Stop a Clot, Save a Life: Becoming a DVT Safety Zone

Thomas-Horton E, Whinney R, Rauscher S, Falker A, Nash J, Mantia P, Dougherty D, Schurrer D, Harris H, Smith J, Jones J; Barnes-Jewish Hospital at Washington University Medical Center, Mo

Purpose: Complications related to deep vein thrombosis (DVT) kill more people than HIV disease, breast cancer, and highway fatalities combined. Virtually every hospitalized patient has risk factors of venous thrombus embolism, yet this silent threat frequently goes unrecognized. A multidisciplinary team was organized to recognize, prevent, and treat DVT. Description: Team members included nurses, physicians, rehabilitation services, OR personnel, safety specialist, operations coordinator, and supply manager. The team’s goal was to establish a hospital-wide DVT program and to make sure 100% of patients receive DVT assessment and appropriate prophylaxis. Our slogan was “Help Make Our Hospital a DVT Safety Zone.” Team members developed tools specific to their area of expertise, which were presented to the team for analysis and feedback. Tools developed included DVT guideline order set and computer-based training for nursing and rehab staff. To improve availability of sequential compression devices (SCDs), the number of devices was increased, SCDs were placed in the OR recovery rooms and surgical ICUs, and the process for obtaining SCDs on the nursing units was streamlined. We developed a TV program and an instructional guide for patients. Because changing processes may increase stress and resistance, a “Clot Man” distributed buckets of candy labeled with the DVT slogan at nursing divisions. In addition, each discipline presented the DVT strategies at their group meetings. Evaluation/Outcomes: Year-to-date data indicate that 96% of patients admitted were assessed for prophylaxis; 70% of patients needing prophylaxis received appropriate prophylaxis, which is a 35% increase from previous years; 2500 nursing and rehab staff successfully completed the online education; and we held 25 DVT presentations. This process has significantly raised the awareness to both patients and staff about DVT prophylaxis.

Push to Prevent: Risk Assessment and Prevention of Pressure Related Wounds in a Medical-Surgical Intensive Care Unit

Zimmerman B, Krall W, LaFary V, Vonderhaar V, Dalhardt D, Haas M; Mercy Hospital, Ohio

Purpose: To help staff identify patients at risk for skin breakdown due to invasive interventions and hemodynamic instability with associated immobility and to initiate preventative measures. Description: A multidisciplinary team investigated and developed a risk-assessment tool and improvement plan, called “Push to Prevent.” The plan included an assessment tool, educational plan, and data collection. The assessment tool was used to analyze activity, hemodynamics, Braden score, and treatments and interventions, and then to stratify risk as low, moderate, and high. General prevention guidelines, suggested for low and moderate risk, included turning every 2 hours, using waffle cushions in chairs, elevating heels, and using barrier wipes to heels and barrier cream. For high-risk patients, general prevention guidelines were suggested with the addition of waffle heel cushions and a physician prompt for Xenaderm (BCT) ointment twice a day, as needed. The educational plan included a documentation competency, quick reference pocket card, and periodic staff meeting updates. Evaluation/Outcomes: Monthly prevalence studies show a decrease in stage 1 hospital-acquired wounds over a 5-month period. In addition, wound care documentation has improved. Thank-you notes for staff recognition are generated for good documentation and initiation of preventative measures. Ongoing prevalence data have been used to further refine the assessment tool.

A Nursing-Driven Strategy to Optimize Patient Outcomes: Spinal Clearance in the Surgical Intensive Care

Tauscheck K, Plach S, Besag S; Froedtert Hospital, Wis

Purpose: To develop and implement an interdisciplinary strategy to optimize nursing care and subsequent patient outcomes by facilitating early cervical/thoracic spinal clearance. Description: The project team, 3 critical care RNs, noted that excess days passed before spinal clearance occurred for patients admitted to the SICU after motor vehicle or motorcycle trauma. This delay hindered the ability to provide optimal nursing care (eg, turning, elevation of head of bed). Furthermore, transfer from the SICU to the radiology department for clearance scans were a safety concern because many patients were unstable, intubated, and/or in traction. To identify the extent of the problem, we collected data about the length of time the patient was in the SICU before spinal clearance and the number of transfers needed for clearance. We also contacted the CT radiologists and the CT manufacturer to determine if the initial CT scans from the ED could be reformatted for a more timely clearance evaluation. Evaluation/Outcomes: Over 3 months, 52 patients had not received spinal clearance before admission to the SICU. Of these, 44 had head, chest, or abdomen CT scans done in the ED. However, only 8 received spinal clearance within 1 day, and 36 were not cleared for up to 6 days. Forty required clearance transfers (range 1–5). On the basis of our data and the manufacturer’s verification that CT scans could be reformatted for spinal clearance, the hospital radiologists, trauma surgeons, and neurosurgeons determined that reformatted CT scans provided adequate views for spinal clearance. This nurse-directed process improvement initiative has led to a dramaticallly decreased number of SICU transfers for spinal clearance; consequently, nursing care and patient safety have been optimized.

Forecasting to Increase Compliance With Best Practice Bundle

Staul L; Legacy Good Samaritan Hospital, Ore

Purpose: The multidisciplinary critical care quality council has long promoted evidence-based best practices through the development of policies and protocols. Quality tracking included the rate of ventilator-associated pneumonias (VAPs) and central venous catheter (CVC) related blood stream infections (BSIs) but not compliance with the specific practices and established policies that were demonstrated to reduce infections rates, the best practice bundle. Our team recognized that we needed to shift the quality focus to compliance and the impact that noncompliance had on patient outcomes to achieve improvement in patient outcome. Description: A review of compliance with the key evidence-based initiatives demonstrated that few had satisfactory compliance. We used forecasting to communicate to the multidisciplinary staff how the level of noncompliance could affect patient care. Forecasting involves estimating the potential patient adverse outcomes that could occur with our current compliance rates. On the basis of the literature, we determined the number of patients needed to treat to gain an effect of the practice intervention. Using the number of patients who should have received the intervention, we calculated the number patients at risk per year by not complying with the recommended intervention. These data created powerful information for the nursing and medical staff and were a motivating factor in increasing compliance. Evaluation/Outcomes: Forecasting was instrumental in assisting us to achieve compliance at over 90% for all components of the best practice bundle. In addition, we observed a clinically significant decrease in VAP and CVC BSIs. Following the implementation of the best practice bundle with forecasting potential adverse outcomes we saw reduction in VAP from a rate of 11.1 per 1000 ventilator days to 1.7 per 1000 ventilator days and a reduction in the CVC BSI rate from 7.9 per 1000 CVC days to 0 per 1000 CVC days.

You’ve Got a PAL in the Business: A Smooth Transition for New Leaders

Ray T, Johanson R, Steinaway S; Harborview Medical Center, Wash

Purpose: To help new leaders transition into management roles at our busy regional trauma center. Description: We created an innovative program called Partnerships in Acclimating Leaders (PAL). The PAL team acts as a support, a friend, a guide, and a familiar face to new leaders; this program is another way to make new leaders feel welcome. Drawing from proven retention strategies, each new leader is assigned a PAL team—experienced leaders who have participated in the strategic leadership program and who have volunteered to share their leadership knowledge and organizational insight with new leaders. A pool of volunteer PALs is maintained by the organizational development and training department. Once a new leader is hired, this department matches him or her with a team of PAL volunteers. This team consists of 1 or 2 hospital leaders, with at least 1 from the same division as the new leader (to make the most of common experiences). The PAL will accompany the new leader to his or her first department manager meeting and will give a facility tour within a few weeks after orientation to answer more detailed questions. The PAL checks in weekly by phone or email, provides informal introductions to divisional colleagues, and helps the new leader navigate the organizational formalities. PALs join the new leader for lunch, breakfast, or coffee regularly, and generally makes them feel welcome. Evaluation/Outcomes: The PAL program has helped make leadership orientation at our facility more personal and friendly, creating an effective network of leaders within the organization. Managers who have benefited from the PAL program have a sense of collegiality with their peers, an appreciation for the relationships they have built with other managers within their division, and contribute to the retention of other new leaders by volunteering as mentors themselves.

Learning to Grow: Education and Leadership Development at a Grass Roots Level

Faber M, Sexton R, Tate J; Harborview Medical Center, Wash

Purpose: To provide a forum for meeting the learning needs of our staff. Description: Routine staff-driven educational sessions are a part of our unit’s Mentoring and Education Program. Although originally designed for new employees on our unit, the senior staff began to express interest in attending when they heard about the quality of information being provided. We accommodated their request and now all nurses are invited to participate in the ongoing education. The sessions are held bimonthly and the topics are derived from nursing issues current on the unit, such as interesting or unusual case studies, new or infrequently used equipment, and patient treatments or studies that we participate in. We have asked senior nurses to develop their roles as leaders through involvement with planning, teaching, and implementing these sessions. Nurses who have expertise in such areas as wound care, PA catheters, and neurosurgery have taught our sessions. Less experienced nurses have also become involved by arranging for speakers and publicizing the sessions, which allows staff to recognize and retain the knowledge of these resources. Some of our best-received sessions were a Jeopardy game highlighting policy and procedure and a talk by organ recipients and donor families. These educational sessions are optional and staff participates because they want to further their knowledge, not because they are required. Evaluation /Outcomes: A large number of nurses on our unit participate in these unit-based education sessions. Nurses have an impact on the educational content, which directly affects the care they deliver. Staff are recognized and developed as clinical leaders through the roles they play in these educational sessions. In addition, physicians have approached us with topic suggestions and have volunteered their time for teaching.

A Three-Ringed Circus: Nurses Who Are Knowledgeable, ArtICUlate and Supported Save Lives

Pyle K, Bethe J, Hewett M, Lepman D, Pierson G; Hoag Memorial Hospital Presbyterian, Calif

Purpose: To assess the cumulative impact of 3 overlapping initiatives on transferred, deteriorating, septic patients to critical care at a nonacademic, nontrauma 510-bed community hospital. Description: In 2005, 3 separate teams implemented each of their initiatives, which included SBAR Communication, a rapid response team (RRT), and the medical-surgical phase of the Surviving Sepsis Campaign (SSC). The cumulative impact of these initiatives were thought to have been an important influence on improved outcomes seen with the severe sepsis population transferred to critical care. Data were analyzed from the Cerner Project IMPACT database, which used 50% random sampling. Retrospective data collection was performed in 2004 (n=41) and compared with 2005 (n=37). The analysis included patients admitted to any medical-surgical floor and subsequently transferred to critical care because of declining status with an acute diagnosis of severe sepsis or septic shock. Patients with DNR status were excluded. Evaluation/Outcomes: The average critical care LOS was reduced from 10.7 to 6.7 days and the average hospital LOS was lowered from 27.8 to 17.2 days. For patients requiring mechanical ventilation, the average number of ventilator days was reduced from 12.2 to 5.7 days. A decrease in the need for hemodialysis (all types) was significant with a drop from 19.5% to 8.1%. Critical care mortality was decreased from 26.8% to 16.2% and hospital mortality dropped 19.7% from 41.5% to 33.3%. Although none of the differences reached statistical significance, resource use and quality improvements were notable. With a methodical, systematic approach to implementing SBAR Communication, the RRT, and the SSC, improved patient outcomes may be achieved.

Mission Possible: Our Path to Certification

Dresser S; Deaconess Hospital, Okla

Purpose: To develop a multipronged strategy for CCU nurses who wanted to demonstrate their professionalism, degree of specialty knowledge, and commitment to excellence by taking the CCRN exam. Description: This initiative had the financial support of the hospital and the guidance of the unit’s CNS. Initially, a survey was done to determine the level of interest in taking the CCRN exam, types of learning formats preferred, choice of audiovisual aids, and preferred times for study. Study group sessions were scheduled for every other week for a total of 10 study sessions, and the calendar and course content were given to each participant before the course. After purchasing the review program and making the review notebooks, the CNS developed a CCRN study library on the unit. Nurses then had the flexibility of reviewing the videotapes, audiotapes, journal articles, puzzles, flash cards, and practice exams at their convenience. To keep the group motivated and focused on the goal of certification, motivational quotes were placed throughout the study notebooks and on the unit and sample test questions were posted on the unit’s bulletin board each week. The nurse who answered the most questions correctly were awarded “hospital bucks” for use in the cafeteria. Evaluation/Outcomes: Before beginning the CCRN study sessions only 2 nurses were CCRN certified. A total of 22 nurses began the program and 17 are currently still participating at the midpoint with plans to sit for the exam. The clinical ladder has been revised to reflect the value of certification with an increase in point value. A CCRN Wall of Fame has been created in a visible location so that both visitors and staff can appreciate these nurses’ committment to excellence.

Power Driven by Proactive and Preventive Strategies: Meeting Education Needs in the ICU Using “Tip of the Week”

Weiss B, Vanjaeckel J, Defilippis M; Morristown Memorial Hospital, NJ

Purpose: Complications of hospitalization are known to increase LOS as well as morbidity and mortality. Research has shown that many complications of a critical illness can be prevented with timely, evidenced-based nursing interventions. While striving to meet JCAHO’s national patient safety goals our ICU initiated a proactive and preventive (PP) care campaign powered by its unit-based performance improvement committee. To help achieve its education goals, the committee decided to sponsor a “Tip of the Week” to educate staff. Description: After reviewing JCAHO and evidence-based practice guidelines, we initiated the PP Tip of the Week campaign. PP tips are based on the educational needs identified from monthly audit results at performance improvement meetings. PP tips are written in easy-to-remember snippets to encourage retention and compliance of the information. New education nuggets are posted weekly with catchy titles and enjoyable graphics to attract attention where all staff will see them—inside the bathroom door. Old PP tips are maintained in a binder. Evaluation/Outcomes: The PP Tip of the Week campaign has been an overwhelming success in the ICU. The tips have stimulated intellectual discussions about important issues on our unit. PP Tips of the Week have led to positive improvements in our monthly audits of patient-safety goals. Our VAP rate has decreased by 50% over the past year after a large education campaign that included a “Whap the VAP” tip. Other improvements include advance directives, glycemic control, and pain and sedation assessments. The improvements in these areas have given us the opportunity to monitor and educate about other important safety issues.

A Method of Using Evidence-Based Learning to Educate Baccalaureate Nursing Students in Critical Care Nursing

O’Sullivan S; The Pennsylvania State University School of Nursing, College of Health and Human Development, SD

Purpose: To implement a strategy to encourage the use of available critical care nursing research literature when teaching a didactic course in critical care nursing. Description: By using an evidenced-based nursing care plan in the classroom, student nurses can develop skills in research evaluation and use in critical care nursing situations. The educator can teach students to form a research question, to evaluate the research findings, and, with the case study information, to implement a nursing care plan based on the research findings. By using simulated patient cases in classroom presentations, the learning becomes more real to students and the use of research evidence is promoted to improve patient outcomes in critical care settings. Evaluation/Outcomes: Implementation of research into practice has been a challenge for nursing educators. However, by using evidence-based learning as a teaching strategy, the nursing student becomes a more proficient consumer of research literature and a more informed practicing nurse in the critical care environment.

Rockin’ Round the Clock: Hourly Rounds in the PCU. Reducing Patient Call Light Use and Increasing Patient Safety

Razo D; Bon Secours St. Francis Hospital, SC

Purpose: To implement a conceptual model of proactive versus reactive nursing in the delivery of patient care, in particular patient call light usage. Description: A 6-week pilot program using data from a single progressive care nursing unit to determine the frequency of patients’ call lights, the reasons patients use call lights, the effects of 1- and 2-hour rounding using specific nursing behaviors on reducing patient call light use, and patient satisfaction and safety (patient falls). Evaluation/Outcomes: A total of 2261 call lights were recorded for this experiment during a 6-six week period and 26 reasons were developed to categorize the reasons patients use call lights. Overall call light reductions showed a decrease of 23.8% from prerounding to weeks 3 and 4. This progressive care unit historically does not have a high fall rate and the recorded falls on the Nursing Scorecard for the entire year of 2005 was 1. However, data for 2006 showed an upward trend with 6 falls recorded for January through May. During the 4 weeks of hourly rounding no falls were reported. Prerounding patient satisfaction scores were documented as being in the 86th percentile for overall quality of nursing care. Postrounding patient satisfaction scores were at 91% for overall quality of nursing care. This new model of patient care delivery demonstrates its effectiveness for bedside nursing care.

Research Ahoy!

Washington G; Mountain States Health Alliance, Tenn

Purpose: To demonstrate the research process in a fun, unique, and nonthreatening manner. A second objective was to use this experiment as a focal point of our upcoming research workshop. Description: Originally used as a teaching tool in a school of nursing to demonstrate the steps of the research process, we decided that the cookie experiment could be used to have fun while teaching about research. Our research council obtained and reviewed the article describing the experiment, revising the survey tool and informed consent for our use. We made arrangements with our facility’s food service to provide 2 different chocolate chip cookies, one made with butter and eggs, the other with margarine and egg substitute. We obtained a convenience sample of employees by approaching them, explaining the purpose, asking for consent, and giving them a sample of each cookie. They completed the Likert scale survey indicating their likes and dislikes of each cookie based on appearance, flavor, texture, and moistness. The raw data were entered into SPSS and the results revealed at our research workshop. When discussing the results, the presentation also included explanations of how the results were interpreted to demonstrate how the researcher draws conclusions from the data analysis. Evaluation/Outcomes: Approximately 700 clinical employees were scheduled to work during the data collection period, and 476 participated in the cookie experiment. The idea was well received when the results were presented at our research workshop. There were 50 in attendance at the workshop, with about 15 having actually participated in the cookie experiment. The workshop participants were given an opportunity to generate their own research questions and to discuss them with the presenters. The evaluations for the workshop were mostly 5 on a scale of 1 to 5.

The Progressive Care Unit: A Case of Mistaken Identity

Lepman D, Hewett M, Pyle K; Hoag Memorial Hospital Presbyterian, Calif

Purpose: The value and benefit of progressive care units are underestimated and underutilized. Sub-ICU beds are an essential key to keeping critical care units (CCUs) available for admission and treatment of critical care patients requiring intensive intervention and treatment. There is a known lack of beds for patients who require acute resuscitation and whose chances for survival outweigh those currently populating CCU beds for long periods. Description: Our facility uses sub-ICU for patients who in the past would only have been admitted to the CCU, including intubated patients, those undergoing percutaneous intervention, automatic internal defibrillator patients, postoperative vascular patients, complex respiratory patients, and certain neurosurgery patients previously admitted only to the CCU. In the CCU, if a ventilated patient is not successfully extubated by day 4, a multidisciplinary evaluation is done to determine sub-ICU transfer status. Daily evaluation is done with the “Daily Goals” check list to determine which patients are ready for the sub-ICU. Evaluation/Outcomes: In the coronary care unit, an improvement in the percentage of patients transferred to sub-ICU from 12.0% in 1999 to 29.1% in 2005 (P<.05) was celebrated; the ICU increased the rate of transfer from 13.6% in 1999 to 18.6% in 2005 (P=.11). Both units show favorable bed use when compared with similar units in the Cerner Project IMPACT database. Transfers from the coronary care unit show better resource use with a sub-ICU transfer rate of 29.1% vs 18.8% (P<.05); telemetry transfer, 31.8% vs 24.2%; and general care with telemetry, 1.3% vs 2.7%. The ICU shows favorable as well with a sub-ICU transfer rate of 18.6% vs 15.4% (P<.05), telemetry transfer 8.4% vs 15.6%, and general care with telemetry 2.9% vs 6.6%. By using sub-ICU beds and specially trained nursing staff, patients may be safely cared for in the sub-ICU with a resultant positive impact on critical care bed availability.

Sponsored by: Hoag Hospital

Utilizing APNs on a Rapid Response Team

Benson L; Bronson Methodist Hospital, Mich

Purpose: Rapid response teams (RRTs) are becoming increasingly popular to proactively identify patients who may have arrest potential and to prevent arrest from occurring. A variety of RRT models are employed at hospitals nationwide. Our hospital chose to employ a nontraditional NP/PA model as the primary responder with a respiratory therapist as backup. Use of an APN model allows for a provider with advanced assessment skills, prescriptive ability, and reimbursement capability. Description: Implementation was multifaceted including protocol development, practice agreements, and a multidisciplinary-targeted educational plan. A predictive query was developed using our documentation system to assist with the identification of patients likely to deteriorate to an arrest situation. These patients were then discussed with the charge nurses of our 5 medical-surgical units. Staff also identify patients of concern and page the team accordingly. The team APNs provide education with each call plus are in the process of developing morbidity educational sessions for each unit containing information pertinent to their specific patient populations. Evaluation/Outcomes: After only 3 months of operation, the team is averaging 30–40 calls per month, has reduced codes per 1000 discharges by 25%, has maintained greater than 70% of the patients seen in a non-ICU setting, has reduced medical-surgical mortalities, and has attained 100% staff satisfaction.

Prevention and Management of Critical Airway Complications in the Surgical Intensive Care Unit

Westhoff L, Guin P, Benken B; Shands at the University of Florida, Fla

Purpose: Patients with extremely vulnerable airways are at risk for critical airway complications. If these patients’ airway became malpositioned, occluded, or dislodged, reestablishment of a patent airway would be difficult and could result in harm to the patient. We developed criteria to identify patients with vulnerable airways who are most at risk, and we developed a nursing initiative to provide safe care and improve patient outcomes. Description: After review of evidence-based practice and CDC guidelines, we developed the Adult Critical Airway Precautions Protocol, which contained the criteria for critical airway precautions and outlined specific interventions to improve both safety and communication among staff members. We recognized 4 risk factors and 9 interventions for critical airway precautions. In-servicing was completed on the Critical Airway Precautions Protocol to the staff. We collected data on protocol compliance daily throughout the patient hospital stay for patients in the SICU; we obtained data through observation, documentation, and inquiry. We then analyzed and disseminated the data to the unit leadership and staff to reinforce compliance with the protocol. Evaluation/Outcomes: The analyzed data revealed that staff was not familiar with different models of tracheostomies and required appropriate reference materials. A tracheostomy module was developed. Over the course of 3 months, compliance with the precautions protocol improved steadily to a 100% compliance. After this nursing quality initiative, no incidences of airway loss were reported. This protocol and educational module resulted in improved patient safety for patients at high risk for airway loss. Preparing staff to manage these high-risk patients resulted in decreased ICU stays, which subsequently reduced costs.

Isolation of Enterocutaneous Fistula Within a Vacuum-Assisted Closure Wound System

Verhaalen A; Medical College of Wisconsin, Wis

Purpose: Enterocutaneous fistulas within wound beds create management challenges. Most fistulas require wound management for weeks to months of before closure results from either granulation or surgery. Often the draining intestinal contents cause local skin excoriation, inhibit wound healing, and require a great deal of nursing time for wound management. We set out to find a solution to minimize dressing change frequency, protect skin integrity, as well as allow for patient healing and independence. Description: For many wounds, the vacuum-assisted closure (VAC) dressing improves granulation, minimizes dressing change frequency while increasing patient comfort and mobility. Currently, mild to moderate liquid enteric contents may be successfully managed with a suction based wound care system. However, once the enteric contents become thicker or the liquid volume becomes too great, the suction-based dressing system becomes less successful, and many times unusable. One may achieve both isolation as well as a quality barrier by wrapping an impermeable dressing around a circular-shaped piece of sponge, then adhering it to the wound base with a tacky substance such as an Eakin ring and stoma paste and placing this into a suction-based dressing system. Evaluation/Outcomes: The application of an impermeable circular foam ring around the base of a stoma has successfully isolated enterocutaneous fistulas within a wound bed when used in conjunction with a VAC system for periods up to 48 hours. The fistula isolation has allowed for stool collection into an ostomy appliance independent from the wound bed to optimize healing, quantify fistula drainage, and reduce direct time spent on wound care. Patients have successfully maintained a regular dressing regimen in the both the hospital and outpatient settings for weeks while simultaneously participating in physical and occupational therapies.

A New Transfer Process From the ICU to Improve Family Satisfaction

Merrill K, Ridling D, Foster C, Ruddy M, Atouani N, Cortez E, Hardiman J, Hawk H, Jackson C, Yalon L; Children’s Hospital and Regional Medical Center, Wash

Purpose: Transferring from the ICU to the acute care unit can be a stressful transition for patients and families. To improve patient and family satisfaction with the transfer process, a new standardized approach was developed. Description: The ICU Practice and Research Council developed a program to improve the ICU transfer process thereby increasing family satisfaction. Input was obtained from ICU nurses, acute care nurses, and managers. On the basis of feedback and the literature, the council revised the existing policy, enhancing the procedure with a detailed checklist and unit-specific transfer packets, and designed a process for complex patient transfers. Nurses were educated about the new process and the need to increase family satisfaction via a global email and a presentation at a staff meeting. The charge nurses were recruited to help predict impending transfers and ensure compliance with the new process. Evaluation/Outcomes: Family satisfaction with the transfer process is measured by survey results using NRC+Picker Family Experience Survey (FES). A low problem score indicates high family satisfaction. We set a goal of 28.1%. Preimplementation scores averaged 42.1%; postimplementation scores were not significantly lower and averaged 41.3%. Therefore, we included education at a mandatory education day and shared comparative data with the ICU staff. FES data are reported quarterly and will assist us in determining if the mandatory education was effective. Our next steps are to audit our process and interview families who have transferred to seek their input.

A Therapeutic Hypothermia Review Group to Ensure Patient Safety

Kupchik N; Harborview Medical Center, Wash

Purpose: An interdisciplinary group was formed at our medical center to review patients receiving therapeutic hypothermia after cardiac arrest. The team reviews patients with the purpose of identifying adverse effects, ensuring patient safety and quality assurance, as well as continually reviewing our protocol and current literature. Description: Our medical center implemented an evidence-based therapeutic hypothermia protocol in 2002 on the basis of published studies revealing therapeutic hypothermia improves neurological outcomes after cardiac arrest. This year a hypothermia review group was formed that meets quarterly to review patient cases, identify any related problems, and strategize plans to prevent complications from this therapy. As a result, our order set was updated and education needs of the physician and nursing staff were identified with a follow-up education plan implemented. Tips for using the hypothermia protocol are printed on the back of each order sheet to assist practitioners with initiation of the protocol as well as patients to avoid. Our presentation will highlight modifications to the protocol and changes in clinical care our group developed to prevent future complications in this population. Evaluation/Outcomes: A therapeutic hypothermia review group of intensive care physicians and nurses was successfully developed that continues to meet quarterly. Recommended protocol changes have been successfully implemented in patients receiving this therapy. We will continue to strive to maintain and improve patient safety by reviewing current literature and implementing evidence-based practice.

A Win-Win Scenario: Using Volunteers in the Burn and Pediatric ICU

Faber M, Jhooty P, Paine J; Harborview Medical Center, Wash

Purpose: To provide community exposure to the burn/pediatric ICU, to increase community involvement in the healing process of our critically ill patients, and to ease staff stress, volunteers have become an integral part of the team on the burn/pediatric ICU. Description: Often, we have limited time and resources to care for our patients the way we would like, and sometimes this means being able to provide only good clinical care without being able to provide holistic care as per our mission statement. In addition, we look to educate the community and provide outlets for giving back to one another. With all these ideas in mind we are now using volunteers as a creative solution. Our unit uses volunteers 7 days a week, both days and nights. Their role has developed into an integral part of the functioning of our unit. The volunteer’s job consists transporting patients, providing support to patients during procedures, stocking equipment and supplies, entertaining our pediatric patients, and sometimes just sitting and holding a hand. Evaluation/Outcomes: The presence of volunteers in our ICU is a success: they are given the opportunity to serve their community; many people who are interested in working in the medical field gain exposure to the challenges and rewards we face daily; our patients receive enhanced care because of the additional resources; and a number of our volunteers have transitioned into the staff positions such as medical assistant, nurse, and physician.

Achieving Tighter Glycemic Control in Our Medical-Surgical ICU

McGinn G; St.Vincents Medical Center, Fla

Purpose: The trend has been to achieve and maintain normoglycemia in our critical care units. A nursing initiative in our unit led us to search for a protocol that would allow us to achieve tighter glycemic control for our patients than our former protocol. Description: After a review of several well-known protocols we selected the Atlanta Protocol for a pilot study. This insulin drip uses a formula and is based on a range chosen by Dr Bode. Our 13-bed medical/surgical ICU served as the experimental group and the other ICUs served as the control group. Twenty heterogeneous ICU patients were studied and their median blood sugar (BS) levels were examined using both the Atlanta Protocol and our former protocol. The Atlanta Protocol uses a multiplier that acts as a measure of the insulin resistance. A formula is used each hour to calculate the dose of insulin to be titrated. A target BS range is chosen for each individual patient by the physician and the multiplier is increased or decreased on the basis of whether the BS level is above or below the range ordered for the patient. In addition, if the patient becomes hypoglycemic (BS <65 mg/dL) he or she is treated by using a formula. The patient only receives enough glucose to elevate his or her BS level to normal range instead of administering a full ampule or half an ampule of D50 causing the BS to surge too high. Evaluation/Outcomes: Our median BS results in the control group was 178.8 mg/dL and the median BS results in the experimental group was 115 mg/dL. The BS levels were less labile in the experimental group. Our physicians were pleased with the results and were eager to extend the pilot to the other ICUs.

Advanced Burn Core: The Other ABC for Nurses With a Burning Desire for More

Tate J, Wolff K, Emerson C, Blayney C; Harborview Medical Center, Wash

Purpose: To ensure that the staff in our burn ICU remain current in burn care practices, biannual advanced burn core (ABC) was developed. Even though the burn ICU nurses are trained in specialized burn care within the first year of being hired, some staff had not received any further formalized burn education in many years. This issue was first identified by our unit-based Best Practice Committee, a group of motivated nurses who meet regularly to work on clinical projects aimed at improving care delivery in the burn ICU. ABC was developed to meet the continuing educational needs of all staff. Description: Members of the committee solicited information from staff regarding what they would like to see in an ABC class. Staff provided more than 50 ideas for class content; the information was then complied and 2 assistant nurse managers took a leadership role in the creation of the ABC curriculum. Topics include the latest in resuscitation, medications, artificial dermis, skin cultures, necrotizing fasciitis, toxic epidermal necrolysis, and electrical and chemical burns. Classes have been well received and are included as part of each nurse’s scheduled hours. To meet the initial need, 6 classes were offered in quick succession that included as many staff as possible with priority given to employees who had worked on the unit for longer than 1 year. ABC is now offered twice a year so that newer staff and those who were not able to attend the first time are given the opportunity to attend. The classes are 3 to 4 hours in length with both a power point presentation and hands-on education. Evaluation/Outcomes: In the 2 1/2 years that the class has been offered, 90% of the burn ICU staff have attended. Staff have expressed gratitude that their needs have been addressed with this comprehensive class. Staff turns to the ABC manual when questions arise.

Airing out the Pediatric Cardiovascular ICU

Staveski S, Leong K, Wong D, Luna R, Mabanglo C; Lucile Packard Children’s Hospital at Stanford Hospital, Calif

Purpose: Pediatric cardiac patients are at increased risk for complications from air emboli. The consequences of undetected air in IV catheters and tubing can be catastrophic, including stroke and death. Meticulous care and vigilance are the keys to optimizing patient safety and outcomes. We developed an interdisciplinary initiative to decrease air in IV catheters and improve our standard of care. Description: After surveying best practices and performing a literature search, we developed a new standard of care for air vigilance on the basis of collaborative, interdisciplinary practices within our ICU team. To implement and monitor the new care guidelines, an audit tool was created and education performed. From November 2005 to April 2006, Quality Management performed weekly sheath audits on 156 patients. Daily peer-to-peer education was initiated to promote the practice change during the months of February through April. The CVICU nurse practitioner and quality manager analyzed the data and disseminated it to the ICU staff and leadership on a weekly basis. Evaluation/Outcomes: The team’s air vigilance practices changed notably following implementation. Immediately after this initiative, 96% of staff consistently removed air from catheters, as compared to 24% before. Postimplementation survey data suggested that the team gained an increased awareness of air vigilance practices and their importance for patient safety, with 62% (after) vs 90% (before) of staff believing air filters were better for safety. Peer feedback was important in embedding this practice change into our unit’s culture. This initiative has helped promote collaborative, interdisciplinary practice and the concept of feedback as a golden nugget of information in the promotion of our patients’ safety.

All Nurse Action Days: An Investment in Retention

Thompson T, Strahle S; The University of Michigan Health System, Mich

Purpose: Retention of nurses is a high priority for healthcare institutions. In 2003, the University of Michigan Health System initiated “All Nurse Action Days.” These 8-hour conference days enable the institution to support UMHS’s dedication to excellence in patient care through direct investment in the nursing community. Description: Action Days are an opportunity to articulate priorities and expectations while imparting essential clinical and performance information. The events are held off site, during and around National Nurses Week. All nurses are encouraged to participate. Nurses attending are on paid time, with overtime often being used so that more staff can attend. Continuing education credits are provided. The topics carry the message of the vital role that nursing plays in patient care at UMHS. These days are meant to honor nurses and are opportunities to learn, build friendships and network in a relaxing environment. Evaluation/Outcomes: This retention initiative has increased in nurse participation and popularity. In 2006, 1560 (48%) nurses participated. Changes in content are made in response to feedback from participants. A healthcare organization that supports nurse retention builds a stronger workforce through the creation of a stable work environment. This year, 89% of the participants found the Action Days effective. At UMHS, the nurse turnover rate is 10.8%, well below the national average of 13.9%. Cost associated with the orientation of new staff is greatly decreased. This is one of the many initiatives that UMHS has implemented to postitvely affect the retention of nurses.

An ICU Journal Club: A Springboard to Evidence-Based Practice

Leaton M, Vanjaeckel J; Morristown Memorial Hospital, NJ

Purpose: The ICU Journal Club had been in place for several years and the format had been informal, focusing mostly on fundamental clinical articles. As we began to investigate processes to develop a culture of evidence-based practice (EBP) in our institution, the Journal Club seemed a ready-made forum for nurses to develop the skills necessary to implement EBP in the ICU. Description: The CNS collaborated with the nurse researcher to integrate the John Hopkins Nursing Model for EBP into our Journal Club meetings. We developed and are using a simple Journal Club template to structure our meetings and generate EBP projects. The members of the Journal Club identify current clinical practice questions they are concerned about. The CNS and the staff nurse presenting the selected topic review the literature, summarize the findings, and choose 1 or 2 articles for the group to critique. If the topic involves other disciplines, they are invited to participate. Members of the Journal Club compare the findings from the articles to current practices in the ICU and determine if there is a need to change nursing practice on the basis of the evidence. If there are opportunities to change current practices, the Journal Club provides leadership for and often implements unit-based EBP projects. Over the course of the last 6 months the number of practice changes the Journal Club has generated lead to the initiation of an ICU Practice Council. Evaluation/Outcomes: The Journal Club has completed 2 EBP projects: (1) a hyperglycemia protocol and (2) a subcutaneous insulin protocol. The Journal Club has recommended 3 other practice changes that are being implemented by our new ICU Practice Council: (1) reliability of the Behavior Pain Scale in the trauma/surgical/medical ICU and the cardiac care unit; (2) implementation of an agitation and delirium protocol; and (3) a patient assessment protocol for readiness for ventilator weaning.

And the Beat Goes On: Basic Concepts of Permanent Pacemaker, ICD, and Cardiac Resynchronization Therapy

Rorapaugh A, Kennedy S; Mount Carmel Medical Center, Ohio

Purpose: The field of electrophysiology (EP) has grown tremendously and is continuing to grow at a rapid rate. As a response to this growth our EP lab developed an in-service. The goal was to increase staff nurse understanding of devices and thereby improve the quality of patient and family education. Description: The EP lab staff initiated bedside preprocedure and postprocedure patient education and found there were frequently asked questions and misconceptions in regards to these devices not only from patients and families but from the staff nurses as well. A 1-day continuous, interactive in-service was developed in response. The format allowed for nurses to come and learn as time allowed with a total of 92 nurses attending. The primarily audience was critical care and telemetry nurses; the only prerequite was basic nursing knowledge, but telemetry experience was helpful. The objectives were to identify indications for pacemakers, ICDs, and CRT; to describe basic device function, to discuss preoperative and postoperative care; and to improve nursing knowledge and patient/family education. Included in the curriculum were indications for use, detailed information about each device, evidence-based studies, goal of the therapies, preoperative and postoperative care, and patient and family education. Evaluation/Outcomes: Feedback was resoundingly positive. Additional in-services are being planned. The in-service has opened the lines of communication between the EP lab nurses and the critical care and telemetry nurses. There has been an increase in the number of correct consents from 77.9% to 95% as a result of improved understanding by the staff nurses. The nurses have indicated they feel more confident delivering patient and family education and alerting physicians to who may benefit from device implantation.

And to All a Good Night: How to Promote Sleep in the ICU Population

Bonnet N, Andrew L; Morristown Memorial, NJ

Purpose: Critically ill patients are known to suffer from severely fragmented sleep leading to sleep deprivation. The 24-hour routine of an ICU make distinguishing day from night challenging, if not impossible, for ICU patients. Frequency of assessments, multidisciplinary diagnosis and treatment interventions, and subsequent evaluation of treatment are some of the reasons this patient population is at higher risk. Sleep deprivation has been explored in both laboratory conditions and clinical areas. Symptoms of sleep deprivation have been shown to be restlessness, disorientation, combativeness, delusions, hallucinations, and increased illness. Description: After review of current literature of the ill effects of sleep deprivation, a change in practice was implemented by the night staff of an 8-bed medical cardiac care unit. Strategies to encourage sleep included routine practice of turning off all lights, decreasing noise levels, and shutting the doors when possible. Nursing activities were condensed to coordinate interventions and decrease interruptions. A complete “down-time” period was established restricitng all activities for a designated period except for life-threatening emergencies. Other disciplines were educated about the goal of our program and the importance of sleep promotion for this patient population. Evaluation/Outcomes: The sleep promotion measures implemented in a cardiac care unit served to enhance the awareness of the importance of sleep in this population. Staff admittedly expressed a laissez faire attitude toward waking a patient before beginning this practice change. Staff who care for sleep-promoted patients report calmer and less anxious patients. This program can be used to increase patient satisfaction and improve patient outcomes. This process has served as an introductory platform for multidisciplinary collaboration for further sleep research.

Assistant Nurse Managers: Leadership With a Clinical Focus

Vogelzang M, Castillo M, Conner L, Stafford A, Tesfamariam A; Harborview Medical Center, Wash

Purpose: To maintain a connection with all staff, to role model nursing excellence, and to serve as a conduit between staff and administration, our facility has developed the role of assistant nurse manager (RN3). Description: Throughout our facility the RN3 works 90% in direct patient care and 10% in an administrative capacity. RN3s complete scheduling, clinical competencies, annual staff evaluations, unit education, interviews, and unit tours. They also oversee new staff and charge nurse orientation. RN3s are involved in or supervise unit development projects such as Best Practice Committees, mentoring programs, newsletters, and unit Web page development. Each unit has RN3s assigned to all shifts to facilitate communication and direct observation of the staff. In the off-shift setting they may be the only management contact a patient or family has available to them. All these tasks are essential, but the most critical aspect of the RN3 role is to model exemplary clinical care and promote high professional standards. RN3s are promoted with the valued input of staff and administration; they represent both elements of the nursing spectrum. Because the majority of their time is spent providing bedside care, the RN3s are often resources for clinical trials, unit design issues, maintaining ideal supply levels, and other functions that enable a unit to run well. Evaluation/Outcomes: The entire nursing staff is better served because of established lines of communication through a nurse that understands the needs and priorities of both bedside nursing and hospital administration. The RN3 is a champion of cooperation and collaborative practice.

At Your Fingertips: Improved Efficiency With Specialized Procedure Carts

Faber M, Pate A, Miller E; Harborview Medical Center, Wash

Purpose: To increase the efficiency of care delivery, to improve physician compliance with procedure consent and verification, and to decrease infection rates, the use of specialized procedure carts has been implemented by our ICUs. Description: Stocked, specialized, procedure carts maintained by medical stores are present on each ICU. They consist of all the equipment required for a procedure including masks, sterile gloves, and gowns. For quality assurance, preprocedure verification sheets are kept on the carts. We have an invasive catheter cart with equipment for central catheters, PA catheters, and A-lines; the ventriculostomy/ICP cart contains equipment requested by the neurosurgical team; a general surgery trauma cart has equipment for bedside procedures such as decompressive laparotomies, open chest resuscitation, pericardialcentesis, and continuous arteriovenous rewarming; and the ER and the pediatric ICU have Broselow length-based carts containing equipment for pediatric emergencies. The presence of the required paperwork on the procedure cart serves as a reminder to maintain compliance with the established patient safety standards. When a patient requires a bedside procedure, the physician calls the unit and notifies the staff to bring the cart to the bedside and await physician arrival. Every unit has identically stocked carts so the physician knows where the supplies are and does not need to spend time searching for equipment. Evaluation/Outcomes: These specialized carts have dramatically decreased the time nurses spend gathering procedural equipment. Procedures and equipment are more uniform with physicians having access to identical equipment carts. Staff compliance with patient safety and infection control standards has increased because of the presence of all the required supplies and forms.

Back From the Edge: Implementing the Sepsis Bundle Utilizing Two Multidisciplinary Order Sets

Johnson A, Evenson L, Gajic O; Saint Marys Hospital, Mayo Clinic, Minn

Purpose: Treating patients who present with sepsis remains a continuing challenge faced in critical care. Evidence shows that to obtain the best outcomes in septic patients, goal-directed therapy must be initiated as soon as possible. To expedite care, 2 multidisciplinary order sets were developed that incorporate the guidelines of the sepsis bundle into a document that also allows for physician orders. Description: Recommendations set forth by the Surviving Sepsis Campaign (SSC) were reviewed by a CNS, staff nurses from the practice committee, and physicians in our 24-bed medical ICU. Two multidisciplinary order sets were developed with input from emergency department (ED) staff. The order sets included guidelines and physician orders for sepsis and severe sepsis/septic shock management. The order sets addressed areas of organ perfusion, antibiotic treatment and source identification, steroid administration, glucose control, and DVT and stress ulcer prophylaxis. The goal was to expedite implementation of therapy within 1 hour of sepsis recognition. All nursing and physician staff in the medical ICU/ED were educated on the order sets and compliance and mortality outcomes were tracked. Evaluation /Outcomes: Data on compliance with these 2 order sets and adjusted outcomes were collected from APACHE III database and patient records. Within 6 weeks of implementation the sepsis order set had a compliance rate of 60%. Five months later the compliance rate was 82%. Compared to a period just before introduction of the order sets, the adjusted hospital mortality (OR 0.42, 95% CI, 0.18–0.94) and ICU length of stay (4.1 ±4 days after vs 6.3 ±7 days before, P=.01) improved significantly. APACHE predicted ICU mortality was 36% and observed ICU mortality was 23%. We aim to efficiently and expediently treat septic patients through continued use and compliance with the sepsis order sets.

Balancing Safety and Variation in Practice: Standardizing Continuous Infusions (“Drips”)

George E, Skledar S, Tasota F, Malich C, Michalec M, Gross P, Guttendorf S, Ervin K, Kowiatek J, Martinelli B, Mcateer B; University of Pittsburgh Medical Center, Pa

Purpose: Over a 13-month period, 9 adverse drug events (ADEs) involving infusion concentration changes were reported in our institution. A multidisciplinary workgroup was formed to examine ADE-causative factors and redesign the existing standard infusion list (SIL) to improve patient safety and reduce ADEs. Description: A development team of pharmacists and physicians revised the SIL to reduce variation. An implementation team of advanced practice nurses, pharmacists, pharmacy technicians, and information systems specialists created teaching tools, updated online resources, and completed interdisciplinary education for conversion to the new SIL. The revised SIL was not only used to designate standards but also to define maximum concentrations and safe dosage ranges. On the implementation day, new infusion concentrations were dispensed and existing infusions were converted to ensure housewide conformity. To provide support to the bedside nurse and reduce error, members of the implementation team rounded to each bedside. The team delivered new infusions, educated nurses, confirmed pump programming accuracy, and verified computer entry. All copies of the SIL were replaced with new versions marked “2006” to differentiate from old versions and reduce error. Implementation was completed over a 72-hour period. Evaluation/Outcomes: The revised SIL reduced variation by 88% (16 drips with multiple concentrations versus 2). Physician prescribing compliance improved from 55% to 95% using the new SIL. There have been zero drip concentration ADEs since implementation, compared to a high of 4 in the quarter before implementation. This interdisciplinary approach to redesign and education ensured a safe and successful housewide conversion.

Bed Trinkets: An Unnecessary Evil

Farlow V, Jones P, Pack B, Sabri B; Duke University Health System, NC

Purpose: Our tertiary care hospital has a committee composed of nurses called Skin Care Champions who teach staff how to prevent and monitor patients for pressure sites. This team identified a pressure site risk factor common to the majority of our ICU patients: “trinkets” in the bed. Description: After resuscitation, catheter insertion, or other procedures, patients may have syringe covers, stopcocks, unattached tubing, etc, entangled in their linen. In addition, necessary items such as urinary catheter tubing, rectal tubes, and catheters can lodge under a patient causing unnecessary pressure points. Trinkets under patients who are bedridden and unable to move on their own or who were unaware that small trinkets were in their beds can cause a pressure site in only a few hours. We collected bed trinkets for 6 months checking beds of patients admitted from outside hospitals, ER, OR, cath lab, and hospital units following procedures and catheter insertions. We proceeded to educate the staff regarding “bed trinkets,” linen checks, turning patients on a routine basis, and using prescribed skin care products when reddened areas were noted. Education was provided on a poster called Bed Trinkets as well as one-on-one conversations and role modeling. The poster was very graphic featuring a collection of bed trinkets actually collected on the unit and pictures of pressure sites. Evaluation/Outcomes: Displaying the poster and reminders from the Skin Care Champions has decreased the number of potential pressure sites from undetected trinkets. The decreased pressure sites that require treatment has decreased length of stay.

Blankets and Bears: Comforting Kids in the ICU

Curtis A, Rivas N; Harborview Medical Center, Wash

Purpose: To provide comfort to pediatric patients during their ICU stay, to provide a distraction from the clinical environment and procedures, and to send patients home with a positive memory from their stay, our unit provides all pediatric patients with a quilt/blanket and transitional item such as a teddy bear or other toy. Description: Many of our patients arrive in the ICU in a rush without having had time to collect comfort items from home. Patients experiencing this new environment can become overwhelmed by the stress. Our pediatric patients are no exception; they are often the most affected by the environment change. Through a community effort, each child admitted to the PICU is provided with a blanket and a toy or stuffed animal. The blankets and quilts are handmade by a variety of community organizations and donated to our facility. The toys and stuffed animals are obtained through direct donations or through funds donated to the hospital for this purpose. The blankets provide a bit of color and fun to the uninviting environment of the ICU. The bears and toys can be used for distraction or fun during or in between procedures. The patients keep these items throughout their hospital stay and can bring them home when they are discharged. Evaluation/Outcomes: Patients and families have a positive response to the gifts of the blankets and toys. Parents have stated that it makes the ICU a little less scary. Nurses report enjoyment at being able to provide comfort and being able to make a small child smile. Patients are able to return home and take with them a positive memory from their stay in the ICU.

Blue Ribbon Recognition for Blue Ribbon Service!

Michalopoulos H, Sala J, Mcgrath R, Causing N, Abaring T, Filipovski J; University of Chicago Hospitals, Ill

Purpose: In 2003, the morale in the University of Chicago Hospitals’ medical ICU was low and the staff nurses wanted to turn that around and revive the unit. The nurses decided they not only wanted to feel the positive energy, but see it as well. Description: A nurse created the Ribbon Recognition program. She provided 3- to 4-inch ribbons with labels with the headings, “To,” “Thanks for,” and “From” for staff to wear. The purpose of the ribbons was for nurses to give their peers positive recognition and encouragement by writing a quick thank-you on the ribbon for their help that day or for a job well done. The honored nurse would tie the ribbon to his or her name badge and wear the ribbon as recognition for hard work. Over time nurses would create a bouquet of ribbons on their name badge. The ribbons were multicolored and were holiday or time of year appropriate. Evaluation/Outcomes: Seeing the ribbons made nurses more aware and more apt to give positive feedback to their peers. This ultimately helped foster better working relationships within the medical ICU. In 2006, the unit-based nursing committee included a thank you card to the recognition program. The cards provided staff an opportunity to write a more complete thank you to their peers. Completed cards were posted in the staff conference room where all staff could admire the work of their peers. Staff was encouraged to copy the cards and present them to their manager who used the feedback during their annual evaluations. Both the ribbons and the cards were a huge success. What an easy way to measure the outcome—seeing ribbons on everyone’s name badge!

Body Substance Isolation Plus Model for Eliminating Multidrug Resistant Acinetobacter

Hamilton R; Harborview Medical Center, Wash

Purpose: To eliminate the transmission of Acinetobacter bacteria in critically ill patients at our medical center. A resistant form of Acinetobacter was introduced to our medical center by a military member injured in Afghanistan and treated at Harborview. Acinetobacter is a highly resistant, opportunistic bug. Therapeutic options for treatment are limited to a highly nephrotoxic antibiotic with subsequent patient morbidity. Description: We implemented the WASH (wipe out Acinetobacter with Surveillance, Substance isolation, and Hand Hygiene) campaign, spearheaded by infectious disease, clinical education, and hospital quality improvement /patient safety. All high-risk patents (intubated, with open wounds, or transferred from another facility) who were admitted to the ICU were given surveillance cultures upon admission and once a week while in the ICU. A patient testing positive for Acinetobacter becomes a body substance isolation plus (BSI+) patient. BSI+ is noted with an orange wrist band, orange stickers on the patient’s chart, and an orange BSI+ signs posted outside the patient’s room. Patients are placed in a private room or with other BSI+ patients. All staff members, family, and visitors are required to adhere to strict gloving, gowning, and hand hygiene. All equipment and supplies are considered contaminated and remain in the SBI+ rooms until patient discharge. After discharge, rooms and equipment are terminally cleaned and all left over supplies are discarded. Evaluation/Outcomes: Before implementing the BSI+ model, up to 5 new cases of Acinetobacter were reported daily. After initiating the BSI+ model, a dramatic decrease in the number of new cases of resistant Acinetobacter was achieved. Harborview had almost completely eradicated Acinetobacter from the hospital with only 1 known case. Because of the tremendous success, the BSI+ model has been expanded to include not only Acinetobacter but also a range of other highly drug-resistant organisms.

Bug Spray: Use of an Atomizer to Zap Vap

Bereznay J, Whitcomb D, Love J, Obeidy M; Oakwood Healthcare System Oakwood Annapolis Hospital, Mich

Purpose: Reducing the risk of ventilator-associated pneumonia (VAP) is a constant challenge in critical care. Chlorhexidine application to the oral mucosa has been identified as an effective way to reduce VAP. This creative solution compared the effectiveness of chlorhexidine using mouthswabs (CS) and chlorhexidine using an atomizer in conjunction with mouthswabs (CAS) in reducing VAP. Description: This project compared results between 2 acute care units. During the 18-month period preceding use of chlorhexidine, the VAP rates at site A ranged from 0–5.38 (mean 1.368) per ventilator day (range 143–276). VAP rates at site B ranged from 0–9.52 (mean 3.133) per ventilator day (range 95–220). When the chlorhexidine protocol was instituted, staff at both sites received education about the use of the product. At site A education included the CAS protocol in which the chlorhexidine was first sprayed into the oral cavity using an atomizer then swabbed. At site B the chlorhexidine was only swabbed in the oral cavity. Evaluation/Outcomes: After implementation VAP rates at site A (CAS) ranged from 0–3.92 (mean 0.436) per ventilator day (range 132–255). This represented a 68% decrease. VAP rates at site B (CS) ranged from 0–8.55 (mean 1.069) per ventilator day (range 97–155). This represented a 66% decrease. Another CAS site also reported a decrease in VAP, but the reduction was only 28%. Reduction in VAP may be related to multiple factors including education, technique, compliance, and patient variables. Further investigation is warranted.

Building Clinical Strength Through Mentoring Relationships

Faber M, Wittgow P; Harborview Medical Center, Wash

Purpose: To meet the education and development needs of staff nurses, to support and encourage new staff, and to maintain a high clinical standard for all nurses on the unit, we used the mentor relationship to make assignments that meet the needs of new staff and our patients. Description: Our unit has an established mentoring program that teams nurses new to our unit with experienced senior nurses. With a positive experience for the program the role that mentors play in staff development has expanded. This past year, our mentors were challenged to aid the clinical growth of new staff by directing the patient assignments of these new team members. The mentors have in-depth knowledge of the challenges and successes that the mentees have had. They routinely meet to discuss the developmental accomplishments as well as the ongoing learning needs of the mentee. This knowledge combined with their advanced clinical skills allows the mentor to direct the mentees to patient assignments that will encourage both clinical growth and caregiving confidence. When a challenging assignment is taken, the mentor serves as a clinical resource and is a strong source of encouragement. With all nurses on the unit exposed to a wide range of acute and challenging patients we build a stronger nursing unit, not just a group of good nurses with a few stars. Evaluation/Outcomes: Word of the support given to our new staff has spread and our unit does not lack for qualified nurses that want to work on the floor. Our staff feel supported and know that someone is there to aid them when they need it. Physicians want their patients on our unit because they know that the patients will receive consistently excellent care from all the nursing staff. The nursing staff cooperates to improve the unit and provide exceptional patient care.

Building for the Future: New Graduates Entering Critical Care

Scott S, Lusardi P, Elliott S, Albano A, Thomas D; Baystate Medical Center, Mass

Purpose: Our ICU is a 24-bed medical-surgical unit in a 641-bed level 1 trauma center, with a variety of high-acuity patients other than the open-heart surgical population. To meet the staffing challenges in our ICU we needed to begin hiring new graduates but did not have a program in place to do so. When we looked at other institutions of comparable size that offered orientation programs designed for new graduates, we noted that they had specialized critical care units. This allowed a new graduate to orient while focusing primarily on a single system problems. Because we were in a unique position we developed a Critical Care Internship Program tailored specifically to our unit. Description: The orientation program was originally designed with 3 phases: (1) a student nurse critical care rotation, (2) a graduate nurse segment on an acute care unit, and (3) a critical care component. Before graduation, the student nurse works in the ICU along with an experienced nurse. After graduation, the new nurse undergoes a 6-month precepted acute care orientation that includes regular meetings with the ICU CNS and the acute care preceptor to assess progress. This is followed by a 6-month precepted experience in the ICU. Extensive mentoring and educational support are in place to sustain the new graduate in his or her transition to the role of a successful critical care nurse. Evaluation/Outcomes: Three new graduates have entered and successfully completed the orientation program. They are functioning independently as staff RNs in the ICU and are being supported by their nursing colleagues and the ICU CNS and nurse educator as they continue to gain critical care experience. Evaluation of the program revealed that the student clinical experience did not significantly contribute to the development of the student nurse as critical care nurse. As such, this piece has been eliminated from the program as of 2007.

Calling All Nurses: A Shared Governance of the Charge Role

Mathews S, Wood C, Kagel E; Grant Medical Center, Ohio

Purpose: To engage all CCU RNs into stepping up to the charge nurse role, and to define that role as one of a shared governance position to enhance nursing satisfaction, patient satisfaction, and quality of care. Description: Because of the increase in patient acuity, the nursing shortage, and tighter nursing budgets, senior nurses constantly felt drained. These feelings were identified during unit meetings and staff satisfaction surveys. As a result, a series of charge nurse meetings were held, where it was expressed that many staff aspired to step into the charge nurse role, and would rather have a charge nurse without patients as opposed to having additional support staff. The next step toward this new charge role involved educational meetings on direct care budgeting and staffing. Aspiring nurses were encouraged to take management classes, preceptor classes, and personality trait seminars. Upon the development of the hospital’s rapid response team (RRT), it was decided that the CCU charge nurse would act as the nurse responder for the hospital and as an assistant to the nurse manager by completing various QA audit tools and performing patient rounds. Evaluation/Outcomes: As a result of this newly created charge nurse position, staff satisfaction has increased. A new sense of unit responsibility has ensued on the part of the nurses. The charge nurse has been able to assist and mentor new nurses fostering a positive ongoing nursing educational process not only in the CCU but on other units through the RRT team. Quality outcomes and goals percentages have increased because of the daily audit tools. Patient satisfaction has increased because patients and families have access to additional support staff. The nursing staff has gained new respect for the management aspect of the role, because they all share in its success and failures.

Cardiac Nursing Practice Group: Uniting Cardiac Nurses With a Shared Vision

Stengrevics S, Anderson C, Bethune C, Carroll D, Cierpial C, Donahue V, Griffith C, Haldeman S, Silva J, Snydeman C, Tubridy A; Massachusetts General Hospital, Mont

Purpose: Patients cared for in our medical center are often complex. In an effort to better “know the patient,” to improve handoffs, and to promote a best practice environment, a cardiac nurse practice group was created. Description: CNSs representing the cardiac units at our institution met to improve communication and to share knowledge and expertise across the continuum of cardiac care. Simultaneously, nurse managers discussed plans for a cardiac center of nursing excellence. Together, the groups developed a vision and 6 goals related to the delivery of nursing care of patients with cardiovascular disease. With the framework of 6 identified goals, approximately 30 clinical nurses, CNSs, and NMs now meet bimonthly to optimize patient outcomes by addressing common issues. A research librarian helps with literature support for initiatives. Clinical nurses, guided by CNSs and NMs, often identify issues and assume leadership of projects. Evaluation/Outcomes: Communication has been enhanced through unit-based open houses and demonstrated by the adoption of a standardized cardiac patient problem/outcome care plan and a service-based patient/family teaching record. Clinical initiatives include development of best practice guidelines for temporary pacing, 12-lead ECG lead placement, measuring pulsus paradoxus, and recording anticoagulation medication administration. A cardiovascular review course was developed to promote professional advancement of clinical nurses through specialty certification. A celebration for cardiac nurses included presentations from a visiting scholar. Additional goals for 2006 include designing a healthy work environment, expanding membership to include other cardiac clinical nurses, aspirin desensitization protocol, and standardizing sheath management. Communication among units is more collegial resulting in improved patient care.

Cartoon Reminders Improve Documentation

Brames N, Rieth S; Barnes-Jewish Hospital, Mo

Purpose: Chart audits frequently show areas that need improvement in documentation. Even though this information is shared with the staff during staff meetings, audits continue to show the need for improvement. Description: We created small reminders using Clip Art relevant to the documentation issue, along with a short reminder statement. We laminate, cut out, and tape the reminders to the computer monitors used for charting. Two reminders are placed on each monitor; each monitor has different reminders. We change the reminders according to the most recent chart audit results using different Clip Art and paper colors. Examples of the reminders we use include pain documentation, patient profiles, documentation of ventilator changes, restraint documentation, alarm documentation, and telemetry documentation. The Clip Art adds humor to a serious issue while ensuring that staff will read and learn from it. Evaluation/Outcomes: The cartoon reminders have helped us to improve documentation in areas that were lacking. The staff enjoys the cartoon characters and remembers the message that goes along with it.

CCU Reference Manual: From Orientation and Beyond

Bull D; VCU Medical Center, Va

Purpose: Nurses are often overwhelmed by the amount of data they receive during orientation, information that they were only exposed to once, or information that they did not receive during orientation. Certain procedures and equipment may not be used on a routine basis; therefore, it can be stressful when they are performed or used in an emergency situation. Orientees have preceptors with different levels of information and teaching styles. The objectives for the manual are to aid staff with the use of accurate information, have readily accessible answers, and improve the nurse’s level of confidence. Description: To meet orientees’ educational needs, a quick reference flip chart was developed. Data were collected from experienced staff and staff with less than a year’s experience. Information that frequently requires verification or answers was added. The flip chart was kept in a central location, so a pocket guide for each orientee was developed. The CCU reference manual was recently revised. The reference manual is pocket size and spiral bound, and consists of 121 pages. Information was classified by sections such as cardiology, respiratory, medications commonly and infrequently used, laboratory values, equipment needed for a procedure, and the nurse’s role during the procedure. Staff members receive a copy of the reference manual on their first day of orientation. Evaluation/Outcomes: During orientation staff routinely use their reference manual. It is not uncommon to see orientees and their preceptors verifying information together from the manual. Beyond orientation, staff continue to refer to their manual and make additional notes they find helpful. The reference manual is a helpful, time efficient, effective tool for both new and experienced staff.

Changing Attitudes About Tight Glycemic Control

Rhatican C; Baylor University Medical Center, Tex

Purpose: To develop and evaluate an educational intervention to change staff attitudes toward tight glycemic control and associated patient outcomes in the adult trauma population. Description: Tight glycemic control has been shown to have a positive impact on patient outcomes. To achieve this goal, the nurse must perform hourly blood sugars and, in response to these results, titrate insulin infusions. Because these activities increased patient care intensity, this medical protocol was not popular with our staff. We felt if staff had a better understanding of the importance of these tasks and the positive impact on patient outcomes that attitudes would improve. Educational content was developed on the basis of current literature, unit procedure, and the medical protocol. The presentation was further refined for 3 target groups (management, staff, and support personnel) to be relevant to the specific issues of each. These groups attended classroom presentations. Evaluation/Outcomes: After attending a classroom session, attendees used a 5-point scale to rate their change in attitude concerning the importance of tight glycemic control. Data collected thus far show 87% of the participants have had a definitive to significant change in their attitudes. Individual suggestions for process improvement were also solicited with the evaluation and communicated to the group through a “Bright Ideas” section of the unit bulletin board. Two ideas in process are the purchase of additional glucometers and the use of barcoding technology to increase efficiency and timeliness of running these tests. Reevaluation of the staffs’ attitudes and the Bright Ideas implemented is planned for January 2007 to see if the gain achieved has been sustained.

Changing the Rise of Ventilator-Associated Pneumonia in the ICUs

Harner A; Tampa General Hospital, Fla

Purpose: High acuities and a large number of patients requiring prolonged ventilator assistance had led to an unacceptable rise in the incidence of VAP. It was decided to develop a method of treatment to reduce and/or eliminate this expensive and often lethal complication. Description: Initially, the guidelines from the Institute for Healthcare Improvement were used in our medical ICU. We developed a 7-item list, which was posted in the chart of every patient on the ventilator. Physicians were asked to write these items as orders, which were then implemented by the nursing staff. A small sign denoting the “Vent Bundle” was posted at the patient room door as a staff reminder. Charts were audited 3 times a week for compliance and the infectious disease nurse followed the incidence of pneumonia. We purchased and began using a mouth-care package that contained all items necessary for a 24-hour period. Following the implementation of the bundle, our unit had 7 months with no VAP. Evaluation/Outcomes: With the success of this plan, it was decided to implement it in all units. Our incidence of VAP has decreased dramatically and we have added the bundle to a full set of orders for the adult ventilator patient. We are in the process of incorporating these orders into standard order sets for other units. Our “Bundle Committee” meets bimonthly to evaluate the success of this house-wide program.

Charge It Up: Developing Authentic Leaders

Faber M, Johanson R, Thomas A, Vogelzang M; Harborview Medical Center, Wash

Purpose: To develop a strong unit staff that takes pride in collaboration, communication, and strong clinical care, our unit has made a choice to train a broad segment of our staff to serve in the charge nurse role. Description: Nurses take the lead in patient care delivery, but not all nurses have the skill set to be great leaders. Our unit has put a priority on developing the staff into a strong group of clinical leaders. The charge nurse role is a natural pathway to the skills required of a good leader. The charge nurse sets the tone for the unit. They have the global picture in mind, and they manage admits, transfers, and discharges. The charge nurse is a resource for other staff and can aid those being challenged beyond their knowledge and experience. The charge nurse must have advanced skills in facilitating communication between disciplines and providing feedback to staff. The charge nurse must be flexible and creative in their problem solving and be a role model of excellent clinical care. A unit is only as strong as its weakest staff member, so training a greater number of nurses to the charge nurse role has strengthened our ICU. Evaluation/Outcomes: Not every nurse is prepared to take on the charge nurse role, but by training a greater number of nurses we have seen a change in the culture of the unit. By rotating the charge responsibilities there is less mental fatigue placed on individuals. The staff is more supportive and accepting of the difficult decisions that a charge nurse must make. Teamwork is the norm rather than a rare event. Nurses are invested in sharing their knowledge and strengthening other staff members. The unit is a place that people are proud to work.

Clinical Ladder Tracks: A Tool for Managers and Advisors

McBroom K, Swearengen P, Bowling L; Duke University Health System, NC

Purpose: The clinical ladder, consisting of 4 levels, is a tool used to recognize and promote nurses who have demonstrated excellence in practice and advanced leadership skills. Staff performance is tied to the Balanced Score Card, our mechanism to measure success. This tool includes clinical quality, customer service, work culture, and financial quadrants. Previously, application requirements were specific to the clinical quadrant. Exceptional work in the other quadrants was difficult to recognize even though a review of applications revealed interest in those nursing opportunities. To support the diverse needs and interests, a clinical ladder committee was formed to expand and further develop our program. Description: The committee identified 3 distinct areas of nursing practice, administration, education, and clinical. Each focus identifies specific skills reflecting leadership, advanced practice, and knowledge. Grids were devised to include preapplication requirements and developmental components. The developmental segments provide a blueprint to assist the manager and nurse in planning activities to support individual learning goals. In-services educated staff regarding changes in the process and reviewed expectations within each track. In addition, intensive training was provided for advisors to effectively guide and coach applicants throughout the advancement process. Evaluation/Outcomes: The 3-track options provided advisors and managers direction while advising the nurse during the process. This method provides the nurses, novice to expert, an avenue for professional growth and recognition. Nurses have a broader understanding of how their practice supports all four quadrants of the Balanced Score Card. The recognition of the administrative, clinical, and education unit experts validates an enhanced respect for nurses and their work toward positive patient outcomes.

Collaborative Practice Enhances Nursing Competence

McBroom K, Soltis L, Apter J, Cowan E, Washington L, Waresak M, Lloyd A, Overman K, Holtschneider M, Gattis K; Duke University Health System, NC

Purpose: As nursing practice moves from general to specialized, nurses experience more autonomy, as well as more responsibility for the expansion of knowledge and expertise in their chosen specialty. As a consequence, floating to another unit has the potential to be a challenging and stressful experience, resulting in questions for unit-specific information. It became apparent that a resource was needed to enhance knowledge and increase comfort levels for nurses. Capitalizing on the fact that our nursing staff possessed a vast range of experience, a task force with representation from each area was initiated to determine how to offer simple, accurate information that would benefit a nurse working in our specialty areas. Description: Each representative offered updated unit-specific information including critical aspects of patient care, as well as important telephone numbers. The guide included expectations for assessments; documentation; preprocedure, postprocedure, and interventional care; critical drips; and IV catheters. This information was compiled in a template in the form of a pocket guide. Nursing staff from included areas were given the opportunity to review the draft and provide comments, suggestions, and recommendations. The pocket guide was completed, approved by the hospital education department, printed and distributed to staff. Evaluation/Outcomes: Collaborative efforts resulted in a concise, accurate, and economical tool for the staff. The nurse that “floats” into an unfamiliar area will have the information needed to better understand routines and requirements, thus providing a safer environment, increased staff satisfaction, and promote positive patient outcomes. Questions regarding drugs, catheters, and equipment are now clearly organized and close at hand, allowing nurses to safely, correctly, and efficiently perform duties.

Color Coding: You Are Now Entering the Medication Safety Zone

Tate J, Johanson R, Blayney C; Harborview Medical Center, Wash

Purpose: To ensure that our staff members have the resources to safely administer IV fluids/medications, our trauma center has instituted 2 major changes to IV administration. The hospital made the transition as easy as possible so that staff would buy into this important safety initiative. The changes are additional visual cues that help to augment the “5 Rights” of patient medication administration whereby seeing a wrong colored/named drug label or tape would alert the nurse that there is a potential error. Description: As part of our trauma center’s continuing priority to provide the safest care, a policy has been instituted to use colored labels for IV medication bags with the additional safety feature of colored medication name labels for all the IV tubing. These labels are placed at the drip chamber, the cassette loading location, and at the IV hub. Staff on our floor trialed the IV tubing labels with these labels being placed in a central location in the medication room. It was a successful trial in which staff took to the colored labels and tape quickly, which led to management placing the colored tape in each room. Pharmacy instituted a major change in how they labeled their IV medication bags. All medication bags used to have yellow labels but with the safety changes all vasoactive agents and nonstandard concentration bags have blue labels and all other IV medications still have yellow labels. Evaluation/Outcomes: In the year since the changes were instituted, IV medication errors (wrong bag hanging) have substantially decreased on our unit. Because of the ease of the changes and no added work load to staff, we have found the change in IV medication administration to be very effective, with nearly complete staff compliance.

Condition O: A Rapid Response Team for an Obstetrical Crisis

Stein K, Baldisseri M, Mcbride-Valizedeh E; Magee Womens Hospital of UPMC, Pa

Purpose: The care of the obstetrical patient presents unique challenges to hospitals and healthcare professionals. Most obstetrical patients are considered low risk in terms of complications, yet they may develop high-risk or life-threatening conditions. The 2004 JCAHO Sentinel Event Alert identified areas of concern in the management of obstetrical emergencies contributing to poor fetal and maternal outcomes. These included poor communication between providers; failure to function as a team; inadequate staff competency, orientation, and training; and physician unavailability or delay. A retrospective case review was conducted by a multidisciplinary task force. This review showed early signs of deterioration not recognized and treated in a timely manner. Description: Our goals in establishing an obstetric rapid response team are to encourage any staff member to initiate this process; provide a critical core group of expert healthcare providers to the bedside of an obstetrical patient with a deteriorating clinical condition, and to lower the number of emergent clinical events. The multidisciplinary task force defined the clinical criteria of an obstetrical crisis and determined the appropriate response team members and roles of the team. Notification and education of the staff and hospital personnel was completed over several months. Evaluation/Outcomes: The Code Response Committee reviews the cases and identifies barriers that may exist to deliver quality patient care. The medical director implemented a human simulation course on obstetric crisis management. Each member of the team is debriefed and educated regarding their performance in their role. The goal of the course is to enhance performance in an obstetric crisis. The goal of the Condition O is deliver a high-quality team approach to obstetrical patients demonstrating early signs and symptoms of a deteriorating clinical condition.

Contamination: Spreading the CCRN Virus

Taylor J, Michalopoulos H, Jones N, Perez E; University of Chicago Hospitals, Ill

Purpose: To implement a professional development plan that supports staff nurses in successfully achieving CCRN certification. CCRN certification is offered to staff nurses who have worked in the ICU for more than 2 years and provides evidence that nurses have acquired an advanced body of knowledge that aids them in providing quality care to critically ill patients. Description: Critical care educators implemented the first CCRN review course in January 2005. Educators met with the cohort at times that accommodated the needs of both the day staff and night staff. The NTI (National Teaching Institute) CCRN lecture tapes, along with the AACN Core Curriculum for Critical Care Nursing textbook were used to prepare participants for the CCRN certification exam. Before the first class, the nurses received a 7-week content outline allowing the nurses to review the information before viewing the videotapes. After review of the videotapes, participants discussed multiple study questions along with answers and related rationales. During the final session, educators incorporated a new interactive monopoly-type game to enhance critical thinking skills and decision making. The winning team received a prize. Evaluation/Outcomes: Using evaluation forms to obtain feedback, the educators developed new ideas to engage staff in learning the vast amount of information required to successfully pass the exam. With each new cohort more nurses participated in this learning opportunity. Since the inception of the CCRN review, 3 nurses reported having successfully passed the CCRN examination. Efforts are currently in place to provide additional guidance and support to individuals who were unsuccessful in obtaining their CCRN certification and to remove the stigma associated with the need to repeat the exam.

Cracked Heart: The Effects of Cocaine on the Heart

Balmer S, Kupchik N; Harborview Medical Center, Wash

Purpose: To appropriately identify and treat patients with the diagnosis of cocaine-induced myocardial infarctions (MIs). Description: Our ICU sees approximately 1–3 cocaine-induced MIs per week. We wanted the staff to have a solid knowledge base of how to effectively treat and manage this specific patient population. This provides the staff the opportunity to act as a knowledgeable patient advocate through staff and resident education. We implemented this by early identification of cocaine-induced MIs in the emergency department, mentoring all staff, and providing resident education at the bedside during rounds. Evaluation/Outcomes: The outcomes of this project were improved management of the cocaine-induced MI. An increased staff awareness and advocacy for this population of patients. In addition, better screening tools used in the emergency department to identify these patients as early as possible. We collected data on the number of patients admitted with cocaine-induced MIs, including management, treatment, and patient education.

Creating a Staff Empowered Recruitment and Retention Team to Enhance a Healthy Work Environment and Improve Satisfaction

O’Roark D, Pileski D, Henry L; Conemaugh Memorial Medical Center, Pa

Purpose: To meet the perceived needs of our staff and increase their overall satisfaction by forming a unit-based retention and recruitment team. The goals of the team were to build a more healthy work environment, per AACN’s Healthy Work Environment initiative, by developing methods to increase satisfaction, decrease communication barriers, develop a more cohesive work team, and provide meaningful recognition to each member of our critical care unit. The team wanted staff to feel empowered to inspire change. Description: To form the team, all staff was asked to collaborate and identify opportunities for improvement. Two early initiatives were the development of a 50/50 raffle and a snack basket to provide funding for initiatives. Survival kits were distributed to welcome new staff. Greeting cards were sent to recognize significant events. Social outings such as a lunch club, family picnic, and a “cutest pet photo” contest were organized to help staff become better acquainted. Monthly newsletters were published incorporating education, humor, staff profiles, valuable tips, and recognition of staff ’s meaningful contributions. Evaluation/Outcomes: The team sent surveys to all staff to evaluate the team’s impact. The staff expressed gratitude for the team’s efforts, especially with the snack basket and others were eager to have more social outings. Overall, staff felt that efforts of the team had a dramatic impact on increasing their satisfaction and providing a healthy work environment. The team recognizes the need to provide meaningful recognition for daily contributions to better relate to each other, retain skilled staff, and work as a cohesive group. Encouraging staff to use their own insight to empower change helps ensure staff needs are being met, leading to improved satisfaction and retention.

Creating Power

Elliott S, Scott S, Thomas D; Baystate Medical Center, Mass

Purpose: A successful rapid response team (RRT) program goes beyond the team; it supports both the ICU staff as well as the frontline nurses on the medical/surgical units. Description: In March 2006, our medical center developed an RRT to be available 24/7. It is composed of a critical care nurse, a respiratory therapist, and an IV nurse. Initially, the plan was for the ICU nurse covering RRT calls to also carry a patient assignment. However, this placed a burden on the ICU staff because we averaged 1–2 calls per 12-hour shift, with an average length of a call lasting 38 minutes. Our concern was how best to support the ICU staff left to cover the RRT nurse’s assignment while he or she was out on a call. ICU nursing leadership supported the addition of an RRT RN on night and weekend shifts, where fewer resources are available. The RRT nurse does not carry a patient assignment and assists coworkers with patient care between calls. On the day shift (Mon–Fri), the role of the RRT RN is covered by the ICU nurse manager, assistant nurse manager, or the nurse educator, none of whom carry a patient assignment. In addition, an opportunity to build collaboration and teamwork developed between the ICU and medical/surgical units. The ICU nurse provides educational and emotional support for the medical/surgical floor staff who call on the RRT. We do follow-up visits on all RRT patients that do not transfer to a critical care unit, seeing the patient and the patient’s nurse. This is a unique opportunity to share insights with the nurse and sharpen assessment skills so that he or she will respond proactively to similar events in the future. Evaluation/Outcomes: There has been an overwhelmingly positive response by both the ICU staff RNs and the medical/surgical nurses. The ICU staff welcome the additional staff support, and floor staff appreciate the clinical and educational support afforded by the follow-up visits.

Creative Collaboration to Promote Professional Involvement

Marzlin K, Webner C; Aultman Hospital, Ohio

Purpose: Both the Magnet and Beacon awards for excellence expect involvement in professional organizations. Low participation in professional organizations is a common problem in today’s busy healthcare environment. Many benefits of professional organization involvement occur at the local chapter level through education and professional networking. However, limited resources and reliance on volunteers often limit the ability of local chapters to provide high-quality programming. This project involved collaboration between Aultman Heart Center and the Canton Akron Chapter of the Alliance of Cardiovascular Professionals (CAACVP) to sponsor an annual regional symposium. Description: Project goals were (1) to increase the number of staff members exposed to nationally known educators and (2) to increase number of staff members engaged in a professional organization. A planning committee was developed using joint leadership between the CAACVP and Aultman Heart Center. A staff nurse chaired the committee. The symposium planning was organized into 5 subcommittees: Speakers and Program, Marketing, Finances, Registration, and Materials/Facilities. The committee met regularly for 1 year. Evaluation/Outcomes: The formal collaborative structure for the 2006 Celebrating Excellence in Cardiac Care Symposium resulted in the following: (1) 79 attended the preconference, (2) 125 attended each day of the 2-day main conference, (3) 8 states were represented, (4) 11 outside speakers brought national expertise to the regional conference, and (4) 98% of the participants rated the symposium as excellent. Aultman Heart Center and the CAACVP hope to expand the partnership to include our local AACN chapter for the 2007 symposium. Professional organizations can successfully collaborate to meet mutual goals. Nurse members of professional organizations are key persons in identifying, proposing, and leading in collaborative projects.

Creative Solutions to Successful Implementation of ECCO

Bettinelli M, Mclaughlin M; Lahey Clinic, Mass

Purpose: In January 2004, ECCO was implemented in a 293-bed tertiary care hospital. Implementation resulted in many challenges, for both the orientee and the critical care leadership team. Previously, orientation had been a traditional model consisting of educators presenting didactic information in the classroom setting. All orientees, regardless of specific area of practice specialty, attended these classroom presentations. The specialty areas consisted of traditional ICUs, postanesthesia care unit, emergency department, and progressive care unit. Other elements of the orientation involved the orientee working with preceptors and unit-based educators. Barriers encountered during implementation were completion of ECCO modules, scheduling of computer time, integrating current module with available patients, and ensuring attendance at corresponding workshops. Other challenges were varied methods of implementing ECCO in diverse specialty areas, as well as varied levels of nursing experience. Description: An ECCO Task Force was created to identify and address implementation challenges. An orientation manual was designed to welcome the orientee to the ECCO program, provide access instructions, and clearly state module completion deadlines. The orientee was scheduled to attend workshops and was assigned computer time. AACN workbooks were purchased for each unit and were equipped with a computer dedicated for ECCO learning. Workshop and overall program evaluation forms were developed. Evaluation/Outcomes: Although some challenges still exist, Task Force members are pleased with the consistency of the orientation. Evaluations have been positive. Orientees have appreciated the orientation manual. The task force continues to meet on a regular basis to monitor progress and address areas of concern.

Curves in the Road: Using Algorithms as a Map

LaTour L, Ramus-Embler A, Mertins L, Mcbroom K; Duke University Health System, NC

Purpose: Throughout any given day, nurses are going to the computer and resource manuals, seeking information about specific process standards or guidelines for a procedure. This is time-consuming and may result in delayed treatments. As frontline leaders, we consistently look for ways that ensure patient safety as well as maintaining staff competence. A frequent request from staff was to develop a tool that contained printed information that could be placed on their clipboard. Description: Staff was asked to prioritize information needed at the bedside. Feedback from staff was presented to the nurse manager/educator and other frontline nurses. Isolation, blood administration, restraints, and femoral pressure device placement were the top 4 priorities. When reviewing these process standards and guidelines, a decision was made to develop algorithms so staff members could easily follow instructions and deliver necessary treatments in a safe, competent and timely manner. Algorithms were developed in compliance with hospital process standard and guidelines. These were presented to and approved by the step-down clinical practice committee. Individual copies and education were provided to all staff members. The algorithms were placed in a nursing resource book for easy accessibility. Evaluation/Outcomes: Staff nurses are better educated and have a higher level of comfort knowing there is a quick and available reference for their review. The algorithms are considered to be a “safety net” by the staff when delivering patient care. Preceptors consistently use this valuable tool to teach new learners and to stimulate discussion during orientation. Treatment is given in a timelier manner, which promotes staff and patient satisfaction. Frontline leaders from other units have requested copies so they may be shared among their unit’s staff.

Decreasing Code Chaos: Identifying Roles, Maximizing Results

Falker A; Barnes-Jewish Hospital at Washington University Medical Center, Mo

Purpose: Code teams respond to acute, life-threatening changes in a patient’s hemodynamic status. The team provides lifesaving care to patients they do not know, in unfamiliar situations, and with healthcare team members they do not work with consistently. To increase the effectiveness of the Code Team, a Code 7 Review Algorithm was developed and implemented. Description: Each time the Code Team responds to an emergent situation, they must quickly assess, treat, and stabilize the patient. The Code Team members must effectively communicate with each other and perform their specific roles. Breakdowns in communication sometimes occur, decreasing the team’s efficiency. Our hospital tries to limit any code chaos by sending new nurses and residents to Mock Code classes. However, we do not currently have 100% compliance. We offer refresher Mock Code classes to staff but enrollment is minimal. To combat this problem, a 2-page algorithm was developed detailing the Code Team members, basic role responsibilities, contents of the crash cart, and nursing responsibilities. These algorithms were placed in the crash cart books located on the crash carts. New nurses and residents received the algorithm as a survival guide, and a copy of the algorithm was placed in nursing staff mailboxes and distributed to residents. Evaluation/Outcomes: Nurses and residents like the algorithm; it is a quick and user-friendly reference guide. It helps staff to rapidly identify who is present and better understand the role responsibilities of the Code Team members. Ultimately, the algorithm decreases the chaos associated with code responses and improves patient outcomes.

Development and Implementation of an IV Insulin Protocol for ICU Patients

Ozanne L, Matthews J, Rogers A, Logsdon C, Whipple R; Memorial Health University Medical Center, Ga

Purpose: There is building evidence that tight glucose control in the ICU decreases mortality, morbidity, and length of stay. In our medical/surgical/neuro/trauma ICU, the percentage of patients with median daily blood glucose of <150 mg/dL was 43%, 37%, and 67% for 2003, 2004, and 2005, respectively. A multidiscipline performance improvement project was undertaken to develop and implement an intensive IV insulin protocol. Our goal was to increase the percentage of ICU patients with adequate glucose control (median daily glucose <150 mg/dL) to greater than 80%. Description: After a thorough literature review, an IV insulin protocol from a published journal article was piloted in our ICU. Education on the importance of glucose control in the ICU and instructions on how to use the pilot protocol was provided to all nurses and patient care technicians. An hourly bedside flow sheet was developed for the patient care technicians to record blood glucose. Multidiscipline input on the ease of use and the interim success of the pilot led to 3 revisions to the pilot within 3 months. Evaluation/Outcomes: Blood glucose values for all ICU patients were collected. The percentage of ICU patients with median daily blood glucose of <150 mg/dL was 87% for the first quarter of 2006. This represents nearly a 30% increase in patients with adequate glucose control when compared to our 2005 data. Following implementation of our IV insulin pilot protocol, the median blood glucose for patients on IV insulin decreased from 141 mg/dL to 136 mg/dL (P<.0005).

Development of an Electronic Reference for Safe Administration of Chemotherapeutic and Hazardous Medications for the ICU

Dudley L; University of California San Francisco Medical Center, Calif

Purpose: To provide guidelines for safe administration of chemotherapy and hazardous agents in the ICU. Description: A quick access to chemotherapy information did not exist in the ICU. A chemotherapy manual did exist but was difficult to understand by nurses who administered chemotherapy infrequently. Many nurses were uncomfortable giving chemotherapy without a more thorough explanation of why, how, and the risks involved. As time can be of essence in an ICU, the information needed to be more easily accessible and user-friendly. This project was the result of collaboration between the oncology clinical nurse specialist and clinical nurse leader in the ICU. The most frequently used agents outside of the oncology unit were identified. A quick guide highlighting the do’s and dont’s of proper set-up, administration, and disposal of chemotherapy agents was developed. The guide included a step-by-step checklist reinforcing the procedures. The references and tools were placed on the nursing department Intranet for access by all units. The Web site includes the quick guide with the original, more comprehensive chemotherapy manual. It also includes a list of all the chemotherapy agents identified with a link to the pharmacy Web site with drug information and patient teaching tools. Evaluation/Outcomes: This guide has been used by all critical care units. Nurses have reported that the site is understandable and easy to use. The Web site format using links to other current resources is quick to access and decreases searching time through the existing manual. This electronically available reference guide provides key information that helps nurses provide safe care related to chemotherapy administration.

Dialogue Heals: Improving Communication Skills on the Frontline of Our Critical Care Unit

Dickerson L; Grant Medical Center, Ohio

Purpose: Critical care nurses are very skilled in critical and creative thinking; however, our training prepares us little in the art of communication. Our CCU staff identified that for our unit to take the next steps in creating a healthy work environment and maintaining or Beacon Award we needed to be not only skilled healers but strong communicators. Description: Our journey began with a brainstorming session identifying scenarios in which the staff and management failed to have important conversations that revolved around mistakes of peers, incompetence, unit standards, lack of support, and back biting of one another. The second leg of our journey focused on education in which we required all staff to read “Vital Smarts Dialogue Heals.” Staff then discussed the previous scenarios and worked through them to be able to raise these concerns in a confident way. Two staff members were also specifically trained to confront safety concerns by addressing these real time on the unit. The final and ongoing leg of this journey is focued on accountabilites and how we handle crucial conversations. This is now included in our peer evaluation tool. Evaluation /Outcomes: Armed with tools to address conversations around broken rules, lack of support, mistakes, incompetence, teamwork, and disrespect our unit’s employee job satisfaction scores improved 16%. Patient safety is improving and staff verbalize increased confidence with improved communication.

Discharge Planning: Your Last Chance to Make a Good Impression

Rosenthal K, Haugen M; Mayo Clinic, Minn

Purpose: Discharge planning is an essential element of providing excellent nursing care and patient service. Poorly executed discharge planning can lead to delayed dismissals, decreased patient satisfaction, and an increased risk for posthospital complications and hospital readmission. To improve the discharge process, the staff of our 33-bed thoracic surgical progressive care unit created an RN-led multidisciplinary discharge planning team. Description: The primary issues affecting patient dismissals were lack of complete and accurate dismissal summaries and prescriptions not written and filled on time, resulting in a delay in discharges. Methods for improvement included quarterly audits of dismissal summary accuracy and prescription timeliness, surveys of patient and staff satisfaction, the implementation of multidisciplinary discharge planning rounds, and discharge planning education with physicians and nurses. Evaluation/Outcomes: Since the formation of the discharge planning team, survey results have shown improvements in all areas. Results included a 47% increase in staff satisfaction and a 32% increase in prescription timeliness. We hope to provide insight into the importance of discharge planning and inspire fellow nurses to improve their own discharge planning process.

Ditzels: Simple and Effective Staff Communication

Vogelzang M, Tate J, Faber M; Harborview Medical Center, Wash

Purpose: To provide a simple means of disseminating information to staff. Description: “Ditzel” is a word born from the burn patients cared for on our unit; we use it to describe small areas of burn requiring minimal intervention. This seemed the perfect way to describe information that we wanted to impart to the staff. It was determined by the Best Practice Committee that practice updates, policy and procedure reminders, as well as standard-of-care cues could be disseminated via low-key, nonthreatening emails. Ditzels are sent out weekly via email so staff may either read them at work or on their own time. They are also placed on the communication board so there is always a hard copy available for perusing during break times. The emails are generally less than half a page so that they are quick to read and easy to remember. We have recently begun to use Ditzels to discuss new products in use on the unit and new studies in which we are participating. The Ditzels are also a mechanism for clearing up any confusion regarding patient care without isolating one individual. The nursing staff on the unit are the primary source for new Ditzel material. Evaluation/Outcomes: This method for distributing information has become a welcomed, consistent, and anticipated means of communicating. The timely and low-key style has become a great way to answer staff questions, educate, and disseminate time-sensitive material. This method for distributing information has been adapted by many other departments in our organization.

Do Desensitizing Decibels Drown Out the Deadly Alarms?

Shatzer M, Frank S, Delucia G, Hannan K, Digiulio N, Rack L, Schmid A; University of Pittsburgh Medical Center, Pa

Purpose: Cardiac monitoring systems rely on a pitch-escalating audible alarm structure to alert the nurse to various patient events. Real-time data notification is an attractive feature of such systems; however, the high frequency of audible noise transmissions can promote an overstimulating and desensitizing environment. The aim of this cardiac monitoring practice transformation is to reduce non–life-threatening alarm occurrences while improving patient safety and decreasing nurse desensitization within an academic medical center’s innovation unit. Description: Initial modifications were aimed at low-level alarms (eg, leads off, battery depletion, or cannot analyze) that potentially posed a patient safety risk when unrecognized or unresolved. Patient care technicians on an 18-bed medical cardiology step-down unit were educated to expand their role to include battery change, low-level alarm recognition, low-level alarm response, and proper lead placement and assessment responsibilities. An additional nursing strategy aimed at mid-level alarms included alarm analysis process improvement and unit default modifications. Evaluation/Outcomes: Baseline low level data revealed 120 lead-related and 3 battery alarms. After protocol implementation, 34 lead-related (71.6% reduction) and 0 battery alarms (100% reduction) remained. Mean response time for low-level alarms improved from 3.42 minutes at baseline to 2.71 minutes after implementation. Mid-level alarm baseline data demonstrated an average daily ring rate of 870 events. Mid-level alarm default modifications reduced the average daily rate to 390 alarm events. By reducing the overall ring time and creating a more streamlined alarm response we have improved the unit environment. Lethal alarms are no longer lost in the extraneous low and mid-level alarm noise.

Doing Safer Things, Doing Things Safer-Patient Safety First

Hewett M, Pyle K, Lepman D; Hoag Memorial Hospital Presbyterian, Calif

Purpose: To ensure compliance with JCAHO’s National Patient Safety Goals and the Environment of Care Standards, Hoag Memorial Hospital Presbyterian’s Safety Management Council created an online, unit-specific audit tool. Description: Each department director selected a safety representative who was oriented to our safety program, which fosters a climate of safety awareness, identifies accident-prone conditions, and initiates appropriate actions. The unit safety representatives educate the staff on the National Patient Safety Goals while conducting Safety/Infection Control Inspections to determine compliance with existing environmental safety regulations. Changes are recommended if needed. They submit their audit data electronically, which is compiled into a database and the results are disseminated to department directors and appropriate vice presidents. The department safety representative and department director are responsible for resolving issues discovered during the audits. When needed, the Safety Management Council and/or Environment of Care Committee monitors performance and provides support as necessary. Evaluation/Outcomes: National Patient Safety goals showed a 97% for 2 patient identifiers used, 92% for sterile field medication labeled, a 98% for time out before surgical or invasive procedure and read back is 100%. “All Alarmed Doors Are Working Properly” has improved from 0% to a 74% average the past 6 months, “Medications Locked Including Refrigerator” improved from 87% to 91%, “Pharmaceutical Waste Container Is Used Properly” improved from 89% to 92%, “Wheelchairs and Gurneys Are Clean” improved from 79% to 92%, and “All Refrigerator and Freezer Temps Checked and Recorded Daily” improved from 89% to 94%. The area we continue to address is the chemical spill kits availability, which was at 71% and only moved to a 79% average during the past 6 months.

Donation After Cardiac Death: A Photographic Journey From the Critical Care Nurse’s Perspective

Norman V, Johnson K; St. Joseph Hospital, Calif

Purpose: To orient the critical care nurse to the OR environment to support donation after cardiac death (DCD). Description: DCD is an option when brain-death criteria are not met. The organ procurement organization is involved in obtaining consent and support for the family and critical care staff. This period is very stressful for staff because of end-of-life ethical and psychosocial elements. When DCD is scheduled, the critical care nurse transports the patient to the OR. Family may be brought into the OR to be with the patient at the time of death. The nurse monitors the patient during withdrawal of life support and pronouncement of death, and assists the chaplain with family support. As the OR environment is unfamiliar to most critical care nurses, photographs were taken of the OR suite and equipment. They are available as a reference book so staff can be prepared for this process before it occurs. The photographs have captions and arrows to specific equipment, such as monitors and suction. This idea came out of the experience of one critical care nurse, who wanted his coworkers to be familiar with the OR before they have to go there with a DCD candidate. We prepared a Powerpoint presentation, which is used for inservicing and reference binders for each critical care unit. Evaluation /Outcomes: The inservicing and reference binders, which are used to orient staff to the DCD process, have been well received by the staff. They are grateful for actually “seeing” the OR in a series of clear photographs, so they can be prepared when the time comes for DCD. This has reduced the stress and contributed to improved staff satisfaction.

Driving Force of Mentorship

Sabatini R, Fidellaga A, Kirk C, Leaton M; Morristown Memorial Hospital, NJ

Purpose: A Shared Governance model supports professional development of nurses. Mentoring is one strategy to meet this need and a formal program can assist with achieving professional goals in a timely fashion and increase satisfaction with professional growth. Description: A mentoring program was first developed at the corporate level through a grant, but later, the Nursing Education Council guided its refinement and execution. The program includes descriptions of the mentee/mentor, a signed contract, goals and timelines, and “tracking” sheet. Goals are formatted around institutional shared values and forces of magnetism. The ICU implemented the program through collaborative efforts between the ICU Practice Council, manager, CNS, and human resources. Eleven pairs of mentors and mentees identified individual goals that focused on increased competency with complex technical skills, committee participation, achievement of CCRN certification and clinical ladder status, and educational presentations. Pairs submit quarterly progress reports and identify obstacles. Evaluation/Outcomes: All mentors are in the process of achieving their goals. Less experienced mentees have achieved competency in technical skills associated with the IABP. Five staff nurses will seek CCRN certification in fall 2006. Four staff nurses have become members of the ICU Practice Council and 3 have joined the Journal Club. These staff nurses are leading presentations and discussions on practice issues, including literature reviews. None of the staff nurses engaged in the mentoring program have terminated their employment. The program has been evaluated and modified with less paperwork, easier “tracking” of individual progress, and process evaluation. Collaborative efforts have been extended to the clinical nurse researcher.

Ed Fellowship-Pathway to Excellence

Williams J; Barnes-Jewish Hospital, Mo

Purpose: To provide a creative and clinically sound orientation program to guide new graduate nurses as members of the Emergency Department Nursing Team. Description: The nursing shortage created a large void in potential staff to work in the emergency department. The CNS sought to develop an orientation program that would provide a safe and effective orientation for new graduate nurses in the emergency department. The Emergency Nursing Fellowship Program was created and implemented in 2001 in our emergency department. The program is designed as an intensive orientation and education program targeted specifically at new graduate nurses and those with less than 1 year of clinical practice in the acute care setting. Using a combination of evidence-based classroom teaching, clinical experience, and focused evaluations of the orientees progress, the members of the fellowship are prepared to care for the complex patients independently in 5 months. The implementation process, critical changes and improvements in the program and the ongoing research initiatives surrounding the program are identified. Evaluation/Outcomes: The program has successfully recruited over 80 staff nurses to the emergency department in 6 years. It has the greatest number of applicants for the positions in the hospital. The program has retained greater that 70% of all members that successfully completed the orientation period. Former members of the program are now in leadership positions within the department and demonstrate rapid assimilation of critical thinking skills required for safe care of emergency department patients.

Empowering Staff to Conquer Codes With Confidence

Murchie W, Hardie N, Pharney R; Children’s Hospital and Regional Medical Center, Wash

Purpose: To increase skill and confidence during a code by creating learning sessions that are standardized, engaging, and participatory. Description: In order for ICU staff to maintain competency, an 8-hour education day is offered 5 times a year. These days cover such competency skills as CRRT, pacemakers, open chest procedures, and codes. Because many clinical staff nurses assisted in teaching the code skills, we found an inconsistency in teaching styles and degree of hands-on practice with the participants. After 1 hour, staff did not feel competent or prepared for a code situation or effective in their role. Last year we chose to redesign the competency day session and called it a Mock Code Session. Each session was tailored toward the core skills of our nurses. The sessions were increased to 2 hours. Laminated “playing cards” were made for review of crash cart contents. Each card had an item or collection of items listed on it. Staff each takes a card, locates the item, and explaines its use during a code. We developed code scenario cards that teams had to choose and act out. Each team fully participates, drawing up medications, opening the crash cart, and operating the defibrillator as the other teams watch. The instructors have their own corresponding scenario card with the expected outcomes of the staff to ensure standardized instruction and followup. Staff is then given a code recording sheet to document scenarios read out from a collection of ICU codes. Each person is to record the code as if it were occurring. Two nurses from the ICU have been consistently teaching the competency sessions for the last year. Evaluation/Outcomes: Staff states they feel more prepared and confident to participate in a code. Staff is more engaged and interest is kept with a fun, interactive method of learning.

Empowering the Bedside Nurse: The Development of an Adult Critical Care Pathway

Shanahan M, Hendersen J; Highland Hospital, NY

Purpose: The Adult Critical Care Pathway was developed in response to a triad of needs. First, to incorporate evidenced-based care in daily thought and practice of ICU RNs. Secondly, to develop a document that would include all critically ill adult patients, regardless of the etiology of their illness. Lastly, to use an acuity scoring system that would accurately reflect the patient’s severity of illness, response to interventions, and the outcome in a measurable, defined parameter. This tool is designed for bedside nurses to efficiently assess both patients’ acuity of illness and their progress on the path to wellness. The bedside nurse simply follows the guidelines at the top of the pathway twice a day. Description: After an extensive literature review for both existing pathways and best practice, combined with the realization that all critically ill patients are systematically affected by illness, a holistic approach was embraced in the development of the Critical Care Pathway. Regulatory requirements as well as safety issues were woven into the design. During the first 3 months, staff (multidisciplinary support team included) simultaneously used and evaluated this documentation tool. After another 3 months, a satisfaction survey was completed by the staff, which produced the “end-of-life” section. Evaluation/Outcomes: The success of the pathway has been 3-fold: standardization of care, the realization of patients’ progression, and the use of the acuity system. Acuity scores are used for many aspects of unit operations: triage decisions, in correlation with nursing indicators for our performance improvement plans, synergistically in staffing assignments with respect to nursing level of competency, and to account for staffing patterns. Our facility promotes a variable staffing plan, that is, we have the autonomy to maneuver our staff; however, we need to justify our actions. The acuity scores reinforce adjusted staffing decisons.

Entrepreneurship in Nursing

Reed M, Skinner M; Martha Reed Foundation, Va