different sessions to preceptors from each unit. This information has been well received by preceptors and charge nurses. It has redirected thinking and planning for the selection of preceptors and the patient care assignment delegated to the new graduate nurse. Measurement of our success will be accomplished through the use of evaluation tools designed to assess new graduate performance, preceptor performance and the effectiveness of the entire orientation experience. Ultimately, our success will be measured through turnover and vacancy rates and nurse satisfaction scores.

Foreign Educated Nurses: A Smooth Transition Into a Unit Culture

Mcbroom K, Davis D, Mostaghimi Z, Holtschneider M; Duke University Health System; NC

Purpose: Our unit has a large multicultural nursing staff, which can result in miscommunication due to varied ethnic views and practices. We wanted to improve our cultural diversity and embrace our unique staff. New, foreign educated nurses are particularly vulnerable due to the numerous barriers they need to overcome such as culture shock, both verbal and nonverbal language. Since, it is essential to care for all patients safely and competently, it became imperative that we react quickly to meet this challenge. A group of multicultural nurses met to develop a system to welcome all newcomers, regardless of background and cultural beliefs that would help them acclimate to our unit and institution. Description: The workgroup included representatives from cultures across the progressive and ICUs. We made the decision to develop a system that ensured nurses receive tools to promote a positive work culture and community environment. Meetings were scheduled during mealtime in a social, relaxed atmosphere to ensure comfort. Members were encouraged to bring an ethnic “covered” dish to share their culture with the group. From these meetings, the idea of a “Welcome Wagon” was created. A group of nurses, from the committee and a representative from the unit, greeted the new nurse with a basket of information, including community and hospital information. This helped to acclimate the employee to the community as well as to the unit. Evaluation/Outcomes: There was an enhanced sensitivity to the needs of foreign educated nurses as well as increased self awareness by the existing nurses. The heightened awareness motivated this group to meet with leadership and hospital education to develop a program hospital wide. This opportunity will be offered during the orientation phase of employment, to help the foreign educated nurse transition more smoothly into the unit culture by jumping on the “Welcome Wagon.”

Stop the Revolving Door Syndrome—Critical Care Nurse Internship Program

Schreyer C, Dembowski J, Mcadams S, Oldham S, Oroark D, Venetsky M; Memorial Medical Center; Pa

Purpose: Our critical care unit was faced with some serious staffing issues. Over a 15-month period, 24 RNs had either transferred out of the unit or terminated employment citing inadequate training and orientation as the primary reason. Our critical care unit is a crucial component of the hospital mission: to be the premier healthcare delivery system on our region. A committee was formed to develop a program targeting orientation with the key goals being retention of new staff to help them function with confidence and competence, attract GNs and RNs who may otherwise who may otherwise not consider this intense environment, and to use “seasoned” RNs as preceptors and reward their participation with incentives and recognition of their expertise and exceptional performance standards. Description: Committee members met regularly until a final plan was developed. The final product was the Critical Care Nurse Internship Program. Recruitment of interns was announced over flyers that were distributed. Selected interns were required to meet academic/performance standards, provide letters of recommendation, and complete interviews. Participants were required to sign a 2-year commitment agreement. A 22-week curriculum was developed to include didactic lecture, ECCO program, hands on simulation,and required education with the clinical component guided by the preceptor. Preceptors were given a preceptor course based on AACN’s guidelines. Weekly progress reports were completed. College credits were awarded to the program from 2 local colleges. The program was started in July to coincide with GN graduation. Evaluation/Outcomes: The program has been held for 3 consecutive years with 17 participants to date. Evaluations have been done amd improvements made. Competency has improved as evidenced by evaluations of physicians and nurses. Number of RN terminations per month has dramatically reduced. 100% retention rate exsists and 7 participants have taken advantage of the college credit opportunity.

Computerized Physician Order Entry: Nurse Input Is Essential for Success

Mcbroom K, Anderle M, Mackowiak L, Bride W, Sawyer T, Swartz C, Duncan L, Harper M; Duke University Health System; NC

Purpose: In our institution, there were several issues brought forward directly related to handwritten physician orders. There were mistakes in writing, interpretation and in cosigning verbal orders. A decision was made by the hospital to change from a handwritten system to a computerized physician order entry (CPOE) system. Traditionally, nurses are the last barrier for patient safety, yet are not often included in problem resolution, such as handwritten physician orders. A nurse was chosen to take the lead in planning for CPOE. Description: Once the decision was made, it became apparent that not only physicians should be involved in the process. Since nurses carry out orders, take verbal orders and write nursing orders, nursing needed to be a key player. Our step-down units became the first to undergo CPOE. Nurses, physicians and administrators, both clinical and from CPOE formed a group to identify, define and produce order sets that followed protocols, standardized orders and clinical practice guidelines. Once the process was finalized, the educational process began. Informational sessions were held for nurses and physicians so that each group could be familiarized in the use of CPOE. The nurses were educated about their own order entry process as well as the physician order entry process, since they would be involved in helping physician colleagues learn the system. CPOE was then implemented with a team of CPOE representatives in conjunction with the clinical team. An oversight committee was established to ensure smooth implementation throughout the hospital. Evaluation/ Outcomes: There has been a definite increase in nurse satisfaction as the nurses feel more valued. Patient care is now more efficient. No longer do nurses have to “hunt down” doctors for orders or for cosignatures. Orders are processed directly with the departments rather than having to use the nurse as a middleman. Although CPOE was started for physicians, it has become a salvation for nursing.

Promoting Professionalism: Rewarding National Certifications

Jones S, Rother L; INTEGRIS Baptist Medical Center; Okla

Purpose: In 2000, INTEGRIS Baptist and Southwest Medical Centers, recruited a multidisciplinary team composed of staff nurses, educators, human resource consultants, and leadership to develop retention strategies that incentivized and rewarded employees for excellence in quality and care. Developed as part of this recruitment and retention program, the National Certification Bonus program (NCBP) serves as a mechanism to financially reward nurses who have demonstrated the commitment, skills, and knowledge to successfully complete the national certification for their specialty. Description: Instituted in January 2001, this program reimburses registered nurses who successfully complete the national certification exams up to $250 for the exam fee. In addition, nationally certified nurses are rewarded with an annual bonus. The NCBP provides full time RNs $1000/year in compensation for their efforts. Part-time RNs working >1000 hours receive $500, those nurses working <1000 hours annually receive $250. Initially this program was available to direct care nurses and clinical educators for bedside certifications. In 2004, the program was extended to all RNs including clinical directors with national certifications in a bedside specialty. This money is paid in a single bonus check. Application to the program is accepted biannually with checks being paid the month after application. Application deadlines are March 1 and August 1. Evaluation/ Outcomes: Benefits of the NCBP include: promotion and recognition for professional development, increased employee satisfaction, and improved quality of care. There were 111 nationally certified nurses eligible for the bonus when it was begun. During the next 3 years the number of nurses taking advantage of this program grew by 165%. Names of nurses receiving national certification are also displayed on a plaque in their respective work areas.

Follow My Lead: Creation of a Leadership Role for Staff RNs

Asleson A, Jacobs P; Mercy Hospital; Minn

Purpose: To increase leadership positions for staff RNs, allowing for greater input into unit decision making, Mercy Hospital created the role of Lead RN. There are 3 lead positions on each unit. One of these positions is the QI/Documentation Lead RN. Description: One part of this job focuses on completing bi-monthly chart audits. To meet this need, and assist the RNs in recognizing JCAHO standards for charting, a chart audit program was created. Each RN has the responsibility of auditing three charts per year. Once the chart audit program was in place, the documentation pitfalls became more noticeable and documentation checklists were posted by each computer used for charting. Several new tools were created to streamline documentation. These tools include a 1:1 report worksheet to help limit report time and an admission checklist showing what steps needed to be completed. A quality issue recognized by the RNs was the issue of continuity of care. A primary nurse program was created allowing RNs to sign up to be “primary” RN for a patient. That RN is always assigned to the patient when they work. As a means of communicating new processes and documentation a newsletter was created. Called “Expecting Excellence,” this gives the staff notice of new tools, new processes, and an idea of why the change is occurring. As a visual cue for the RNs as the changes progress, an icon of a pirates map has been posted at each location on the unit where new documentation can be found, or the items for a new process are being kept. Whenever the RNs come across a map, they look through the folder and/or drawer and become familiar with the change. Evaluation/ Outcomes: The outcome that has been most noticeable in the first 6 months of this program is an increase in charting compliance. Expected outcomes with the newest changes are a decrease in incremental overtime related to the 1:1 report worksheet and the admission checklist, and an increase in continuity of care for patients with the primary nurse program.

Engage Your Staff: Transform Nurses’ Solutions Into Professional Poster Abstracts

Becker C, Petlin A; Barnes-Jewish Hospital; Mo

Purpose: We believe that nurses are natural clinical problem solvers. Submitting poster abstracts for the AACN-NTI presents an excellent opportunity to share solutions professionally. However, many of our nurses feel intimidated when thinking about how to showcase their work. Description: Several of our staff members have had posters displayed at past NTIs. Building upon this experience, we organize a brainstorming meeting in the early summer to recall activities and projects of the past year that merit development into poster abstracts. We pair the interested nurses with a mentor who helps them write and polish the abstract. We expect that the mentor defers first-authorship of the poster to the mentee so that new staff get to attend the annual meetings. This also helps promote new membership in AACN. After we receive the notices about which posters are accepted, we provide more support to the presenters. We use a standard hospital template with our logo for the slide presentations. We have a distinct look for the display posters as well. We show the 11- by 17-inch proof copies of the posters during the hospital’s Nurses Week celebrations. At the NTI the poster presenters also spend time in our recruitment booth talking to conference participants. The hospital covers a substantial part of the expenses to attending the meetings. After the meetings our corporate publication lists all the authors for each abstract. Our local AACN chapter displays the posters the following year at the annual symposium expanding the audience even more. Evaluation/Outcomes: We began this drive to encourage more of our nurses to attend the NTI and to present their creative solutions. We had seventeen posters displayed at the 2005 NTI. The nurses return with a renewed enthusiasm for their work and a commitment to participate in AACN and other professional organizations. This enthusiasm has spread to nurses in other departments at our hospital who now submit abstracts to their professional societies using a similar mentor-mentee model.

Innovation, Collaboration and Technology to Enhance Recruitment and Retention in the Critical Care Unit

Goldsworthy S, Graham L; Durham College/UOIT; International

Purpose: This innovative program was designed in collaboration with the hospital and college partners to provide an advanced coronary care program for nurses that had an interest in working in the coronary care unit. It was designed to be flexible yet comprehensive enough to provide the skills required to practice safely in this advanced practice area. Description: In order to be eligible for this advanced coronary care option, nurses had to have prerequisite courses which included arrhythmia interpretation, 12-lead analysis, hemodynamics, and care of patients who had experienced an MI. The program consisted of in-class activities as well as simulated lab experiences. In addition to the classroom and sim lab experience students were able to complete a portion of the program through a web based class (Web CT). Within this Web-centric environment students were able to complete assigned activities, submit work and communicate with the professor. The program duration included 10 weeks of classroom/lab/ Web learning and 60 hours of preceptored clinical placement. The program was facilitated by the clinical practice leader at the hospital site and the professor from the college site. All classes took place at the hospital or through Web CT. Evaluation/Outcomes: The 10 weeks of intensive learning through class activities, simulation, and Web-centric learning combined with the 60 hours of preceptored clinical placement proved to be very successful. All participants have now been recruited into the CCU. Student feedback was positive and the facilitators have incorporated changes that will be introduced into future programs to enhance delivery.

When Is Checking Post Operative Blood Glucose Not Enough? An Introduction to Tracking Hemoglobin A1Cs

Severance B, Jones S, Merrill A; INTEGRIS Baptist Medical Center; Okla

Purpose: Initially implemented as a tool for postoperative glycemic control in the cardiovascular surgery population, this study grew into a project to identify cardiovascular surgery patients with previously undiagnosed diabetes (DM) in the immediate postoperative period. Description: A hemoglobin A1C (HbA1C) was performed as part of the postoperative cardiac surgery glycemic control protocol. This information was initially used to identify those patients that needed intensive glycemic management. Evaluation of the patients requiring postoperative intensive insulin therapy and their preoperative HbA1C revealed a large number of patients who met the definition for DM or metabolic syndrome. Initially, those patients with a HbA1C greater than 6.8 were targeted for aggressive management and follow-up. Further review of the patients’ charts demonstrated that follow-up and outpatient management was indicated for those individuals whose HbA1C was 6.0 or greater. Evaluation/Outcomes: As a result of these findings we now not only screen those who require postoperative glycemic management, but all cardiovascular surgery patients. Patients who have poor glycemic control postoperatively are at greater risk to develop surgical site infections. Numerous studies have demonstrated the cost of a deep chest surgical site infection to be approximately $20 000. The identification of patients with previously undiagnosed DM has ramifications far beyond the immediate postoperative period. It is our hope that by identifying these previously undiagnosed individuals, that we can not only decrease the cost and complications associated with their post surgical care, but also prevent some of the long-term complications of DM. DM impacts numerous body systems including central nervous system, cardiac, renal, and peripheral vascular to name a few. Identification and referral of these individuals for proper glucose management is the first step toward decreasing the complications associated with uncontrolled hyperglycemia.

Applying Pulmonary Rehab Strategies to the Acute Care Setting: Improving Outcomes in Hospitalized Patients With COPD

Livesay S, Warren M; St. Luke’s Episcopal Hospital; Tex

Purpose: Pulmonary rehabilitation is a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy. Because of the established clinical effectiveness of pulmonary rehabilitation strategies in the outpatient setting, our institution felt it was worthy to begin these strategies in the inpatient acute care setting. A multidisciplinary team was formed to develop, implement, and evaluate an inpatient acute care COPD pulmonary rehabilitation program. Outcomes measures included length of stay, cost per case, readmission rates, and patient satisfaction. Description: A protocol outlining the components of the program and the roles of all key players was developed. Upon ordering of the protocol by a physician, the patient received a focused teaching session regarding disease management from both the RN and RT. Physical and occupational therapy was consulted for endurance training and breathing techniques to manage dyspnea. Case management was consulted for discharge planning. Care was coordinated and communicated via a multidisciplinary progress sheet that was located in the physician’s progress note section of the chart. Education on the protocol and general COPD management was provided for all disciplines on all shifts. Evaluation/Outcomes: When compared to a control group, length of stay and cost per case were decreased and the readmission rate was 66 % lower in the group that received pulmonary rehabilitation. Patient satisfaction scores were high in those patients who received rehabilitation. The multidisciplinary team reported increased communication and coordination of care as a result of the multidisciplinary communication sheet. Though statistical significance was not present, incorporating elements of pulmonary rehabilitation into an in-patient comprehensive program yielded positive outcomes in the COPD patient population.

Crowning a Sugar Queen (or King): Developing a New Nurse Practitioner Role in Inpatient Diabetes Management

Mabrey M, Mangum J; Duke University Medical Center; NC

Purpose: When implementing a new intravenous (IV) insulin protocol in our cardiothoracic surgery (CT) ICU and step-down units, we discovered the need for an endocrine specialist to collaborate with the healthcare team, and to educate staff and patients. We also needed someone to medically manage patients to optimize glycemic control. Description: At any given point, up to 75% of ICU patients are hyperglycemic, yet rarely are patients admitted to the ICU specifically for glucose control. Diabetes is frequently much lower on the problem list. Research demonstrates controlling blood glucose levels, particularly in the ICU, decreases mortality, reduces length of stay, and decreases postoperative complications such as infection, renal failure, and critical illness polyneuropathy, thereby saving healthcare costs. Hospitals need a clinical expert to direct patient care and assume responsibility for the continuation of diabetes management beyond an IV insulin protocol. Our clinical pharmacists could manage patients whose diabetes was previously controlled and transition them back to their appropriate home medications. But, it was an unrealistic to expect new rotating surgical house officers to learn the fine nuances of medical management of newly diagnosed or poorly controlled diabetes. Because clinical endocrinologists are in high demand and short supply, a ripe opportunity existed for a nurse practitioner (NP) to fill the void. The new NP started in this role and within 3 days the new protocol began. Through a unique collaborative practice with nurses, pharmacists, and multispecialty physicians, we initiated effective, evidence-based medicine. Evaluation/Outcomes: Our average blood glucoses and sternal wound infection rate have decreased. We are safely using IV insulin in the CTICU and throughout the inpatient care arena thus, achieving glycemic control from the operating room to discharge and preventing associated surgical complications.

CCRNs in the Field; Lessons From a Nurse Based Transport System: A 5-Year Follow-Up of an NTI Creative Solution

Hallinan W, Myers D; Strong Hospital; University of Rochester Medical Center; NY

Purpose: The transport of critically ill patients between facilities can place patients at risk, creates stress for families, and often breaks the close bonds between nurses and their patients. The resources available for these transports are often adapted EMS systems or independent departments. The Strong Health model for critical care transport trains unit based critical care nurses for the transport process and creates the true continuity of nurse to nurse collaboration and transition of care. The NTI 2002 featured the original abstract Developing an Interfacility Transport Team: A Critical Care Nurse and EMS Partnership, this creative solution abstract will reflect back on the lessons learned in the past five years and discuss how nurses faced with the transport of a critically ill patient can apply these lessons. Description: The transfer of a critically ill patient may never be performed without encountering a problem and learning from it. The most common or highest risk issues identified are: what patients require a specialty transport team, who is to sick to travel, how to educate patients an families about the implications of transition to another level of care, how best to stabilize critically ill patients before transport, what education is required of a transport team, what is acceptable medical direction, and how to foster the relationships between teams and sending facilities. Evaluation/Outcomes: Most problems have been addressed with development of guidelines and tiered categories for patient triage. Staff spends on average 45 to 60 minutes educating families. Stabilization of patients requires collaboration and commitment that has kept teams on location over 9 hours. Medical direction now uses advanced practice nurses, telemedicine and protocols. Relationships with sending facilities are fostered through good follow up, hosting training, and shadowing experiences. Further directions include critical care transport grand rounds and publication of critical care transport handbooks.

After the Code: Supporting Each Other

Elchos S; The Methodist Hospital; Tex

Purpose: In our MICU, approximately 80 patients die per quarter and of these patients, 37 have resuscitative efforts initiated. During a code, doctors, respiratory therapists, patient care assistants, nurses, chaplain and secretaries give their all— whether it is to the patient or a family member. But what happens after the code? How do we feel? How did we do? Because night shift had many new staff members, management and staff developed a system to support all team members who participated during the code while at the same time reviewing emotional and technical responses during the code. Description: First, nurses decided what needed to be reviewed after a code was called on the unit and then developed a code review form. Unit charge nurses were responsible for completing the form. The code blue review is held during the shift in which the code occurred to encourage staff members who participated in the code to share their feelings of what went well and what requires improvement. An important component of this process is the shared chaplain’s experience with the family, whether they were in the room during the code or had decided to wait in the family room. This is also the time to provide positive feedback to everyone involved and identify any learning opportunities or process issues. Management reviews all code review forms to provide additional positive feedback and/or follow-up with individuals who had an emotionally difficult experience. Evaluation/Outcomes: 100% of our charge nurses were trained in code review requirements. Since the initiation of the program, 149 codes were called in the MICU and 50 reviews have been held. Staff has voiced their appreciation for the opportunity to share their emotions and experience, and receive recognition of their work.

Peer Evaluations in the PICU

Hassett M, Daugird D; Duke University Medical Center; NC

Purpose: To provide better feedback from peers through a shared governance model for peer evaluations. Description: In order to enhance the organization’s staff evaluation system, a Peer Review Board (PRB) was developed, with a staff nurse as the coordinator. The PRB coordinator and nurse manager then recruited staff nurses to be members of the peer review board. The board reflects the staff composition by considering shifts, expertise and clinical ladder status. Annually an evaluation packet is sent to all staff to complete a self-evaluation. Two peers are also selected for each staff member to complete peer evaluations. The review board meets as a group with the nurse manager to discuss overall performance. The review board then divides into small groups to write each staff ’s evaluation. A final rating is determined by the PRB in collaboration with the nurse manager. One to 2 members of the board then meet with each staff to review the evaluation. The nurse manager meets with any staff member per request or if a developmental plan is necessary. Evaluation/ Outcomes: This program has added value to the evaluation process, by providing more meaningful feedback to staff from their peers. It also has improved team member’s accountability to each other for behaviors as well as clinical performance. In addition, it has shared the nurse manager’s work load to allow for more time to coach and mentor staff at the bedside.

Storytelling for Grown Ups: Narratives, a Component of Annual Evaluations

Mcclellan E, Hanna L, Elchos S; The Methodist Hospital; Tex

Purpose: Nursing narratives, a form of story telling, have been incorporated into the annual review process for all nursing staff. This is an opportunity for nurses to share a memorable experience where they believe they made a significant difference. These stories contain acts of heroism, grief and joy about patients, families, and staff members. Description: The Methodist Hospital is excited to be using narratives as a method to communicate the impact nursing has among patients and families to other nurses, team members in the hospital and the community. A review of nursing narratives reveals the complex environment of practice and perhaps more clearly outlines the role of nurses better than any textbook or job description. Literature about narratives suggests this is a powerful tool to reflect on practice, and potentially enhance knowledge and competency. It also serves as a communication tool providing nurse leaders an opportunity to view patient care through the lens of each individual nurse. These stories celebrating life, days of hard work and team coordination, have been extended beyond the scope of the performance review. Recently, the narratives, with staff ’s permission, have been posted to unit websites, appeared in the hospital nursing newsletter, and placed in the family waiting rooms. Evaluation/Outcomes: Ultimately, the narratives will improve patient care and change nursing practice. Nurses report that they enjoy writing the narratives and learn by reflecting on their practice. These stories assist with translating what nurses do everyday into objective measures in the evaluation process. The narratives are being updated on the unit Web sites weekly, monthly in the family waiting rooms, and have been included in the hospital nursing newsletter.

Critical Care Certification: Raising the Bar!

Tovar S, Erickson T, Braathen A, Brown S, Koch J, Shannon J, Stackhouse R; Mercy Medical Center; Iowa

Purpose: How could we increase the number of certified nurses in our adult critical care units? To show commitment to excellence in professional practice, the Critical Care Leadership Team sought to promote certification in the institution. Description: Historically, the 3 adult critical care units maintained a core group of certified nurses, equivalent to 10% (13/125) of the staff. Despite the financial reimbursement for certification fees as well as an annual recognition luncheon, the nurses did not acknowledge certification as a validation of expertise in clinical practice. The leadership team assessed staff interest in a CCRN review class. This event was scheduled in advance, allowing each unit to arrange staffing schedules for those interested in participating. Strategies to promote certification included CCRN review books available to staff, practice test questions posted in units and current CCRNs assisting staff with core review and registering for the examination. After the first few nurses obtained certification, the theme of “I can do it” was palpable in the units. A CCRN recognition luncheon was held and speakers included physicians, directors, and administrators congratulating the group on their achievement and presenting unit exemplars of the value of certification. Each CCRN received a CCRN bag, pen, and badge to display with their hospital ID badge. A DVD highlighting every CCRN was presented to the group. Each unit displayed plaques with names of the CCRNs in their area and included these accomplishments in unit newsletters. The pursuit to achieve certification continued as other staff became aware of the recognition of CCRN in the institution. Evaluation/Outcomes: Patients noticed the badges when cared for by CCRNs, providing an avenue for education on the value of certification. As of July 2005, 36% (45/125) of the critical care staff are CCRNs (>300% increase) and others are rising to the challenge by working toward their CMC/CSC certification!

Learning Research Together in a Hospital/Academic Partnership

Ballard N, Robley L; WellStar Health System/Kennesaw State University; Ga

Purpose: Conducting nursing research in a community hospital setting is distinctly different from that in a major medical center where resources, long-established research committees and protocols are a matter of form. This partnership was designed to streamline the process, learn from each other and develop reciprocal research relationships. Description: A qualitative research project, identified by the critical care CNS prompted formation of a partnership between the university and the hospital system. This presentation will address how the research project was conceptualized, how registered nurses in critical care (1) participated in education about the research process, (2) assisted with data collection, (3) participated in data analysis, and (4) how the expertise of nurses from academia and practice contributed to the success of the research endeavor. Evaluation/Outcomes: The final product of this partnership was the completion of a qualitative research project with significant findings for practice and manuscript submission. By-products of the partnership were (1) a new found respect on both the academic and clinical side for colleagues in a different arena, (2) an excitement about nursing research in the clinical arena, and (3) identification of a process to facilitate nursing research in the community hospital setting. The experience of these researchers can be illustrative of the potential for other cooperative scholarly endeavors between hospitals and local universities.

Teaming Up With Staff Nurses: Bringing Research to the Bedside

Cuipylo K; Winchester Hospital; Mass

Purpose: To stimulate staff in developing research studies from the questions that they ask. Description: Staff is continually coming to the CNS with questions that are potential research studies. With encouragement and support of the CNS, these questions are brought to the Director of Nursing Research. This Director acts as a mentor to the CNS and staff nurse as they develop the research study. The research study is broken down into manageable components. Each are given items to complete within a specific time frame. Weekly meetings serve to keep the energy level up and to move the research process along. The staff nurse gives monthly updates to the Nursing Research Council (NRC). Once the study is approved by the NRC, the CNS coaches and goes with the staff nurse when presenting to the IRB. The staff nurses then conduct the research study on the unit after presentations in staff meetings. The staff nurse researcher engages peers to actually carry out the research study. Evaluation/Outcomes: There have been 10 research studies approved by the IRB and 5 studies currently being prepared. Posters have been displayed during our annual Research Day showcasing the studies that have been completed. These have generated more interest and energy from the staff nurses to become more involved in research projects.

Dividing the Tasks: Doubling the Success! ICU Collaboration

Dickinson S, Dammeyer J; University of Michigan Health System; Mich

Purpose: The CNSs in conjunction with the educational nurse coordinators (ENCs) at the University of Michigan Health System needed to improve communication, standardization, education, and coordination of care across the ICUs. Inconsistent practice standards between units placed additional stress on nurses and confusion for interns and residents, especially when patients are accommodated in another ICU. We sought to standardize practices that traversed across all of the various medical and surgical ICUs to enable medical and nursing staffs to provide seamless, evidenced based care. Thus we developed a committee that would actively standardize practice across all of the ICUs called the “Clinical Critical Care Committee.” Description: An operational group was formed to standardize both nursing practice and the documentation. Many initiatives were developed and operationalized including; a nursing flow sheet combining best practices, CRRT flow sheet capturing charges, standard neurological assessments and emergency carts, medication concentrations with maximum dosing guidelines, and sedation protocols. Evaluation/ Outcomes: Nursing and medical staff state that standardization has increased confidence that there is less confusion about care initiatives, as well as, less medication errors. A retrospective review of 40 standardized nursing and CRRT flow sheets demonstrate consistent and more complete documentation in multiple ICUs. We conclude that it is possible to simultaneously enhance the quality of care and reduce errors in a large organization by modifying nursing practice using a collaborative approach.

CNS Use of Data From Staff Perception Survey of the Practice Environment to Influence the Development of Staff Nurse Education Programs

Haldeman S, Griffith C, Brush K, Martin A, Jones D; Massachusetts General Hospital; Mass

Purpose: The CNS uses several information sources to plan educational programs designed to address the learning needs of staff. The result from the Staff Perception Survey of the Practice Environment is a valuable source of data for identifying staff nurses learning needs. Description: Flourishing in close proximity to the patient experience and supported by a practice environment of high-quality patient care, the CNS subroles are founded on clinical expertise and systems thinking. More importantly, these subroles possess the interlocking spheres of influence critical to achieving the CNS mission of excellent patient care. Historically, staff nurse perception surveys have been used as common strategies for identifying the problematic patient care issues. A large academic medical center has implemented a novel approach to overcome the barriers and limitations of these traditional approaches. Each year a quality improvement approved survey is mailed to the home of each staff nurse. The staff nurse is asked to report perceptions of the practice environment, the frequency of common patient problems, the level of individual preparedness and the perceived access to the appropriate resources for managing the problem. The data are collated and analyzed for trends and themes across both the larger organization and for each individual patient care unit. To a unit-based CNS this data set, both qualitative and quantitative, demonstrates trends and responses to programs and initiatives that change over time. The CNS is well prepared to scrutinize the data and validate the findings as compared to other sources of data. Validation of this data source can be integrated from trends in healthcare, organizational patterns, sentinel events, staff morale, adequate staffing levels, can also be used to establish the core needs of staff nurses. Evaluation/Outcomes: The results of the Staff Perception Survey can be used in CNS practice to demonstrate and measure the impact of such initiatives.

Hi-Top Sneakers Improve Patient Outcomes

Bissonnette K, Rasmussen S; Roger Williams Medical Center; RI

Purpose: Mangement of the long-term mechanically ventilated and sedated patient presents many nursing care challenges. Maintaining skin integrity and proper body alignment became one area of concern in our critical care unit. A variety of commercial products were trialed to protect our patient’s feet, none of which were completely satisfactory. During a staff meeting, a suggestion was made to try hi-top sneakers as an alternative. Description: Initially, family members purchased hi-top sneakers for their loved ones, but this became stressful as they were difficult to find. We then contacted our purchasing department and they were able to stock a limited number of sizes. The use of these sneakers to protect our patient’s skin and provide proper foot alignment was found to be very effective, so our purchasing department started to explore other possibilities. After contacting several manufactures of sneakers, we found a company eager to support our idea and provide us with all colors and sizes of hi-top sneakers. Evaluation/Outcomes: To date we have implemented the use of hi-top sneakers on 30 patients resulting in no problems with skin integrity or foot drop. Families are pleased to be involved in the care of their loved one with the selection of their favorite color sneaker. Patients reversed from sedation have expressed their satisfaction with this intervention as they felt warmer and more comfortable. Physical therapy continues the use of the sneakers after the transfer from critical care to provide safe ambulation during rehabilitation.

Portable Teaching Aides Benefit Patients and Staff

Brames N, Kehrer L; Barnes-Jewish Hospital; Mo

Purpose: Many times it is not easy to understand a simple, commonly performed procedure. We found this to be a problem in our interventional radiology department. Patients having a Port-a-Cath (port) placed often do not understand how or where the port will be implanted or how it will be used. Many verbalize anxiety and fear about having a port. We also discovered that many of our newer staff members had not worked with ports before. The staff did not understand the differences between tunneled and nontunneled lines. We sought to implement a creative solution to meet the teaching and education needs of our patients and our staff. Description: We created a portable teaching board to address this problem. We drew an outline of a human chest, including major blood vessels, on a piece of foam-core poster board. We attached a real port to the drawing using Super Glue. We placed the port at its approximate insertion site into the body. We then covered the chest drawing with craft foam and cloth felt to simulate the overlying skin. We attached the “skin” to the foam board using Velcro for easy release and replacement. The teaching board allows patients and staff to visualize how the port is likely to appear from the outside. They can touch the board to see how the port and the tunneled line might feel under the skin. We can remove the “skin” to show how the physician implants the port in the body. We can also demonstrate how we access the port later for blood sampling and medication administration. Evaluation/Outcomes: The patients and staff members received the portable teaching board with enthusiasm. Patients now verbalize a better understanding of the procedure and appreciate the hands-on approach. Newer staff members also have a better understanding of the differences between tunneled and nontunneled lines. We find this portable teaching board to be an effective teaching method for both patients and staff.

Identifying Patients ‘At Risk’ for Acute Alcohol Withdrawal: An Evidence-based Practice Change

Brown D; Hoag Memorial Hospital Presbyterian; Calif

Purpose: Overlooking potential for alcohol withdrawal syndrome (AWS) can have devastating consequences for critically ill patients and have an unexpected impact on intensity of nursing care. Obtaining accurate initial assessment data on alcohol usage is essential in dealing with this problem proactively. CCU nurses on the Nursing Research Council sought to improve the alcohol usage questions on the admission history form. Description: Evidence-based admission assessment questions were reformulated to better identify patients in whom AWS may factor into the plan of care. The goal is to detect alcohol withdrawal as a causative factor in any ineffective coping behaviors thus enabling interventions that are more timely and specific. The alcohol use history questions include frequency and quantity of regular alcohol consumption, most recent intake and concern that not being able to drink may be stressful. Poster presentations and a hospital Intranet PowerPoint presentation were developed to educate nurses about the practice change using a case study approach and emphasizing the supporting evidence and rationale. Nurses were directed to initiate the problem Potential for Ineffective Coping related to alcohol withdrawal according to specific responses to the assessment questions. In our electronic charting patient problem screen, clicking on Show Reference brings up a Focused Standard for Ineffective Coping including expected outcomes and interventions. Evaluation/Outcomes: Nursing Research Council members were committed champions of this practice change. Patients are being identified at risk for acute alcohol withdrawal with increased awareness and this is communicated in shift report and in daily rounds with the intensivist, as well as on the daily goal sheets. Project members are working with Information Services to flag patients “at risk” according to the assessment answers and automatically trigger the potential problem in the plan of care.

Pulling Out All the Stops: Conquering Postoperative Constipation

Damian A, Ochoa L, Griffin R; Barnes-Jewish Hospital; Mo

Purpose: Postoperative constipation is related to many factors including general anesthesia, narcotic analgesics, decreased activity, poor hydration, altered diet with low fiber, and medications such as iron supplements. In our thoracic surgery patient population, we had little patient education by nurses about the importance of taking prescribed stool softeners and laxatives when also taking narcotic analgesics. The problem of constipation continued after discharge with distress calls from patients about their discomfort. There were even several readmissions for small bowel obstructions due to bowel dysfunction. Although the literature focuses on constipation in the oncology population that takes opioids to relieve pain, there is little research on constipation in the general surgery patient population. Description: We used a multipronged approach to address this problem. We educated the nurses about the importance of giving the patients the prescribed stool softeners and laxatives when giving narcotic analgesics. We paid attention to hydration to be sure that patients receive sufficient oral or intravenous fluids. We taught the patients about the importance of taking stool softeners and/or laxatives. We gave details about nutrition, hydration, and activity strategies as they relate to overcoming constipation and promoting postoperative healing. We explained how abdominal discomfort due to constipation aggravates postoperative pain. We reminded both the physicians and the advanced practice staff to prescribe sufficient laxatives at discharge. Evaluation/Outcomes: Since we began this program of patient education we have had no readmissions for postoperative bowel dysfunction. Our patients are happier because they have better pain control with fewer side effects. They are more likely to participate in their home activity regimen if they are pain-free and have normal bowel patterns. We are proud that our thoracic surgery nurses are engaged in a proactive role in discharge planning for home care.

Pharmacology in the Pediatric During Emergency

Egman S; IsMeTT- UPMC- Italy; Iowa

Purpose: Understanding the difference in treating pediatric patients is essential to provide medication in safe doses. This is especially true in an emergency, when medications have to be provided quickly. Therefore, the pharmacists prepare a sheet for each child that is admitted, with appropriate doses of emergency medications for their weight. Description: The main goal is to provide the nurses and physicians with a reference that lists safe doses of emergency medications for the child’s weight. The sheet contains all emergency medications as well as the proper doses of intubation medications. The sheet is placed in the patient’s room in a visible location, and it stays with the child if he or she is transferred. Evaluation/Outcomes: The nurses and physicians are familiar with the resource of the medication sheets and have found them useful in situations that require quick reaction. The hope is that the nurses will become so familiar with these fact sheets that they will immediately reference them in critical situations and diminish the response time.

Who You Gonna Call? Making a Critical Response Team a Reality in a Small Community Hospital

Gooding M; Seton Northwest Hospital; Tex

Purpose: Patients often have several hours of instability or deteriorating status before an emergency situation exists. Our goal is to target these patients and intervene early to stabilize their condition. Our 113-bed community hospital faced many obstacles in trying to successfully initiate a critical response team (CRT). We developed an advanced assessment team of experienced critical care responders to assist staff RNs in assessment of patients with a change in status. Description: Our ICU manager met with other department managers and with ICU, ER, and respiratory (RT) staff to create a CRT response plan specific for our hospital. Concerns included minimal staffing, safe patient care while ICU and CRT responders are off the unit, and plans for when the ICU staff is unable to respond to CRT calls. The CRT ICU nurse is available by phone. The ICU unit manager, night shift supervisor, ER charge nurse, IMC, or RT staff are alerted by phone as needed either for possible short-term ICU coverage or to respond to the CRT when the ICU cannot. As a resource, ICU staff created a CRT book with copies of hospital emergency protocols, ACLS algorithms, chain of command information, and SBAR (Situation, Background, Assessment, Recommendation) report prompts. Evaluation/Outcomes: A written form was created showing why a CRT was called, interventions, outcomes, physician response, and whether transfer to a higher level of care was needed and then ordered by the physician. Periodically, all staff involved in a particular CRT meet to critique and learn from what was done and to discuss what might have been done differently. Indications thus far are that the CRT program has decreased the percentage of codes in the noncritical care areas of the hospital and improved collaboration between hospital units.

Using MAGIC to Promote Evidence-Based Practice and Reduce Ventilator-Associated Pneumonia

Grumme V, Boothe C, Birmingham C, McCall P, Millheiser D, Manning F, Neshkoff L, Levine J, Rivera J, Silverman L, Findeisen D, Bassin B; Memorial Regional Hospital; Fla

Purpose: To incorporate current evidence-based practice in a standardized plan of care for all patients receiving ventilation in the ICU to reduce incidence of ventilator-associated pneumonia (VAP). Description: Using our hospital’s MAGIC (Measure, Assess, Generate, Implement, Check) quality improvement tool, an assessment was made of our prevalence of VAP in the MICU/CCU and SICU and compared to national benchmark. Current literature and guidelines were reviewed and a mandatory inservice was created for the ICU staff. The AACN Practice Alert for VAP was also distributed and reviewed with staff. A QI data collection tool was created for daily rounds, which included HOB elevation, oral care, PUD (stress ulcer) prophylaxis, DVT prophylaxis, and daily sedation vacation for evaluation of weaning readiness on all patients receiving ventilation. Additionally, CASS endotracheal tubes for subglottic secretions were made standard for the ICU. Evaluation/Outcomes: Compliance with the “Ventilator Bundle” is evaluated and reviewed monthly at staff meetings. VAP rates are published monthly against benchmark and have shown marked reduction in the first 6 months of our initiative. Posters with our MAGIC theme are updated monthly in the department to share our success and motivate staff. As we celebrate our success, we are constantly evaluating all aspects of care of patients receiving ventilation to continue to reduce our VAP rates.

How Sweet It Is— Implementing a Tight Glycemic Control Protocol in an Urban Tertiary Medical ICU

Halash C, Mclellan B, Patten S, Brown G, Mlynarek M, Corpus K, Price N, Phillips L, Hoff H, Smith D; Henry Ford Hospital; Mich

Purpose: To design and implement a successful protocol for tight glycemic control in MICU patients that could be applied to all ICUs. Also, to decrease morbidity, mortality, and length of stay (LOS) by implementing stricter glycemic control (80–110mg/dL) in MICU patients. The intention was to foster a culture of safety based on a consistent and standardized protocol for all ICU patients. Description: We are all aware of the benefit tight glycemic control has in critically ill patients. However, for the MICU population, there is a lack of data for such tight control. The MICU at Henry Ford Hospital has been using TGC protocols for more than 2 years. Protocols were developed and implemented with limited success. Staff was presurveyed to target problem areas and to evaluate understanding of the current protocols. An interdisciplinary collaborative team was formed to redesign and standardize the protocol for the 5 different ICUs (124 beds). The team used a PDCA approach to revise the protocol. Process measures tracked were glucose readings, percent of readings below 50, and daily compliance with the protocol. Implementation involved reeducating staff on the new tighter protocol with a focus on pathophysoiology of hyperglycemia, and sharing specific evidence-based findings for the MICU. Daily interdisciplinary rounds addressed compliance with the protocol on every patient. Compliance audits were completed to evaluate the progress and for process improvements. Evaluation/Outcomes: A multidisciplinary PDCA approach to TGC in MICU achieved our goals. Overall, the percentage of glucose readings between 80–150 mg/dL has increased from 27.1% to 67.35% with only a 1.15% incidence of glucose readings below 50. The incidence of LOS decreased by 14.6% or by 0.67 days. An additional outcome was our BSI rates decreased by 65% in the last 6 months.

I Want to Be Sedated! A Sedation Protocol for Patients Receiving Mechanical Ventilation to Prevent Oversedation

Harrison D; Harborview Medical Center; Wash

Purpose: A standardized sedation protocol is essential in preventing oversedation in patients receiving mechanical ventilation. Description: Mechanical ventilation is often necessary for patients in the ICU. Adequate sedation is often difficult to achieve without oversedating a patient. There are also comfort issues due to the ETT, high-frequency rates with low tidal volumes. Proper sedation and analgesia can ensure the patient more comfort and help in healing without oversedating. Deciding on the type of sedation, how much to give, and how often, changes with each physician who orders medications. Having a standardized protocol for sedation and analgesia is helpful for new residents and attending physicians. Before starting the protocol, the ordering physician is referred to a flow sheet to assist in selecting the appropriate sedation and analgesia for the patient. There are 2 choices of analgesia, sedation, and 1 antipsychotic. The protocol gives exact doses and frequencies of bolus doses and the initiation of a medication drip if the boluses are not effective. Pain can be rated on a numerical rating scale or by physiologic descriptors. Sedation is graded on a Modified Ramsay Scale. The sedation goal is that the patient is able to open his or her eyes when asked or stimulated. A sedation vacation is ordered every morning to evaluate sedation and decrease the amount they are getting if possible. This allows for spontaneous breathing trials to be performed every morning. Evaluation/Outcomes: All patients receiving mechanical ventilation are placed on the sedation protocol. The protocol takes the guessing out of ordering proper sedation for these patients, which in turn prevents patients from being oversedated.

Parental Satisfaction Increases With Involvement in Bedside Rounds

Jarvis D, Woo M, Moynihan A, Levin D; Childrens’ Hospital at Dartmouth, Dartmouth Hitchcock Medical Center; NH

Purpose: To determine if rounds done with families at the bedside affected patient care and increased satisfaction. Rounds have occurred outside of the patient’s space and out of family hearing for most of rounds history. We undertook a change in 1999 to incorporate the family at eye level to bring them into the discussion. Many papers have been published showing families need information about their child’s treatment and prognosis, and that care ranks highest in “needs assessments.” Description: This is a prospective descriptive study without the use of a control group. A 16-question survey was distributed to 41 families both in the unit and after discharge to analyze whether being part of the rounds process increased their participation in their child’s care and increased their satisfaction. Anonymity was ensured and verbal consent was received. None declined to fill out the survey. In addition we have been collecting discharge satisfaction survey comments for added information. Results were tabulated and comments were analyzed for content, but not subject to statistical analysis. Evaluation/Outcomes: Parents were mostly supportive of involvement in decision making for their child with the most common response (with a mean response of 4.8–4.96/5) around knowledge of their child’s history and health, opportunity to offer input, asking questions, and being part of the discussion. Most family members were very supportive of rounds at the bedside and being a larger part of the discussions regarding their child’s care.

PICU Nurses With Specialized Skills Help Minimize the Length of Time It Takes to Place Patients on ECMO

Scafidi L, Johnson D; Children’s National Medical Center; DC

Purpose: Rapid deployment extracorporeal membrane oxygenation (RD-ECMO) was instituted in October 2004 to improve the outcomes of patients in respiratory and cardiac failure/arrest by expediting cannulaltion and the initiation of bypass. The demand for immediate OR assistance and supplies in RD-ECMO cases and their inability to respond quickly created the challenge to duplicate part of the OR nurse role. PICU nurses trained to be circulating, and scrub nurses in emergency bedside surgery became part of the RD-ECMO team to further facilitate this process. Description: The PICU in conjunction with the OR nurse educator developed an education program highlighting training in specialty supplies kept in an OR cart maintained on the unit, identifying and passing instruments, sterile technique and the use of a bovie and headlamp bought by the PICU. Teaching was in the form of in-services and classes that targeted all PICU nurses. Evaluation/Outcomes: Since October 2004, 55 nurses (80%) work with the OR cart, which has been available at 100% of the 18 RD-ECMO cases. Making these supplies quickly accessible to the surgeon has shortened response time. Since June 2005, 26 nurses (38%) have completed the course and 4 have scrubbed into the all of the last RD-ECMO cases affording the opportunity for immediate cannulation upon the surgeon’s arrival. The average time to ECMO has gone from 2 hours to <1 hour in the past 10 months. Time wasted waiting for OR assistance and materials has been alleviated by adding this new skill set to the PICU nurses repertoire. Sponsored by: Children’s National Medical Center, Washington, DC

Innovative Management of the COPD Patient: Incorporating Pulmonary Rehabilitation Strategies to the In-Patient Setting

Livesay L, Warren M; St. Luke’s Episcopal Hospital; Tex

Purpose: Pulmonary rehabilitation is a multidisciplinary program of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy. Because of the established clinical effectiveness of pulmonary rehabilitation strategies in the outpatient setting, our institution felt it was worthy to begin these strategies in the inpatient acute care setting. A multidisciplinary team was formed to develop, implement, and evaluate an inpatient acute care COPD pulmonary rehabilitation program. Outcomes measures included length of stay, cost per case, readmission rates, and patient satisfaction. Description: A protocol outlining the components of the program and the roles of all key players was developed. Upon ordering of the protocol by a physician, the patient received a focused teaching session regarding disease management from both the RN and RT. Physical and occupational therapy was consulted for endurance training and breathing techniques to manage dyspnea. Case management was consulted for discharge planning. Care was coordinated and communicated via a multidisciplinary progress sheet that was located in the physician’s progress note section of the chart. Education on the protocol and general COPD management was provided for all disciplines on all shifts. Evaluation/Outcomes: When compared to a control group, length of stay and cost per case were decreased and the readmission rate was 66 % lower in the group that received pulmonary rehabilitation. Patient satisfaction scores were high in those patients who received rehabilitation. The multidisciplinary team reported increased communication and coordination of care as a result of the multidisciplinary communication sheet. Though statistical significance was not present, incorporating elements of pulmonary rehabilitation into an in-patient comprehensive program yielded positive outcomes in the COPD patient population.

Freezing Frenzy: Induced Hypothermia After Cardiac Arrest

Kupchik N, Balmer S; Harborview Medical Center; Wash

Purpose: In Seattle, approximately 60% of patients admitted for pre-hospital, nontraumatic cardiac resuscitation never awaken. Recent studies have shown that mild hypothermia induced after resuscitation from cardiac arrest may improve neurological outcomes. A hypothermia protocol was developed and implemented at our facility in hopes of preserving neurological function. Description: In 2002, a hypothermia protocol was developed and successfully implemented for resuscitated cardiac arrest patients who remain comatose. The protocol has been adopted as a hospital-wide standard of care. Standing order sets were established and revised on the basis of feedback from the nursing staff. Efforts are made to cool patients as early as possible. Patients are cooled using a noninvasive, body surface temperature cooling device, and paralytics and sedation are administered to prevent shivering. Core temperature is monitored using an esophageal probe. Once the goal temperature of 33°C has been reached, the paralytics are discontinued. Electrolyte levels are monitored closely as potassium levels may drop precipitously as patients are cooled. Bleeding times are also monitored closely because of the potential development of coagulopathies. After 24 hours, or if the patient awakens, the protocol is discontinued and patients are allowed to rewarm passively. Evaluation/Outcomes: Having an established protocol and standing orders have standardized the care of postarrest patients.

Effect of Oral Care Policy on the Nursing Practice in Intensive Care and Progressive Care Units

Lewis L; Carolinas Medical Center; NC

Purpose: To use evidence-based practice model in the evaluation of the current oral care policy with regard to mechanically ventilated and unconscious patients in critical care units. Description: Current oral care policies were reviewed and found to be open to interpretation leading to lack of clarity, decreased compliance, and incomplete documentation. This was reflected in the quality assurance scores. The majority of nurses were not suctioning the oral cavity frequently enough, or using Chlorhexidine rinse consistently. A literature review was conducted to determine the evidence-based practice for oral care. On the basis of this information, the current oral care policy was revised. Next, we educated the interdisciplinary staff of the ICUs as well as the pharmacist. Finally, we repeated the survey to reevaluate the oral care nursing practice documentation as well as to review quality assurance scores. Evaluation/Outcomes: By understanding the link between hospital-acquired pneumonia (HAP) and oral care, the bedside nurse was able to follow the oral care policy leading to a decrease in patients’ risk of HAP. Nurses’ ability to follow policy by obtaining information related to evidence-based practice improved the performance of oral care. The nurses’ actions are based on the research evidence, resulting in practice changes at the bedside. The updated policy benefits patients by decreasing the incidence of HAP while increasing patient comfort. The correct use of Chlorhexidine saves nursing time and hospital care costs plus decreases the chance of plaque buildup or staining of patient’s teeth. Nursing staff have increased knowledge of the interaction between Chlorhexidine, toothpaste, and Nystatin. The staff and patient benefit from the current evidence-based role of oral care for ICU patients.

What’s That Beeping Sound? Patient and Family Education Related to Intensive Care/Step-Down Care Unit Equipment

Moran M, Macklay H, Orgill M, Fiddler J, Davideck A, Moneke N, Hubisak J, Ward A, Jordan M, Forbes V; The New York Presbyterian Hospital-Weil Cornell Medical Center; NY

Purpose: Staff members identified that patients and family members often express anxiety related to the various types of equipment and alarms in the critical care areas of a large, urban teaching hosptial. No written resource was available for reinforcement of verbal education provided at the bedside. A reader friendly, brief, informational brochure related to critical care equipment was developed and distributed to patients and family members in the critical care units throughout the hospital. Description: A committee with nurse representatives from the CCU, burn ICU, burn step down unit, surgical ICU, medical ICU, and cardiothoracic ICU met and discussed the following aspects of brochure development: requirements for format of the prospective brochure; equipment requiring inclusion; use of color digital photographs; and analysis of readability of text. Committee members were assigned components for brochure text development and to obtain digital photographs of actual equipment currently in use in the critical care units. Drafts were reviewed and revised at committee meetings. Final approval was obtained through the Hospital Nursing Council for Patient Education. The new pamphlet titled “What’s That Beeping Sound?” was distributed to patients and family members along with an evaluation tool. Evaluation/Outcomes: Positive feedback was received from patients and family members as well as saff members. After review of of the evaluation tools (190 respondents from 6 separate units), 99%–100% of nurses, patients, and family members rated the text and illustrations as current, accurate and purposeful. 90% of patients and family members described the brochure as “informative.” Effectively informing patients and family can decrease anxiety and increase comfort levels in a highly technological environment at a very stressful time.

An Interdisciplinary Process for Development of an Adult Behavioral Pain Scale for Nonverbal Critically Ill Patients

Mangan D, Krueger B; Mayo Clinic-Saint Marys Hospital; Minn

Purpose: Nurses and physicians in a pulmonary vascular surgical ICU recognized the need for (1) a valid and reliable means for assessment and documentation of pain for surgical patients who are not able to communicate and (2) the development of a surgical pain order set to facilitate effective interdisciplinary pain management. Description: Pain is a complicating factor in critical illness. Effective pain management can only be achieved with accurate pain assessment. However, this is difficult in critically ill surgical patients who are often unable to communicate verbally due to the presence of endotracheal/tracheostomy tubes, sedation, and paralyzing agents. Nurses therefore rely on behavioral and physiological indicators to establish the presence of pain. Interdisciplinary ICU staff identified a priority clinical research focus of accurate pain assessment, consistent and comprehensive documentation of patients’ pain, improved pain management, pain protocol development and pain outcome measurement. The first priority was the development and implementation of a pain assessment tool to facilitate accurate, comprehensive and objective assessment and documentation of a patient’s pain. The Adult Behavioral Pain Scale (ABPS) was developed and is being tested for validity and reliability through an IRB approved research project. This poster will present, in story board format, the process for development of four domains for adult behavioral pain assessment. The ABPS assessment categories include Face (Expression), Activity (Movement), and Respiratory Rate/Ventilation. Three additional pain control outcome measurements will also be shared. Evaluation/Outcomes: This interdisciplinary evidenced based approach to pain management has had a major positive impact on interdisciplinary communication and collaboration in ICU patient care. Preliminary research data indicate great potential for the ABPS as a valid and reliable assessment scale.

Helping Kick the Habit…“The Quit for Life” Program

Diehl R, Erickson C, Mehlbrech M; VCU Medical Center; Va

Purpose: A retrospective review of medical records of patients admitted to our cardiac unit revealed a deficiency in tobacco dependence assessment and cessation education. With tobacco assessment and cessation education an important aspect of clinical care as well as a priority for the JCAHO, a clinical nurse developed and implemented a “Quit for Life” tobacco cessation program. This program allows the staff to develop a greater knowledge of tobacco cessation education as well as enhance the clinical care provided to our patients. Description: The “Quit for Life” program includes a team of tobacco dependence cessation nurses, a tobacco dependence admission assessment form, a patient identification system using smiley face magnets to identify patients ready to quit and smiley face pins to identify patients who received cessation education, a tobacco dependence cessation educational packet, individualized one on one counseling and a follow-up phone call for support. In an effort to help newer nurses become involved in patient education and quality assurance, this group of twelve nurses developed the “Quit for Life” team. The chair, an experienced clinical nurse, organized a group to develop the goals of the program and educated each member on tobacco dependence cessation using “Treating Tobacco Use and Dependence In Hospitalized Smokers” produced by the Center for Tobacco Research and Intervention University of Wisconsin Medical School. The rest of the staff was then educated on how the program would work and how they could contribute to its success. Evaluation/Outcomes: Retrospective medical record reviews now reveal that 100% of patients admitted to the cardiology unit are assessed for tobacco dependence and smoking cessation education is documented including both the patient’s readiness to learn and preferred method of learning. The staff nurses on the “Quit for Life” team continue to be energized about the program and orient new staff to the program.

The Development of a Nurse Driven Pediatric Wound Assessment Tool (WAT)

Cambron G, Miller B, Moushey R, Rosenthal P, Seigel J, Strombach K; St. Louis Children’s Hospital; Mo

Purpose: The number of wounds has increased in the pediatric population. Contributing factors include increased life span of chronically ill children, extensive surgical procedures, prolonged ICU stays and decreased clinical resources at the bedside. Description: A Wound Skin Team was developed to review the current practices in wound care to meet the clinical needs of a growing population. The team identified challenges in providing optimal wound care including conflicting terminology, multiple wound care products at the bedside, inconsistent documentation, and lack of communicaiton. The team developed the WAT to standardize the treatment of wounds and simplify documentation. WAT content includes a glossary of terms, description of wound, products used, child’s response to treatment and pain score. Evaluation/Outcomes: Nursing staff completed a learning packet on use of the WAT in 2004. Nurses who attended the WAT educational program in 2005 implemented the tool on their units. Nursing attendance is required for the WAT educational programs in 2006 Implications: Nursing approval is integral to the successful implementation of the WAT. Results from a survey that measures nursing satisfaction with the use of the WAT are pending. Conclusion: Multiple wound care products at the bedside are costly and confusing to staff and caregivers. The team developed the WAT to standardize the treament and documentation of wound car. Use of the WAT for wound care is a sinigicant step in promoting the well being of a child.

Web-Based Education Is “On Demand” for Heart Surgery Patients

Norman V, Barnes M; St. Joseph Hospital; Calif

Purpose: Presurgery and postsurgery education allows patients undergoing open heart surgery to feel confident and helps in the recovery process. The cardiac liaison and the critical care nurses provide 1:1 education to our patients and families, but they may be unable to comprehend the information, especially due to the stress of this time. Providing additional open-heart surgery education via the Web allows access to the information when it is convenient for the patient and family. Description: Adult patients, who are undergoing open-heart surgery, both coronary artery bypass and valve surgeries, require a lot of preparatory education to help reduce stress and increase compliance. Generic educational materials are available commercially, but patients and families will have questions about their specific experience, so a handbook written by one of our critical care staff nurses was developed and put on our hospital Web site for patient/family to access when it is convenient for them. The booklet includes pictures of our hospital entrance, lobby and CV-ICU. Pictures taken in our unit with a “patient” complete with all of the equipment (eg, ventilator, IV lines) help to prepare the patient and family for what to expect. Phone numbers of departments and physicians on our staff are there for easy reference. Other topics include explanation of the surgical procedures, post-operative equipment, pain management, use of incentive spirometry and activity. Transfer from CV-ICU to the Telemetry unit is described. Postdischarge information on diet, activity, medications and a journal are included to supplement the cardiac rehabilitation phase of recovery. Evaluation/Outcomes: The educational material has been well received by patients, families, physicians and hospital staff. Physician offices provide patients with the website. Patients appreciate the reinforcement of the 1:1 education and the ability to access the information at home.

“Aspiration Prevention Audit Tool” in the Medical Step Down and Respiratory Care Unit

Pak M, Lukowski K, Hoffman G, Inchiocca R, Filetto A, Santora C; Stony Brook University Hospital; NY

Purpose: A large patient population is at risk for aspiration in the MSU/ RCU, with pulmonary aspiration of gastric contents the most serious complication of tube feeding. Aspiration is one cause of ventilator-associated pneumonia, which increases patient stay by an average of 16 days and costs the hospital about $30000 per case. A nursing initiative for quality care was undertaken to create a standard of care (SOC) to provide safe care and improve patient outcomes. Description: After reviewing evidence-based practice and the CDC guidelines, a SOC was developed. The SOC detailed 8 risk factors and 5 warning symptoms for aspiration, and provided 11 precautions to take against aspiration. To enforce the SOC, an Aspiration Prevention Audit Tool (APAT) was designed to generate data on the presence of risk factors and warning symptoms for aspiration in unit patients, and unit compliance with the recommended precautions. After inservicing the audit tool to the nursing staff, data on SOC compliance were taken daily throughout the patient hospital stay by observation, documentation audit, and inquiry. The CNS analyzed data and disseminated to the unit leadership and staff to reinforce compliance and education with the APAT to meet the SOC. Evaluation/Outcomes: The APAT found that all patients in the MSU/RCU were at risk for aspiration, because most patients had tracheostomies, received mechanical ventilation or enteral feeding, or a combination of the three. During 4 months, compliance with the precautions against the tool steadily reached near 100%. After this nursing quality initiative, no incidences of aspiration-induced pneumonia were reported in the MSU/RCU. The APAT was instrumental to increase compliance by identifying patients at high risk and providing aspiration precautions to reduce costs and improve patient outcomes and quality of care.

Yes, You Can Ambulate Patients With Chest Tubes to Suction

Petlin A, Becker C, Damian A; Barnes-Jewish Hospital; Mo

Purpose: Chest tubes are integral components in the care of thoracic surgical patients. Sometimes they have sustained air leaks (2 days to 2 weeks) after thoracic surgery due to the type of the operation or the underlying anatomy. Keeping the chest tubes to suction prevents accumulation of air and development of a tension pneumothorax. Removing suction puts patients at risk for either of these potentially serious complications. However, chest tubes interfere with the patient’s mobility that is so important after surgery. Wall-suction tubing to the chest drainage unit limits the distance that patients can walk away from their beds. Description: Early mobility helps prevent the complications of bed rest, increases patients’ strength and endurance, and promotes their preparation for discharge. We collaborate with both physical therapists and pulmonary rehab specialists to ensure that our thoracic surgery patients ambulate at least several times daily. In order not to limit walking distance to the wall suction tubing length, we worked with the vendor of our chest drainage system to find a reliable battery-operated suction pump. We connect the 11-lb (5 kg) pump to ambulation equipment or set it in the seat of a wheelchair. The pump allows the patient to remain connected to the prescribed level of suction. The patient then walks with the help of our nursing staff or our physical therapists. The 2-hour rechargeable battery maintains suction whenever the patient is walking, or when the patient leaves our unit for tests such as radiographs or CT scans. We surveyed the staff about the durability, ease of use, portability and battery life of this portable suction pump. The surveys were overwhelmingly positive. Evaluation/Outcomes: We now have a safe system to maintain chest tubes to suction while allowing patient mobility. We also use this portable pump when our patients walk on a treadmill in pulmonary rehabilitation. Having a chest tube air leak is no longer a barrier to early ambulation, physical therapy and rehabilitation.

Hand You a What? Finding the Right Instrument When Splitting a Chest

Reeves J; Missouri Baptist Medical Center, BJC Health System; Mo

Purpose: The CVR staff are expected to act as scrub nurses when opening a critically ill patient’s chest at the bedside. Because of the infrequency of the procedure, staff were nervous and hesitant to assist the surgeon. To promote confidence and improve the staff ’s knowledge, we needed to have a way for the staff to identify the procedure and instruments involved in opening a chest. Description: A CVR nurse with one of the scrub nurses from the heart team opened the chest splitting tray, to review the instruments in the tray. The scrub nurse then identified the instruments, labeling them and assisting the CVR nurse in taking pictures of the instruments. The procedure for opening a chest was reviewed and broken into section, similar to the ACLS algorithms. The pictures and chest splitting procedure were organized in a 1-inch notebook, with plastic protectors. To further assist, the chest splitting cart was arranged to follow the book. The book and a blue bin were placed on the top shelf with everything needed to initially open the chest. This prevented the staff from having to run around the unit or fumbling on the cart, looking for the items they needed. Once, the book, bin, and cart were organized, all the staff were in serviced and tested on the information. Evaluation/Outcomes: Evaluation is ongoing because of the infrequency of the procedure. Staff evaluation of the book, bin, and cart has been positive. The book is easy to use during the procedure; it can be held up and the pictures easily seen by the nurses in the sterile field. With new staff coming into the CVR, it has made it easier to teach them about the chest splitting procedure. The staff ’s confidence in assisting the surgeons has improved. The staff now review it yearly, for part of their CVR competency skills.

Impact of a Tight Control Insulin Protocol

Roderman N, Patel G, Farmer J; Medical Center of Plano; Tex

Purpose: The project was initiated to determine what impact a tight control insulin protocol would have on the average blood sugar of patients admitted to the ICU. Description: The impact of hyperglycemia in medical and surgical patients in the ICU is well documented in the literature. The incidence of infection, sepsis, cardiovascular abnormalities, neuronal injury, and mortality are all greater when hyperglycemia is present. Although the benefits of euglycemia with a tight control insulin protocol are well-known, it is not known whether these patients are subjected to significant episodes of hypoglycemia. A tight control insulin protocol was developed and approved by all relevant hospital committees after determining that the average blood sugar with the current tight control protocol was 151 mg/dL. The new protocol called for a target blood sugar of 81–110 mg/dL with an insulin continuous infusion. The nursing staff was educated on the titration mechanics and calculations. Monitoring parameters included number of patients who acheived target blood glucose and number of episodes of hypoglycemia. Evaluation/Outcomes: Patients’ blood sugar levels on the new tight control protocol were closely monitored from initiation of the insulin drip for up to 3 days. All patients monitored (18), except for 1, were maintained within the targeted blood glucose range of 81–110 mg/dL. Episodes of hypoglycemia, defined as a blood glucose of less than 60 mg/dL, were infrequent. Of 1031 blood glucose levels measured, only 34 (3%) were below 60 mg/dL. A tight control insulin protocol in the ICU allowed for patients to achieve and maintain euglycemia without subjecting them to significant hypoglycemia. Hypoglycemia has been perceived as a roadblock to initiating a tight control insulin program. The authors believe that with proper education, the clinical benefits of euglycemia can be reaped without hypoglycemia being an issue.

Critical Care Nurse Presentations During Bedside Rounds

Stafford A; Harborview Medical Center; Wash

Purpose: Interdisciplinary participation in physician rounds and planning patient care is of great importance to nursing staff in order to provide quality care and for overall satisfaction among nurses. Historically, in large teaching hospitals the resident physician is the primary contributor during morning rounds. Because of frequent changes in patient condition, erroneous information is commonly presented by the physician. The bedside nurse can often play an important and indispensable role in providing current information during rounds. Description: The SICU staff and the SICU medical director initiated a project to involve nurses in presenting patient information during bedside rounds. The medical director of the SICU identified specific data that would be presented by the primary nurse caring for each patient. Nurses were given a formal opportunity to provide the most recent information pertinent to planning patient care. Worksheets were developed to organize and reference information during their presentation. Data included vital signs, current hemodynamic values, ventilator settings, level of sedation and most recent lab results. The resident caring for the patient continued to present assessment findings and diagnostic test results. Evaluation/Outcomes: The process has greatly improved the accuracy of information discussed during morning rounds. Resident physicians have come to appreciate the benefits of collaborative daily goal planning. It has enabled better communication between nurses and physicians and has empowered nurses to play a more active part in planning patient care. The nursing staff in the SICU has verbalized an increase in overall job satisfaction and autonomy in their position.

Timely Patient Transfer Out of the ICU While Maintaining Cardiac Surgery Postoperative Glucose Control

Staul E; Legacy Health System; Ore

Purpose: Management of hyperglycemia in cardiac surgery patients has been demonstrated to reduce mortality and improve outcomes. We developed a protocol for transition of the patient from an intensive insulin protocol to a subcutaneous (SQ) insulin regime to enable timely transfer from the ICU while still maintaining glucose control. Description: We have been successfully using a nurse driven intensive IV insulin protocol in our ICU for several years. However, continuing the IV protocol on transfer to the cardiac telemetry unit was not practical. As the patient’s PO intake increased the intensive IV insulin protocol required multiple adjustments with frequent monitoring and patient glucose checks, creating patient dissatisfaction and increased nursing time. In the ICU, transfers were often delayed for patients on insulin infusion while we awaited endocrinology consultation. We developed a SQ insulin protocol to be used for the first 24 hours after ICU transfer on the basis of the patients’ insulin requirements in the ICU. Evaluation/Outcomes: Before development of the protocol the average capillary blood glucose (CBG) in the 24 hours following transfer from the ICU was 180 mg/dL for patients without endocrinology consult. The average CBG in the 24 hours following transfer from the ICU was 133 mg/dL for patients with endocrinology consult. Following the institution of the protocol the average CBG in the 24 hours following transfer from the ICU was 142 mg/dL. Despite tighter control of CBG in this period no patients had CBGs less than 80 mg/dL. The use of a subcutaneous insulin protocol to be used for the first 24 hours after ICU transfer on the basis of the patients’ insulin requirements in the ICU resulted in better glucose and control and more timely transfer from the ICU.

Leech Containment: Stop That Wayward Worm

Taylor J; University of Chicago Hospitals; Ill

Purpose: To identify a better means of containing leeches during leech therapy. Introduction: The characteristic leech bite creates prolonged localized bleeding and aids in reducing venous congestion that may threaten flap viability. Description: The burn unit provides care for patients needing flaps during reconstructive surgery. Flaps are the transfer of muscle, tissue and/or bone. In the past staff would apply leeches directly to the site. In subsequent applications we have used a cup, with a hole at the bottom, placed to the affected site to contain the leech(es). This method revealed that the leech was able to wander out of the hole to surrounding tissue. However, by simply, inverting the clear plastic cup and applying transparent dressings around the edges the leech was contained from wandering out from under the cup or under the edges. A window at the base of the cup was created and covered with another partial transparent dressing. Once fluid collected at the base, approximately 3–4 hours, the cup was rotated to another location and the leech (s) and the transparent dressing were reapplied. Evaluation/ Outcomes: Various attempts to contain the leech via use of the inverted plastic cup and transparent dressings at the edges proved effective in containing leeches at the affected site, thereby reducing patient, family, and staff anxiety. The use of an inverted cup is inexpensive and easily applied comfortably on a patient. This offers a simple solution to an age-old problem: stopping the wayward worm.

Saving Money and ICU Resources: Moving Stable Chronically Ventilated Patients From ICU to Acute Care

Unger N, De Guzman C, Oenning G; Harborview Medical Center; Wash

Purpose: In a climate of tight hospital budgets and increasingly ill patients, ICU beds always seem to be at a premium. Keeping the stable chronically ventilated patients in the ICU ties up important resources and contributes to frustrations among nurses and other providers. We describe the process one hospital initiated to move the care of certain stable chronically ventilated patients from the ICU to designated beds on a progressive care unit. Description: Initial steps included working on a multidisciplinary task force composed of critical care attending physicians and nurse managers, administrators, acute care clinical nurse specialist, medicine educator, respiratory care clinicians, the medicine attending physician, progressive care nurse manager, and assistant nurse managers. The task force defined the type of patients appropriate for the progressive care beds, developed policy and criteria for transfer, and identified barriers and needs for implementation. Responsibility for initial and on-going education for staff was assumed by the acute care clinical nurse specialist, medicine educator and respiratory care. Evaluation/Outcomes: During the 3 years of implementation, many chronically ventilated patients have been moved the ICUs to the progressive care unit saving the hospital valuable ICU resources and decreasing overall cost. Initially, patients from the emergency department were not included in evaluation for the progressive care beds, however, success of the program prompted the task force to expand the patient pool to include chronically ventilated emergency department patients admissions.

Making a Case for Induced Hypothermia After Cardiac Arrest

Warren M, Cushman L; St. Luke’s Episcopal Hospital; Tex

Purpose: Treatment with induced hypothermia for up to 24 hours has been shown to significantly improve the neurological outcomes and improve mortality in patients with primary cardiac arrest who remain comatose after return of spontaneous circulation (ROSC). A multidisciplinary team including physicians, advanced practice nurses, nurse managers, and pharmacists was formed to develop a protocol for induced hypothermia after in-hospital cardiac arrest. Description: A neurointensivist with experience in hypothermia lead the team’s efforts in developing a protocol that outlined inclusion and exclusion criteria and care of the patient based on the literature. First-year cardiology fellows who serve as first responders to resuscitation efforts were asked to initially identify appropriate patients. The CCU was selected to pilot the protocol on 4 patients. The purpose of the pilot was to gain experience with induced hypothermia in regards to the use of the protocol and assessing the patient’s physiologic response to cooling. The pilot also provided an opportunity to gain experience with advancing technology in cooling. Education on the protocol, concepts of hypothermia, and the new cooling devices was provided to the CCU staff. The team identified process and outcomes measures and was available to support the staff during the pilot period. Evaluation/Outcomes: The pilot was completed within 6 weeks resulting in positive neurological and functional recovery in 3 of 4 patients. Changes in the protocol were made to improve the flow of patient care and assist the nurses in carrying out the interventions. Process improvements related to pharmacy were also made. The pilot demonstrated that induced hypothermia after cardiac arrest is safe and effective. This practice is now being implemented house-wide as standard of care following cardiac arrest.

Just Chill Out: Facilitating Induced Hypothermia in a Small Community Hospital

Williamson J; Seton Northwest Hospital, Seton Healthcare Network; Tex

Purpose: Our ICU uses a protocol of induced hypothermia for management of coma postcardiac arrest. In addition we must be prepared to treat hyperthermic states, ie, malignant hyperthermia, neuroleptic malignant syndrome and heat stroke. To facilitate best practice, our goal is to cool these patients quickly and safely. Supplies need to be available on an emergency basis. We developed a prepackaged bundle which contains everything needed to start the cooling process immediately, including a copy of our protocols and a brief evaluation tool. Description: We reviewed our institution’s induced hypothermia protocol as well as treatment of malignant hyperthermia. On the basis of that information, we compiled a list of supplies that we need immediately to quickly and safely cool these patients. In a 2.5-gallon “Hefty slider” bag (zip-top) we placed a disposable hypothermia blanket, esophageal/rectal probe, lubricating jelly, 6 large ice bags, a spray bottle for misting with tepid water, and our “Induced Hypothermia” orders. Also included is a laminated flash card with a list of additional supplies that can be used and where to find them, ie, nasogastric tube, irrigation set and saline for iced saline lavage, fan, location of ice machines, where to obtain malignant hyperthermia cart and iced IV fluid from the surgery suites, and how to administer IV dantrolene for hyperthermia treatment per hospital policy. Evaluation/Outcomes: We have used our bundle several times for induced hypothermia and once in a case of neuroleptic malignant syndrome with severe hyperthermia. The nurses using the bundle report it has been helpful both as a timesaving measure as well as a clinical reference tool. Data from the evaluation tool help us fine-tune the implementation of the protocol and promote best practice.

Promoting CCRN Certification in NYPH Weill Cornell Medical Center

Moneke N, Parsons W, Moran M, Davidek A; New York- Presbyterian Hospital; NY

Purpose: To increase the number of CCRN-certified RNs in our medical center and to promote membership in AACN, thereby disseminating cutting edge critical care knowledge in the units. The NYPH, Weil Cornell Medical Center is composed of the coronary care unit (CCU), cardiothoracic intensive care unit (CTICU), medical intensive care unit (MICU), surgical intensive care unit (SICU), neurosurgical intensive care unit, burn unit, and the progressive/telemetry unit (PCU). Description: Before commencing the project, we calculated the number of CCRN in the units; the CCU had 7%, MICU, 3%; CTICU, 13%; and PCU, 0%. We conducted inservices to increase nurses awareness of the importance/benefits of CCRN certification. CCRN review courses were organized and an outside speaker was invited to conduct the review classes. Poster was presented during Nurses’ week, which highlighted NTI updates, AACN membership, and CCRN eligibility requirements. Nurses were encouraged to take the CCRN practice questions, which were installed on the staff learning computer. A Journal Club was created where articles pertaining to acute/critical care nursing was discussed and critiqued. Cram Review sessions were organized for those nurses preparing to sit for the CCRN Certification Examination. Evaluation/Outcomes: The number of CCRN-certified nurses has more than doubled in the CCU and there have been substantial increases in the other units. Many nurses are actively studying for the CCRN certification. More initiatives are being implemented such as CCRN review courses and group study sessions. We are encouraging more nurses to be CCRN certified. Our goal is to have more than 50% of the nurses in all the units CCRN certified by 2007.

Increasing Nurses Awareness of the Acute Coronary Guidelines for Patients in a Progressive Care Unit

Thomas T, Walsh R; Washoe Medical Center; Nev

Purpose: In patients diagnosed with acute coronary syndrome (ACS), aggressive medical management and education has been shown to improve patient outcomes. The purpose of this blended learning approach was to increase the awareness of the progressive care nurse using a focused educational plan. Description: Two nurse educators were assigned to assess the current quality of compliance to ACS guidelines and then develop an education strategy based on the findings to improve nurse awareness and compliance with established guidelines. Over a 2-month period several creative interventions were used: (1) posters depicting ACS guidelines, (2)development and implementation of an ACS caremap, (3) group in-services, (4) bimonthly cardiac team breakfast, (5) one-on-one in-services, (6) ACS caremap song (to the tune of the ‘Banana Boat’ song), (7) scrubs with logo “Have you charted on your ACS caremap today?”, (8) PCU newsletter, and (9) reward and recognition celebrations for improved compliance. Evaluation/Outcomes: Although there has not been significant improvement of the quality indicators for the ACS patient, the nurses have benefited by having an increased awareness on best practice for the ACS patient and implementation of standard of care. As a result of this education, nurses in the progressive care unit increased their documentation and individualization on the ACS caremap. There has also been increased collaboration between nurses and physicians in the form of conversation and patient rounds about the appropriateness of medications for the patients.

Grass Root Efforts To Impact House-Wide Tobacco Cessation Program

Warren M, Livesay S; St. Luke’s Episcopal Hospital; Tex

Purpose: One in 3 tobacco users will die prematurely of tobacco-related disease. The American Lung Association gave an F to Texas in the areas of smoke free air, tobacco prevention and control spending and cigarette taxation. Being a tertiary care hospital in Texas poses unique challenges in tobacco cessation efforts. A comprehensive program developed around the concept of unit-based tobacco cessation resource nurses (TCRN) was developed. Description: The tobacco cessation program incorporated the US Public Health Service Report’s clinical practice guideline for treating tobacco use and dependence and included patient assessment of tobacco use, patient education materials, and behavioral and pharmacological interventions. To assist with the implementation of the program, a unit-based resource nurse model was used. Responsibilities of the TCRN include assisting bedside clinicians in making appropriate tobacco use assessment and tobacco cessation teaching/counseling; assisting bedside clinicians in making referrals on a timely basis to other resources; participating in teaching and learning activities regarding tobacco cessation; assisting in the implementation of new programs related to the tobacco cessation; serving as data collectors for the assessment of tobacco use and completion of tobacco cessation teaching; providing at least two educational programs related to tobacco cessation for unit staff annually. Units identified staff interested in the TCRN role and a 4-hour workshop was provided to increase knowledge on tobacco use, tobacco cessation, and tools available at the hospital. Evaluation/Outcomes: As a result of the TCRN program, compliance with assessing and documenting tobacco use and providing and documenting education has improved by 78%. In addition, the TCRNs have been directly involved with ongoing quality improvement activities to improve the communication and documentation of tobacco use and education.

A Consortium for Critical Care Education and Training: It Takes a Village

Alvarado-Greer V; Veterans Administration Central California Healthcare System; Calif

Purpose: With hospital budgets being scrutinized, increased numbers of nursing education departments were being eliminated. A consortium was developed to meet the needs of Critical Care education. Description: The CNS received requests from other Central Valley hospitals to provide critical care education and training for their nursing staff. The training included 3 weeks of didactic, 2 days of skills lab, and 4 weeks of clinical preceptor ship. After 1 year the number trained grew from an average of 15–24 annually to more than 50. A proposal was developed to take to Central Valley hospitals offering participation in a Consortium of Critical Care education to the nurses of the Central Valley. There were 6 hospitals interested in this program with the AACN Critical Care Core training program used. It was decided the hospitals would rotate providing host hospital to provide a facility for the program and an individual to coordinate 3 programs for 1-year period. Nonprofit status was established for the Central California Critical Care Consortium with a program board made of representatives from each hospital. A bank account was opened for this Consortium in which to place funds made by the registration fees paid. The speakers for the programs were from nursing staff of the participating hospitals. For every speaker a hospital sent to speak at a program, the hospital received 1 voucher with a cash value of $800 toward the training of 1 of their staff. Evaluation/Outcomes: Every year up to 100 nurses are trained using this program, which has become the gold standard for this community. The Consortium has continued to meet quarterly to review curriculum, account balances and discuss progress with the host hospital. The cost to hospitals to train nurses has been greatly reduced by using this program. The Consortiums bank account has been in the black and has allowed this group to donate to AACN local chapter nursing scholarship fund.

Food for Thought: Educational Sessions Increase Awareness and Decrease Errors Associated With Insulin

Apter J, Mangum J, Mabrey M; Duke University Medical Center; NC

Purpose: Developing and implementing a diabetes education program in a cardiothoracic (CT) ICU and step-down unit was imperative for patient safety. With the increased use of insulin in the CT patient population there was an increase in adverse drug events. Insulin has had a high association with adverse drug events nationally. Many errors occur because of a lack of knowledge of diabetes and treatment. An education program was needed to address these errors. Description: The endocrine nurse practitioner and the CT clinical nurse specialist collaborated to address this problem. An extensive analysis of reported errors identified deficits related to order entry and transcription, administration of insulin, and nursing knowledge. A comprehensive program was developed and implemented to educate the staff on diabetes, care management issues, and safe use of insulin with the CT patient population. A series of 6 classes on diagnosis, insulin, oral medications, nutrition, discharge education, and patient care scenarios was developed with specific learning objectives for each. The classes were offered during staff lunch breaks where food was provided and were repeated to allow all staff to attend. Contact hours were awarded for attendance. Evaluation/Outcomes: As hoped, the timing of the sessions and enticements promoted staff attendance. A majority of the staff was able to attend one or more of the sessions. Monitoring of adverse drug events after the education program revealed a marked decrease in the number of events related to insulin administration. Attendees evaluated the sessions and reported increased knowledge they were able to incorporate into practice immediately.

Team Building Through an Interdisciplinary Journal Club

Baldwin-Rodriguez B, Dobson A; University of California Irvine Medical Center; Calif

Purpose: Comprehensive burn care requires participation and cooperation of many medical disciplines. A common challenge is to clearly understand the rationale and treatment goals for each different discipline involved. Committed to providing innovative burn care and promote team building, a quarterly journal club was organized to discuss best practice and evidence-based practice as it relates to the total care of burn patients. Description: The burn team consists of nurses, physicians, respiratory therapists, physical therapists, occupational therapists, dietician, pharmacist, social worker, chaplain, and case manager. One team member was identified to be lead organizer of the journal club to ensure consistency for all meetings. Once a current practice topic was identified a search of the literature was completed and 5 to 6 key articles identified. Two weeks before the journal club meeting, the articles would be e-mailed to each member of the team for review. Topics have included: “ICU Sedation with a Focus on Propofol,” “Family Presence during Procedures and Resuscitation,” “Post Traumatic Stress Disorder,” “Hot topics in critical care,” and “Optimal Multidisciplinary Care of the Burn Patient.” Participation from all members has been encouraged by assigning one individual to present a summary of one article during the journal club meeting. Evaluation/Outcomes: With major support from the nursing and medical leadership of the burn team there has been at least 20 participants, 42% of the burn team, at each of the 5 journal club meetings. Success of the journal club is evidenced by the high level of participation, continued enthusiasm of all burn team members, and discussion of the article content by team members before and after the journal club meeting each quarter. Practitioners state that reviewing the articles has influenced their practice and helped them to have a better understanding for interventions and treatments from other members of the team.

Wanted-CCRNs: Engaging a Culture of Certification

Beauford T, Baisden S, Fahey A, Metersky S, Dickerson L, Lanthorn C; Grant Medical Center; Ohio

Purpose: Striving for professional nursing excellence is a focus for the CCU. Our unit recognizes the importance of obtaining CCRN certification as an example of its commitment to the highest level of nursing care. With the support and financial assistance of our management team, a creative approach to promote CCRN certification was addressed. Description: A CCRN committee was formed to develop strategies to motivate and empower the nurses to successfully pass the CCRN exam. The first step was to build a CCRN resource library center, which includes study guides, CD-ROM practice exams, and audiotapes. Once a resource center was established, a campaign was launched to encourage nurses to attend CCRN review courses and “bring it back” to their peers. Preparation methods promoting the journey toward certification included study groups, CCRN jeopardy board, and CCRN prize box questions. To exemplify the importance of certification, yearly staff performance evaluations were modified to include goals towards certification. Rewards and recognition are a key component to obtaining CCRN certification. Nurses are celebrated by posted banners, pot lucks with specialty cakes, personalized congratulatory cards from the management team, addition of name to unit’s CCRN plaque, announcements in the “Kudos” section of the hospital’s newsletter, and certification pay differential. Evaluation/Outcomes: The CCRN campaign transformed the culture of our CCU to one of enhanced professional practice excellence. Forty percent of our nurses have obtained certification with a 100% first time passage rate. CCU has increased its percentage of CCRN-certified nurses from 25% to 40% over 12 months. Our goal is for all CCU nurses with 2 or more years of critical care experience to be certified by December 2006.

Dress Rehearsal for Critical Care: Using a Human Patient Simulator to Augment Clinical Thinking

Collins A, Edwards R, Graves A; Capstone College of Nursing; Ala

Purpose: Matching a clinical assignment to the level of the student, the available options, and the acuity of the assignments for a clinical group in critical care is a challenge. Each student wants a chance to learn the complex skill set required in critical care and the experience of working in high-risk situations. Use of a human patient simulator allows us to make sure that every student has additional exposure to high-risk, low-frequency clinical situations. Description: The 2 scripts used by the educators were on malignant hyperthermia and anaphylactic shock. Groups of 5 students entered the clinical lab and received index cards that outlined their designated role. Before their time in the laboratory, they were required to read and answer questions relevant to the nursing care of these situations. The simulator was programmed and activated to respond to the students’ interventions. Monitors displayed the real-time vital sign changes and assessment findings. The students were able to practice teamwork as well as “seeing” the results of their nursing decisions. The students also struggled to communicate and prioritize the interventions. Evaluation/Outcomes: Students believe that this experience is more engaging than other simulation methods because it is “close to the real thing.” There is also immediate feedback from the consequences of their efforts. Because nurses can practice for years in critical care and rarely see these particular high-risk/low-frequency events, simulation can be important to improve recognition and outcomes for these patients. Additionally, inclusion of this simulation improves the skills of teamwork and critical thinking. Our next step is to use this dress rehearsal method with additional critical care situations in orienting new staff. Some education challenges can be addressed through use of a human patient simulator.

Collaborating to Expand Skills Day Throughout a Medical Center

Connor K, Cady L, Sepulveda D, Akins J, Lombardo J, Yefsky J, Walsh C, Prochnow D, Macdonald K, Ladbury T, Zepeda M; Long Beach Memorial Medical Center; Calif

Purpose: Only the critical care units at this facility have completed annual skill validation separately or combined routinely. The decision was to expand the process to all general care areas. The challenge for the clinical nurse educators was to devise a collaborative plan to validate skills in 1100 licensed nurses in an efficient, comprehensive manner including safety and infection control education. Description: Five months before the event, each clinical educator, identified high-risk, low-frequency or problem prone skills for each area using the critical care units’ skill validation worksheets as a template. A spreadsheet with the specific skills/topics listed and which units needed to attend was compiled. The educators decided the skills/topics would be evaluated by direct observation, simulation, or post-test. The group identified the new policies or JCAHO /DHS items that should be included for the entire medical center. Each educator chose the stations for which they would be responsible and wrote behavioral objectives, modules, and post tests; staffed direct observation stations; and created posters. The Nursing Education Director developed the layout of 35 stations; color-coded and compiled the individual packets for each service. The CNSs collaborated by developing learning materials and manning stations. The respiratory care practitioners participated at the airway management/ventilator stations for adults and pediatrics. Staff nurses, vendors, organ procurement agency and ancillary staff also participated in the education. Evaluation/Outcomes: Seven 8-hour sessions and 2 additional makeup days were held during a 5-week period. The majority of staff finished in 5–6 hours depending on their learning needs and style. Approximately 120–190 nurses attended per day for a total of 1100 nurses by completion. The most important feedback was nursing reports of immediate use of the skills/knowledge gained.

Chocolate, Cookies and Nurses: A Fun Way to Introduce Research to Nursing

Crawford L, Balerno L, Cravener D, Dills S, Hamm L, Martin P, Nelson M, Ramirez A, Robertson D, Sutherland S, Woodard R; Mission Hospitals; NC

Purpose: Promoting a 2-fold goal of introducing staff nurses to the research process and having fun, the Nursing Research Council conducted a creative and interactive cookie experiment. Replicating a previous project, employees sampled chocolate chip cookies and evaluated 4 different characteristics. Description: The “Great American Cookie Experiment” was one of the planned activities for Nurses Week 2005. Advertising before the event was accomplished by displaying creative poster boards and flyers throughout the hospital. Brightly decorated carts filled with chocolate chip cookies and milk were transported to every nursing unit on both campuses and during all shifts. Staff members enthusiastically sampled and rated cookie “A” and cookie “B” for appearance, texture, moistness, and taste. A “bubble sheet response card,” completed by the participants, provided for easy evaluation and data tabulation. During the taste testing, council members shared information about nursing research and listened to research ideas from participants. Evaluation/Outcomes: Over 600 employees participated in the event. Data were analyzed by the hospital’s Performance Improvement and Research Departments. Results were communicated via an article in the organization’s Nursing Newsletter as well as during a special “Lunch-and-Learn” session that used the cookie experiment as the platform to discuss aspects of conducting nursing research. Overall, results were positive: nurses felt this experiment and follow-up session were creative methods for deploying education and information in a nurturing environment. The Nursing Research Council found the event to be an excellent way to introduce a large number of nurses to the research process.

Staff Nurses Starring: ICU Curriculum Classes

Davis D, Holtschneider M, Mostaghimi Z, Miller C, Mcbroom K, Newman M, Davis J, Bryan C, Onouha J, Superville J, Blackwell M; Duke University Health System; NC

Purpose: The ICU and progressive care units in our tertiary care hospital identified the need for improving education to new staff. Although orientation gave orientees the information to function safely and competently, we developed an additional plan to reinforce the core curriculum by specifically addressing the unique flow and care of our patient population. Description: In collaboration with the nurse educator, the unit preceptors presented a class in skit format designed to include care of cardiology patients representing various levels of acuity from admission to discharge. The skit began with a staff nurse playing the role of a patient from a different cultural back ground who was admitted with unstable angina. A discussion of cultural sensitivity ensued. Other nurses admitted, assessed the “patient,” and intervened as she became unstable. The “patient” was sent emergently to the interventional cardiac catheterization lab where she had an angioplasty and intra-aortic balloon pump (IABP) placed. Discussion regarding the angioplasty was lead by a cath lab nurse. The “patient” was then transferred to the CCU for further care. The skit included a preceptor teaching a new orientee the routine care for the patients with an IABP and a discussion of frequently used medications. The “patient” was eventually transferred back to the floor and discharged home. Evaluation/Outcomes: This unique teaching methodology not only encouraged interaction by both new and old staff but was entertaining, keeping the participants interested and engaged. ICU nurses better understood the care of patients on other units and the unique difficulties that staff nurses there might face. They learned about resources used on the other units that could be used in their own areas. Some voiced interest in floating to the other floors for experiences. Feedback from participants was resoundingly positive. Additional class days are currently being developed with different patient scenarios and skits.

Innovative Approaches to Continuing Education: Shop and Learn—“On the Bus to Chicago”

Szpara T, Labeske M, O’Brien D, Dickinson S, Glas J; University of Michigan Health System; Mich

Purpose: Facing the current challenges in healthcare delivery and tremendous changes predicted for the coming years, CNSs in partnership with educational nurse coordinators (ENCs) at the University of Michigan Health System needed to consider nontraditional approaches to meet the learning needs of critical care and perianesthesia nurses. Bedside nurses are continually facing the challenge of balancing patient care and meeting professional educational requirements. Traditional approaches to continuing education have diminished in popularity and value for today’s bedside clinicians. Innovative approaches to continuing education programs can lead to positive participation, improve retention and reduction in staff turnover, and strengthen partnerships among critical care and perianesthesia nurses. Description: CNSs and ENCs from the surgical ICU (SICU) and the postanesthesia care unit (PACU) met to evaluate options for creative continuing education programs. A total of 47 nurses from the SICU and PACU participated in an educational bus trip from Ann Arbor, Mich, to Chicago, Ill. Presentations included: “Eat, Drink, and Go To Surgery?” “EBP: The Driving Force Behind Establishing Optimal Clinical Practice,” and “Humor in the Workplace.” Food, fun, and 6 contact hours were provided to and from Chicago. Evaluation/Outcomes: A multiple session evaluation form was completed by each participant. 42 of 47 participants stated that the objectives related well to the overall purpose/goal of the program and the content was congruent with the purpose and objectives. Qualitatively, participants universally enjoyed the opportunity to learn and shop. As a result of this nontraditional educational endeavor, a vital partnership now exists between the nurses from the SICU and the PACU. This has positively affected interprofessional communication and nurse to nurse relationships.

Medication Assessment: Reject, Revamp, Rethink

Dixon J; Baylor University Medical Center; Tex

Purpose: A new hire general medication assessment is a common orientation activity that is part of an initial baseline competency assessment, meets various standards, and contributes to patient safety. Our institution uses a multiphase assessment including a written exam, learning modules, skills lab, and preceptorship. We were using a commercial written exam that required a raw score of 80% or greater to pass. Orientees often told us the medications on this assessment were not ones commonly encountered in practice. The raw score did not provide educators or preceptors with details on where to focus their efforts. Given these issues, we decided to construct our own assessment to reflect our practice environment. Description: The exam blueprint consisted of 2 major assessment components, calculations, and patient management. Prevalence and trend data from drug charges and medication variances determined medication/drug family selections. A clinical expert panel reviewed question stems and answer options. Each question has a key concept and a specific learning prescription including pertinent resources and references. If an orientee answers a question incorrectly, the learning prescription appears on an individualized profile each orientee receives and provides direction for educational efforts. Our goal was to move away from an exclusive focus on percentages and put greater emphasis on identified learning needs. Evaluation/ Outcomes: Six months after the July 2002 launch, 238 assessments were evaluated and the exam was revised as necessary. Through July 2005, more than 1000 new hires have taken this revision. Percentile rankings show the traditional passing score of 80% equals a very low percentile rank. Drug charges and medication variances are reviewed periodically to verify consistency with the current practice environment. Trends are shared with educators, preceptors, managers, and local nursing schools.

Use of a Learning Management System to Facilitate Education in Emergency Preparedness Principles

Eckert S, Donnellan J, Shamloo C; Washington Hospital Center; DC

Purpose: Use of a Web-based learning management system allows just-in-time training for large numbers of personnel on a variety of topics, including content on conventional and nonconventional disasters. Description: Educators continue to search for creative methods to educate practitioners on topics that enhance patient care, promote safety, and stimulate professional growth. In the post-9/11 era, increased emphasis has been placed on ensuring that healthcare practitioners have the knowledge and training to manage patients who may have been exposed to biologic, chemical, or radiologic agents. Sitel, a Web-based program, is a learning management system that allows practitioners to access content on relevant topics and test their knowledge. Reports of modules completed and staff participation may be automatically e-mailed to interested managers or educators. The site offers video clips and 3-D imaging of devices that allow exploration by the learner of all function keys and controls. The system accommodates flexible schedules of staff, large numbers of learners simultaneously accessing the site and provision of content by experts in the field. Although initially set up to meet the demands of enhancing preparedness of staff for disaster situations, its design has been flexible enough to add modular contant on any topic of interest. Evaluation/Outcomes: Our emergency preparedness committee tracked the number of modules completed by staff related to disaster planning/ content with the implementation of the system. The number of registered participants grew by 20% (from 2000 to 2400) during FY 2005. The number of modules completed also steadily increased throughout the year as staff became familiar with the system. 1009 modules were completed, an increase of 25% from the first quarter to the last quarter tracked. Use of a modular, Web-based, learning management system allows easy access for staff, tracking capabilities for educators/managers and provision of expert content in the field of emergency preparedness.

Designing a Hospital Learning Lab: Answering the Competency Question

Fleischman R, Napier K, Werstler J; Aultman Health Foundation - Heart Center; Ohio

Purpose: Competency assessment has become the answer to the loaded question of whether a facility can deliver a safe level of nursing care. Our coronary care unit is answering the question through the development of an innovative learning lab that supplements clinical skills with the already offered staff education program. Description: The learning lab simulates an ICU patient room outfitted with monitoring equipment where realistic situations can be enacted. These simulated appraisals require staff to actually perform as expected rather than merely verbalize knowledge. The lab is designed into skill stations based on identified needs. Each of the 22 stations has a standardized checklist where staff is scored on key criteria and evaluated as “expert,” “proficient,” or an “advanced beginner.” The newly purchased electronic manikin, tutorial CD-ROM programs, along with cardiac monitors and IABP simulators add to the learning environment. Evaluation/Outcomes: Evaluations reveal the revised CCU RN competency to be a positive experience. 100% reported the information covered at each station pertinent in providing “best practice” to the cardiac population. A 360-approach was used to determine what the nurses would like to see “more of,” “less of,” and “the same” for future competency sessions. The 1:1 experience with an expert clinician and the overall organization/content of the skills were identified as important to continue. On a scale of 1–10 with “10” being most satisfied, the average satisfaction score for the competency experience is 9.3. The learning lab also serves as a positive resource for new nurse orientations, postorientation mentoring, and preceptor skill development. Preceptors and mentors have been trained to teach skill stations during orientation when clinical skills have not been demonstrated or problem areas have been identified. Monthly station review sessions have also been implemented for ongoing staff skill development.

How Far Will Technology Take Us? The Nurses’ Role in the Successful Implementation of Field Telephonic Informed Consent

Haley T, Tatgenhorst D, Gaughran G, Saver J, Starkman S; University of California Los Angeles; Calif

Purpose: An early goal directed, ambulance treatment study can offer tremendous opportunity to improve patient outcomes, but requires a new process for obtaining research consent from patients. This report’s purpose is to describe required training and preliminary experience with a novel field telephonic strategy to elicit informed consent from the first 27 patients in a prehospital stroke trial. Description: Because the majority of acute stroke patients remain lucid, informed consent is conducted before study drug initiation. Cellular phones connect the paramedics to an enrolling physician who is a stroke neurologist. Given that the paramedic role has not typically included facilitation of consents, clinical research nurses, in collaboration with the emergency medical service (EMS) nurse educators, trained the paramedics in stroke recognition, facilitation of consent, and study procedures. Stroke recognition was taught using a standardized stroke screen, the Los Angeles Prehospital Stroke Screen (LAPSS). Facilitation of consent included training the paramedics how to access enrolling physicians 24/7. Only after completion of the consent process can paramedics continue with the study procedures. Given that the consent process is an ongoing responsibility, hospital staff were also trained. Evaluation/Outcomes: A team of 16 nurses trained 3000 paramedics and staff nurses at 21 hospitals. To date, 51 patients who met consent elicitation criteria were provided access to the enrolling investigators, and 27 (53%) were enrolled. Consent was obtained in a variety of locations, the patient’s home, restaurants and accident scenes. The prehospital consent procedure reduced paramedic arrival to study agent delivery time to a median of 25 minutes compared to 139 minutes in standard in-hospital acute studies. The authors’ discussions will include strategies for teaching the elements of explicit informed consent, outcomes of education and early study enrollment. Sponsored by: The prehospital stroke study, Field Administration of Stroke Therapy-Magnesium (FAST-MAG), is funded by a National Institutes of Health grant

Teach Them All: A Tiered Approach to Staff Education for an Artificial Heart Program

Hallinan W, Myers D; Strong Memorial Hospital; Univeristy of Rochester Medical Center; NY

Purpose: The use of ventricular assist devices has become a standard of care in many institutions for the treatment of cardiogenic shock. More than 200 000 patients annually can benefit from the use of short-term, bridge-to-transplant or lifetime therapy devices. The introduction of such technology can be overwhelming to many nurses. This often leads to many institutions using nonnurses such as engineers, perfusionists, or therapists to manage these devices. Additionally, a busy program requires the flexibility to care for patients in a variety of units as well as the community. The technology growth also requires frequent education and reeducation. To meet the demands of this type of program, a tiered level of training with a comprehensive education plan was developed that also includes promotional rewards for critical care nurses. Description: Nurses from the operating room, critical care units, floors, rehab units and consulting services all have unique education needs to care for patients with a ventricular assist device. A system of awareness level, caregiver level, user level and advanced operator level training was developed to meet these needs. Critical care nurses initially need to become credentialed to care for all 8 types of ventricular assist devices. Quarterly training, laboratory skills demonstrations or advanced classes keep them credentialed throughout a calendar year. Staff that have completed the education requirements and care for ventricular assist device patients then receive additional monetary compensation as well as become a candidates for promotion within the hospitals advancement system. Evaluation/Outcomes: This program has expanded the role of the critical care nurse, continuously promotes the value of nursing and rewards nurses for their efforts. Over 75% of the critical care nursing staff maintains full credentialing and it has served as a motivator for their involvement in first responder training and family teaching.

Simulation Training: An Innovative Way to Teach Critical Care Nursing Skills

Kappus L, Leon V, Lyons A, Meehan P, Hamilton-Bruno S; Childrens Hospital; Mass

Purpose: Using the resources of an onsite simulation suite, our PICU developed and implemented a simulator program that addresses specific learning needs of all levels of nursing expertise. Description: A meeting of nursing leadership staff was held to identify learning needs of staff amenable to simulation training. Learning needs identified were basic skills, communication skills, crisis resource management (CRM), and high-risk event review. From this meeting 2 programs were set up. The first is an Orientation Curriculum. New critical care nurses undergo 8 sessions of simulator training. The first 4 sessions focus on skill-based learning objectives. During the final 4 sessions, the orientees participate in critical event scenarios with critical care fellows that apply the skills learned in weeks 1–4. The second is a Continuing Education course. This is a 3-hour course with 3 scenarios that focus on competencies, communication, and advanced skills. During the first 2 scenarios, the instructor stops intermittently to focus on important teaching points. The third scenario focuses on CRM principles and includes a multidisciplinary critical care team dealing with a crisis. This scenario is videotaped for review during the debriefing session. Evaluation/Outcomes: In the first year, 98 (100%) nurses went through the continuing education program. Participants’ performance was evaluated during debriefing sessions. The debriefing sessions focus on self-reflection and experiential learning. This learning model allows participants to look back on the event and reflect on different aspects of their teamwork, skills and communication. Participants also filled out a survey after going through the simulation session to rate the program and ways to improve it. The debriefing sessions are the most commonly identified helpful aspect of the program. Reviews of patient codes reveal an overall improvement in team function.

Hot Topics in Critical Care: Enhancing Education Through Nurse and Physician Collaboration

Hoff K, Baldwin B, Espinoza M; University of California, Irvine; Calif

Purpose: Providing dynamic and state of the art critical care education presents a challenge within the nursing profession. Using a shared governance model, the critical care practice council at UCI Medical Center organized a day of presentations to enhance education within the adult critical care units and promote physician and nurse collaboration. Description: In order to provide a creative and interesting approach to critical care education a seminar was organized to update nurses regarding current trends in critical care practice. A nurse and physician from each critical care unit collaborated to identify a current hot topic for their area of specialty. The topics developed for presentation included: Sepsis and the use of Xigris; Syndrome of Inappropriate Diuretic Hormone, Diabetes Insipidus, and Cerebral Salt Wasting; Sudden Cardiac Death and Automatic Internal Cardiac Defibrillators; Necrotizing Fasciitis; Chest Trauma; and End-of-Life Care. A 1-hour time format was used; the physician presented first and the nurse presented during the second half hour. The physician spoke about the “current state of the science” and current practice whereas the nurse elaborated on nursing assessment, interventions, and best-practice issues relating to their educational topic. At the end of each presentation there was time for questions and comments Evaluation/Outcomes: With more than 60 nurses in attendance the seminar was a success; evaluations gave an overall positive response. Physicians commented on the interest and enthusiasm of the nurses. Further success of the seminar was realized when the medical-surgical practice council organized their own day of “Hot Topics in Med-Surg.” The pediatric area has also indicated that they may also adopt the format for educational offerings as well. We have already scheduled the third annual “Hot Topics in Critical Care” seminar for June 2006.

Because the Night Time Is the Right Time

Hylton C; Tampa General Hospital; Fla

Purpose: To find a means to provide evening and night shift nurses with mandatory and optional educational offerings without having to stay after their scheduled shifts and respecting their days off. Description: Tampa General Hospital created a position for a night shift educator. Now available at night are cardiopulmonary resuscitation classes, nursing grand rounds, night shift fairs (education, wellness and communication), at least 1 night shift CEU program every month, and multiple in-services as well as clinical ladder assistance. In addition, 6 night shift hospital committees now exist. The night shift educator not only supports our clinical expertise, but also our leadership skills and advancement by assisting and encouraging staff to present in-services on their units. Our educator was also responsible for bringing certification to the night shift. We have had trauma nurse core certification, advanced burn life support and end-of-life nursing Education Consortium certification classes all at night. The educator also compiles and distributes a Tampa General Hospital Night Education Night Owls monthly newsletter. The night shift educator works various hours each week to allow coverage for evening and night shift, as well as at least 1 Sunday night shift per month to meet the needs of the weekend specific staff. Evaluation/Outcomes: Before inception, 75% of clinical ladder participants were day shift nurses. Now that clinical ladder requirements are able to be met conveniently, many more night and evening shift nurses are either participating or seeking clinical ladder status. The number of hospital-based committees has developed from 0 to 6. The last end-of-life class had 40 nurses become nationally certified. Ninety four nurses attended the night Wellness Fair, an event that would have previously been lacking in night shift representation. Now the night shift employees are not left in the dark and are truly and member of the healthcare team.

Utilizing the Expertise of Eighth-Grade Students to Revise Educational Material on a Complex Concept–Sepsis

Johnson V, Maxwell D, The S.E.P.S.I.S. Project Team; Banner Desert Medical Center; Ariz

Purpose: Developing teaching materials for patients and families can be challenging when addressing a complex concept such as sepsis. In an effort to provide a better understanding of this topic, the S.E.P.S.I.S Project Team at Banner Desert Medical Center recruited a local eighth-grade science class to assist with the development of these brochures. Description: After creating the 2 educational pamphlets for the public, “Severe Sepsis,” and “Sepsis and Activated Protein C,” these brochures were presented to an eighth-grade science class to critique. Twenty-six students were divided into 2 equal groups with each group given 1 of the 2 brochures to read. After reading the brochures, the students were given a 9-question multiple-choice quiz specific to their brochure, which included a comment section, to evaluate their understanding of sepsis. The ninth question asked for a rating on a scale of 1–10 (1 being the easiest) “How easy was it to understand the brochure?” The results of the quizzes were tallied and along with the written comments were used to make revisions. The revised brochures were presented to the same 2 groups to read and they were given the same quiz to complete. Evaluation/Outcomes: On the first quiz, the ninth question which asked for a rating on the ease of understanding had an average overall score of 5.5 (using the scale of 1–10, 1 being the easiest to understand). On the quiz for the revised brochures, the score was 5.1. Also on the first quiz, the question “In basic terms, what is severe sepsis?” both groups had 0% correct answers. On the revised brochures both groups scored 23% correct. Using the recommendations of the students, the sepsis education pamphlets were again modified to make them easier for our patients and their families to understand.

You’re Draining What? A Picture Guide to Caring for Patients With Lumbar Drains

Katers C, Boxeth L, Bruggeman E, Cox J, Carrol H; Mercy Hospital; Minn

Purpose: Neurological patients requiring lumbar drainage are assigned to the ICU or the critical care step-down unit in an attempt to improve and standardize evidenced-based care for this population. Because lumbar drains are a high-risk low-occurrence event on the step-down unit there was a need for an “in-time” referenc