Oral Presentations

Creating a Healthy Work Environment With Collaborative Team Meetings

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

Purpose: 2004 NDNQI staff satisfaction survey showed nurses on the cardiac surgical step-down unit and cardiac surgical ICU rated job satisfaction lower than the national average. In an effort to improve the working environment, an informal weekly mee ting was developed to facilitate communication amongst the cardiothoracic nursing, physician, and physician assistant leadership and key nursing staff. Description: This process has allowed for open discussion of pressing issues brought forward by the interdisciplinary team that affect the continuum of the patient’s stay. Plans of action are developed that allow for immediate changes in practice as well as the development of a process for continued quality improvement. Evaluation occurs at a designated time, and changes to the plan are made, if necessary. Role out of the plan occurs simultaneously in both units with all members of the interdisciplinary team. Resolution of problems has occurred in a timely fashion. The plan, do, check, act approach has been rewarding. This informal meeting optimizes a true collaborative approach, skilled open communication, effective decision making, and meaningful recognition of staff. All of this leads to clinical excellence, optimal patient outcomes, and staff satisfaction, which promote a healthy work environment. The staff recognizes their power to influence positive change by participating in this process. Sample topics have been patient chart review, patient satisfaction results, protocols, time out process, and nurse physician documentation and communication. Evaluation/Outcomes: Immediate response to issues with a plan and resolution has allowed consistency in practice across the cardiac thoracic continuum of care. This process has played an instrumental role in leading to clinical excellence and an increase in staff satisfaction which was evidenced by 2005 NDNQI resurvey results in both units. jchapman2@maine.rr.com

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

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

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

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

Jay L; Seton Medical Center; Tex

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

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

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

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

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

Cox L, McAdams K; Memorial Medical Center; Pa

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

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

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

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

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

Brown D; Hoag Memorial Hospital Presbyterian; Calif

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

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

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

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

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

Lepman D; Hoag Memorial Hospital Presbyterian; Calif

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

Foreign Educated Nurses: A Smooth Transition Into a Unit Culture

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

Purpose: Our unit has a large multicultural nursing staff, which can result in miscommunication due to varied ethnic views and practices. We wanted to improve our cultural diversity and embrace our unique staff. New, foreign educated nurses are particularly vulnerable due to the numerous barriers they need to overcome such as culture shock, both verbal and nonverbal language. Since, it is essential to care for all patients safely and competently, it became imperative that we react quickly to meet this challenge. A group of multicultural nurses met to develop a system to welcome all newcomers, regardless of background and cultural beliefs that would help them acclimate to our unit and institution. Description: The workgroup included representatives from cultures across the progressive and ICUs. We made the decision to develop a system that ensured nurses receive tools to promote a positive work culture and community environment. Meetings were scheduled during mealtime in a social, relaxed atmosphere to ensure comfort. Members were encouraged to bring an ethnic “covered” dish to share their culture with the group. From these meetings, the idea of a “Welcome Wagon” was created. A group of nurses, from the committee and a representative from the unit, greeted the new nurse with a basket of information, including community and hospital information. This helped to acclimate the employee to the community as well as to the unit. Evaluation/Outcomes: There was an enhanced sensitivity to the needs of foreign educated nurses as well as increased self awareness by the existing nurses. The heightened awareness motivated this group to meet with leadership and hospital education to develop a program hospital wide. This opportunity will be offered during the orientation phase of employment, to help the foreign educated nurse transition more smoothly into the unit culture by jumping on the “Welcome Wagon.” mcbro004@mc.duke.edu

Stop the Revolving Door Syndrome—Critical Care Nurse Internship Program

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

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

Computerized Physician Order Entry: Nurse Input Is Essential for Success

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

Purpose: In our institution, there were several issues brought forward directly related to handwritten physician orders. There were mistakes in writing, interpretation and in cosigning verbal orders. A decision was made by the hospital to change from a handwritten system to a computerized physician order entry (CPOE) system. Traditionally, nurses are the last barrier for patient safety, yet are not often included in problem resolution, such as handwritten physician orders. A nurse was chosen to take the lead in planning for CPOE. Description: Once the decision was made, it became apparent that not only physicians should be involved in the process. Since nurses carry out orders, take verbal orders and write nursing orders, nursing needed to be a key player. Our step-down units became the first to undergo CPOE. Nurses, physicians and administrators, both clinical and from CPOE formed a group to identify, define and produce order sets that followed protocols, standardized orders and clinical practice guidelines. Once the process was finalized, the educational process began. Informational sessions were held for nurses and physicians so that each group could be familiarized in the use of CPOE. The nurses were educated about their own order entry process as well as the physician order entry process, since they would be involved in helping physician colleagues learn the system. CPOE was then implemented with a team of CPOE representatives in conjunction with the clinical team. An oversight committee was established to ensure smooth implementation throughout the hospital. Evaluation/ Outcomes: There has been a definite increase in nurse satisfaction as the nurses feel more valued. Patient care is now more efficient. No longer do nurses have to “hunt down” doctors for orders or for cosignatures. Orders are processed directly with the departments rather than having to use the nurse as a middleman. Although CPOE was started for physicians, it has become a salvation for nursing. mcbro004@mc.duke.edu

Promoting Professionalism: Rewarding National Certifications

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

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

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

Asleson A, Jacobs P; Mercy Hospital; Minn

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

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

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

Purpose: We believe that nurses are natural clinical problem solvers. Submitting poster abstracts for the AACN-NTI presents an excellent opportunity to share solutions professionally. However, many of our nurses feel intimidated when thinking about how to showcase their work. Description: Several of our staff members have had posters displayed at past NTIs. Building upon this experience, we organize a brainstorming meeting in the early summer to recall activities and projects of the past year that merit development into poster abstracts. We pair the interested nurses with a mentor who helps them write and polish the abstract. We expect that the mentor defers first-authorship of the poster to the mentee so that new staff get to attend the annual meetings. This also helps promote new membership in AACN. After we receive the notices about which posters are accepted, we provide more support to the presenters. We use a standard hospital template with our logo for the slide presentations. We have a distinct look for the display posters as well. We show the 11- by 17-inch proof copies of the posters during the hospital’s Nurses Week celebrations. At the NTI the poster presenters also spend time in our recruitment booth talking to conference participants. The hospital covers a substantial part of the expenses to attending the meetings. After the meetings our corporate publication lists all the authors for each abstract. Our local AACN chapter displays the posters the following year at the annual symposium expanding the audience even more. Evaluation/Outcomes: We began this drive to encourage more of our nurses to attend the NTI and to present their creative solutions. We had seventeen posters displayed at the 2005 NTI. The nurses return with a renewed enthusiasm for their work and a commitment to participate in AACN and other professional organizations. This enthusiasm has spread to nurses in other departments at our hospital who now submit abstracts to their professional societies using a similar mentor-mentee model. cmb0806@bjc.org

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

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

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

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

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

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

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

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

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

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

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

Purpose: When implementing a new intravenous (IV) insulin protocol in our cardiothoracic surgery (CT) ICU and step-down units, we discovered the need for an endocrine specialist to collaborate with the healthcare team, and to educate staff and patients. We also needed someone to medically manage patients to optimize glycemic control. Description: At any given point, up to 75% of ICU patients are hyperglycemic, yet rarely are patients admitted to the ICU specifically for glucose control. Diabetes is frequently much lower on the problem list. Research demonstrates controlling blood glucose levels, particularly in the ICU, decreases mortality, reduces length of stay, and decreases postoperative complications such as infection, renal failure, and critical illness polyneuropathy, thereby saving healthcare costs. Hospitals need a clinical expert to direct patient care and assume responsibility for the continuation of diabetes management beyond an IV insulin protocol. Our clinical pharmacists could manage patients whose diabetes was previously controlled and transition them back to their appropriate home medications. But, it was an unrealistic to expect new rotating surgical house officers to learn the fine nuances of medical management of newly diagnosed or poorly controlled diabetes. Because clinical endocrinologists are in high demand and short supply, a ripe opportunity existed for a nurse practitioner (NP) to fill the void. The new NP started in this role and within 3 days the new protocol began. Through a unique collaborative practice with nurses, pharmacists, and multispecialty physicians, we initiated effective, evidence-based medicine. Evaluation/Outcomes: Our average blood glucoses and sternal wound infection rate have decreased. We are safely using IV insulin in the CTICU and throughout the inpatient care arena thus, achieving glycemic control from the operating room to discharge and preventing associated surgical complications. mabre002@mc.duke.edu

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

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

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

Poster Abstracts

After the Code: Supporting Each Other

Elchos S; The Methodist Hospital; Tex

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

Peer Evaluations in the PICU

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

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

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

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

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

Critical Care Certification: Raising the Bar!

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

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

Learning Research Together in a Hospital/Academic Partnership

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

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

Teaming Up With Staff Nurses: Bringing Research to the Bedside

Cuipylo K; Winchester Hospital; Mass

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

Dividing the Tasks: Doubling the Success! ICU Collaboration

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

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

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

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

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

Hi-Top Sneakers Improve Patient Outcomes

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

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

Portable Teaching Aides Benefit Patients and Staff

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

Purpose: Many times it is not easy to understand a simple, commonly performed procedure. We found this to be a problem in our interventional radiology department. Patients having a Port-a-Cath (port) placed often do not understand how or where the port will be implanted or how it will be used. Many verbalize anxiety and fear about having a port. We also discovered that many of our newer staff members had not worked with ports before. The staff did not understand the differences between tunneled and nontunneled lines. We sought to implement a creative solution to meet the teaching and education needs of our patients and our staff. Description: We created a portable teaching board to address this problem. We drew an outline of a human chest, including major blood vessels, on a piece of foam-core poster board. We attached a real port to the drawing using Super Glue. We placed the port at its approximate insertion site into the body. We then covered the chest drawing with craft foam and cloth felt to simulate the overlying skin. We attached the “skin” to the foam board using Velcro for easy release and replacement. The teaching board allows patients and staff to visualize how the port is likely to appear from the outside. They can touch the board to see how the port and the tunneled line might feel under the skin. We can remove the “skin” to show how the physician implants the port in the body. We can also demonstrate how we access the port later for blood sampling and medication administration. Evaluation/Outcomes: The patients and staff members received the portable teaching board with enthusiasm. Patients now verbalize a better understanding of the procedure and appreciate the hands-on approach. Newer staff members also have a better understanding of the differences between tunneled and nontunneled lines. We find this portable teaching board to be an effective teaching method for both patients and staff. neb3116@bjc.org

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

Brown D; Hoag Memorial Hospital Presbyterian; Calif

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

Pulling Out All the Stops: Conquering Postoperative Constipation

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

Purpose: Postoperative constipation is related to many factors including general anesthesia, narcotic analgesics, decreased activity, poor hydration, altered diet with low fiber, and medications such as iron supplements. In our thoracic surgery patient population, we had little patient education by nurses about the importance of taking prescribed stool softeners and laxatives when also taking narcotic analgesics. The problem of constipation continued after discharge with distress calls from patients about their discomfort. There were even several readmissions for small bowel obstructions due to bowel dysfunction. Although the literature focuses on constipation in the oncology population that takes opioids to relieve pain, there is little research on constipation in the general surgery patient population. Description: We used a multipronged approach to address this problem. We educated the nurses about the importance of giving the patients the prescribed stool softeners and laxatives when giving narcotic analgesics. We paid attention to hydration to be sure that patients receive sufficient oral or intravenous fluids. We taught the patients about the importance of taking stool softeners and/or laxatives. We gave details about nutrition, hydration, and activity strategies as they relate to overcoming constipation and promoting postoperative healing. We explained how abdominal discomfort due to constipation aggravates postoperative pain. We reminded both the physicians and the advanced practice staff to prescribe sufficient laxatives at discharge. Evaluation/Outcomes: Since we began this program of patient education we have had no readmissions for postoperative bowel dysfunction. Our patients are happier because they have better pain control with fewer side effects. They are more likely to participate in their home activity regimen if they are pain-free and have normal bowel patterns. We are proud that our thoracic surgery nurses are engaged in a proactive role in discharge planning for home care. adl5362@bjc.org

Pharmacology in the Pediatric During Emergency

Egman S; IsMeTT- UPMC- Italy; Iowa

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

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

Gooding M; Seton Northwest Hospital; Tex

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

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

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

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

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

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

Purpose: To design and implement a successful protocol for tight glycemic control in MICU patients that could be applied to all ICUs. Also, to decrease morbidity, mortality, and length of stay (LOS) by implementing stricter glycemic control (80–110mg/dL) in MICU patients. The intention was to foster a culture of safety based on a consistent and standardized protocol for all ICU patients. Description: We are all aware of the benefit tight glycemic control has in critically ill patients. However, for the MICU population, there is a lack of data for such tight control. The MICU at Henry Ford Hospital has been using TGC protocols for more than 2 years. Protocols were developed and implemented with limited success. Staff was presurveyed to target problem areas and to evaluate understanding of the current protocols. An interdisciplinary collaborative team was formed to redesign and standardize the protocol for the 5 different ICUs (124 beds). The team used a PDCA approach to revise the protocol. Process measures tracked were glucose readings, percent of readings below 50, and daily compliance with the protocol. Implementation involved reeducating staff on the new tighter protocol with a focus on pathophysoiology of hyperglycemia, and sharing specific evidence-based findings for the MICU. Daily interdisciplinary rounds addressed compliance with the protocol on every patient. Compliance audits were completed to evaluate the progress and for process improvements. Evaluation/Outcomes: A multidisciplinary PDCA approach to TGC in MICU achieved our goals. Overall, the percentage of glucose readings between 80–150 mg/dL has increased from 27.1% to 67.35% with only a 1.15% incidence of glucose readings below 50. The incidence of LOS decreased by 14.6% or by 0.67 days. An additional outcome was our BSI rates decreased by 65% in the last 6 months. chalash1@hfhs.org

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

Harrison D; Harborview Medical Center; Wash

Purpose: A standardized sedation protocol is essential in preventing oversedation in patients receiving mechanical ventilation. Description: Mechanical ventilation is often necessary for patients in the ICU. Adequate sedation is often difficult to achieve without oversedating a patient. There are also comfort issues due to the ETT, high-frequency rates with low tidal volumes. Proper sedation and analgesia can ensure the patient more comfort and help in healing without oversedating. Deciding on the type of sedation, how much to give, and how often, changes with each physician who orders medications. Having a standardized protocol for sedation and analgesia is helpful for new residents and attending physicians. Before starting the protocol, the ordering physician is referred to a flow sheet to assist in selecting the appropriate sedation and analgesia for the patient. There are 2 choices of analgesia, sedation, and 1 antipsychotic. The protocol gives exact doses and frequencies of bolus doses and the initiation of a medication drip if the boluses are not effective. Pain can be rated on a numerical rating scale or by physiologic descriptors. Sedation is graded on a Modified Ramsay Scale. The sedation goal is that the patient is able to open his or her eyes when asked or stimulated. A sedation vacation is ordered every morning to evaluate sedation and decrease the amount they are getting if possible. This allows for spontaneous breathing trials to be performed every morning. Evaluation/Outcomes: All patients receiving mechanical ventilation are placed on the sedation protocol. The protocol takes the guessing out of ordering proper sedation for these patients, which in turn prevents patients from being oversedated. seal223@hotmail.com

Parental Satisfaction Increases With Involvement in Bedside Rounds

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

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

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

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

Purpose: Rapid deployment extracorporeal membrane oxygenation (RD-ECMO) was instituted in October 2004 to improve the outcomes of patients in respiratory and cardiac failure/arrest by expediting cannulaltion and the initiation of bypass. The demand for immediate OR assistance and supplies in RD-ECMO cases and their inability to respond quickly created the challenge to duplicate part of the OR nurse role. PICU nurses trained to be circulating, and scrub nurses in emergency bedside surgery became part of the RD-ECMO team to further facilitate this process. Description: The PICU in conjunction with the OR nurse educator developed an education program highlighting training in specialty supplies kept in an OR cart maintained on the unit, identifying and passing instruments, sterile technique and the use of a bovie and headlamp bought by the PICU. Teaching was in the form of in-services and classes that targeted all PICU nurses. Evaluation/Outcomes: Since October 2004, 55 nurses (80%) work with the OR cart, which has been available at 100% of the 18 RD-ECMO cases. Making these supplies quickly accessible to the surgeon has shortened response time. Since June 2005, 26 nurses (38%) have completed the course and 4 have scrubbed into the all of the last RD-ECMO cases affording the opportunity for immediate cannulation upon the surgeon’s arrival. The average time to ECMO has gone from 2 hours to <1 hour in the past 10 months. Time wasted waiting for OR assistance and materials has been alleviated by adding this new skill set to the PICU nurses repertoire. ddonovan29@yahoo.com Sponsored by: Children’s National Medical Center, Washington, DC

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

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

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

Freezing Frenzy: Induced Hypothermia After Cardiac Arrest

Kupchik N, Balmer S; Harborview Medical Center; Wash

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

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

Lewis L; Carolinas Medical Center; NC

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yes, You Can Ambulate Patients With Chest Tubes to Suction

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

Purpose: Chest tubes are integral components in the care of thoracic surgical patients. Sometimes they have sustained air leaks (2 days to 2 weeks) after thoracic surgery due to the type of the operation or the underlying anatomy. Keeping the chest tubes to suction prevents accumulation of air and development of a tension pneumothorax. Removing suction puts patients at risk for either of these potentially serious complications. However, chest tubes interfere with the patient’s mobility that is so important after surgery. Wall-suction tubing to the chest drainage unit limits the distance that patients can walk away from their beds. Description: Early mobility helps prevent the complications of bed rest, increases patients’ strength and endurance, and promotes their preparation for discharge. We collaborate with both physical therapists and pulmonary rehab specialists to ensure that our thoracic surgery patients ambulate at least several times daily. In order not to limit walking distance to the wall suction tubing length, we worked with the vendor of our chest drainage system to find a reliable battery-operated suction pump. We connect the 11-lb (5 kg) pump to ambulation equipment or set it in the seat of a wheelchair. The pump allows the patient to remain connected to the prescribed level of suction. The patient then walks with the help of our nursing staff or our physical therapists. The 2-hour rechargeable battery maintains suction whenever the patient is walking, or when the patient leaves our unit for tests such as radiographs or CT scans. We surveyed the staff about the durability, ease of use, portability and battery life of this portable suction pump. The surveys were overwhelmingly positive. Evaluation/Outcomes: We now have a safe system to maintain chest tubes to suction while allowing patient mobility. We also use this portable pump when our patients walk on a treadmill in pulmonary rehabilitation. Having a chest tube air leak is no longer a barrier to early ambulation, physical therapy and rehabilitation. amp2645@bjc.org

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

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

Purpose: The CVR staff are expected to act as scrub nurses when opening a critically ill patient’s chest at the bedside. Because of the infrequency of the procedure, staff were nervous and hesitant to assist the surgeon. To promote confidence and improve the staff ’s knowledge, we needed to have a way for the staff to identify the procedure and instruments involved in opening a chest. Description: A CVR nurse with one of the scrub nurses from the heart team opened the chest splitting tray, to review the instruments in the tray. The scrub nurse then identified the instruments, labeling them and assisting the CVR nurse in taking pictures of the instruments. The procedure for opening a chest was reviewed and broken into section, similar to the ACLS algorithms. The pictures and chest splitting procedure were organized in a 1-inch notebook, with plastic protectors. To further assist, the chest splitting cart was arranged to follow the book. The book and a blue bin were placed on the top shelf with everything needed to initially open the chest. This prevented the staff from having to run around the unit or fumbling on the cart, looking for the items they needed. Once, the book, bin, and cart were organized, all the staff were in serviced and tested on the information. Evaluation/Outcomes: Evaluation is ongoing because of the infrequency of the procedure. Staff evaluation of the book, bin, and cart has been positive. The book is easy to use during the procedure; it can be held up and the pictures easily seen by the nurses in the sterile field. With new staff coming into the CVR, it has made it easier to teach them about the chest splitting procedure. The staff ’s confidence in assisting the surgeons has improved. The staff now review it yearly, for part of their CVR competency skills. JudiAnn55@aol.com

Impact of a Tight Control Insulin Protocol

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

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

Critical Care Nurse Presentations During Bedside Rounds

Stafford A; Harborview Medical Center; Wash

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

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

Staul E; Legacy Health System; Ore

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

Leech Containment: Stop That Wayward Worm

Taylor J; University of Chicago Hospitals; Ill

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

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

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

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

Making a Case for Induced Hypothermia After Cardiac Arrest

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

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

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

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

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

Promoting CCRN Certification in NYPH Weill Cornell Medical Center

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

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

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

Thomas T, Walsh R; Washoe Medical Center; Nev

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

Grass Root Efforts To Impact House-Wide Tobacco Cessation Program

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

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

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

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

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

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

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

Purpose: Developing and implementing a diabetes education program in a cardiothoracic (CT) ICU and step-down unit was imperative for patient safety. With the increased use of insulin in the CT patient population there was an increase in adverse drug events. Insulin has had a high association with adverse drug events nationally. Many errors occur because of a lack of knowledge of diabetes and treatment. An education program was needed to address these errors. Description: The endocrine nurse practitioner and the CT clinical nurse specialist collaborated to address this problem. An extensive analysis of reported errors identified deficits related to order entry and transcription, administration of insulin, and nursing knowledge. A comprehensive program was developed and implemented to educate the staff on diabetes, care management issues, and safe use of insulin with the CT patient population. A series of 6 classes on diagnosis, insulin, oral medications, nutrition, discharge education, and patient care scenarios was developed with specific learning objectives for each. The classes were offered during staff lunch breaks where food was provided and were repeated to allow all staff to attend. Contact hours were awarded for attendance. Evaluation/Outcomes: As hoped, the timing of the sessions and enticements promoted staff attendance. A majority of the staff was able to attend one or more of the sessions. Monitoring of adverse drug events after the education program revealed a marked decrease in the number of events related to insulin administration. Attendees evaluated the sessions and reported increased knowledge they were able to incorporate into practice immediately. apter001@mc.duke.edu

Team Building Through an Interdisciplinary Journal Club

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

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

Wanted-CCRNs: Engaging a Culture of Certification

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

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

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

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

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

Collaborating to Expand Skills Day Throughout a Medical Center

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

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

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

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

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

Staff Nurses Starring: ICU Curriculum Classes

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

Purpose: The ICU and progressive care units in our tertiary care hospital identified the need for improving education to new staff. Although orientation gave orientees the information to function safely and competently, we developed an additional plan to reinforce the core curriculum by specifically addressing the unique flow and care of our patient population. Description: In collaboration with the nurse educator, the unit preceptors presented a class in skit format designed to include care of cardiology patients representing various levels of acuity from admission to discharge. The skit began with a staff nurse playing the role of a patient from a different cultural back ground who was admitted with unstable angina. A discussion of cultural sensitivity ensued. Other nurses admitted, assessed the “patient,” and intervened as she became unstable. The “patient” was sent emergently to the interventional cardiac catheterization lab where she had an angioplasty and intra-aortic balloon pump (IABP) placed. Discussion regarding the angioplasty was lead by a cath lab nurse. The “patient” was then transferred to the CCU for further care. The skit included a preceptor teaching a new orientee the routine care for the patients with an IABP and a discussion of frequently used medications. The “patient” was eventually transferred back to the floor and discharged home. Evaluation/Outcomes: This unique teaching methodology not only encouraged interaction by both new and old staff but was entertaining, keeping the participants interested and engaged. ICU nurses better understood the care of patients on other units and the unique difficulties that staff nurses there might face. They learned about resources used on the other units that could be used in their own areas. Some voiced interest in floating to the other floors for experiences. Feedback from participants was resoundingly positive. Additional class days are currently being developed with different patient scenarios and skits. davis066@mc.duke.edu

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

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

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

Medication Assessment: Reject, Revamp, Rethink

Dixon J; Baylor University Medical Center; Tex

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

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

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

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

Designing a Hospital Learning Lab: Answering the Competency Question

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Because the Night Time Is the Right Time

Hylton C; Tampa General Hospital; Fla

Purpose: To find a means to provide evening and night shift nurses with mandatory and optional educational offerings without having to stay after their scheduled shifts and respecting their days off. Description: Tampa General Hospital created a position for a night shift educator. Now available at night are cardiopulmonary resuscitation classes, nursing grand rounds, night shift fairs (education, wellness and communication), at least 1 night shift CEU program every month, and multiple in-services as well as clinical ladder assistance. In addition, 6 night shift hospital committees now exist. The night shift educator not only supports our clinical expertise, but also our leadership skills and advancement by assisting and encouraging staff to present in-services on their units. Our educator was also responsible for bringing certification to the night shift. We have had trauma nurse core certification, advanced burn life support and end-of-life nursing Education Consortium certification classes all at night. The educator also compiles and distributes a Tampa General Hospital Night Education Night Owls monthly newsletter. The night shift educator works various hours each week to allow coverage for evening and night shift, as well as at least 1 Sunday night shift per month to meet the needs of the weekend specific staff. Evaluation/Outcomes: Before inception, 75% of clinical ladder participants were day shift nurses. Now that clinical ladder requirements are able to be met conveniently, many more night and evening shift nurses are either participating or seeking clinical ladder status. The number of hospital-based committees has developed from 0 to 6. The last end-of-life class had 40 nurses become nationally certified. Ninety four nurses attended the night Wellness Fair, an event that would have previously been lacking in night shift representation. Now the night shift employees are not left in the dark and are truly and member of the healthcare team. cah33511@yahoo.com

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

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

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

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

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

Purpose: Neurological patients requiring lumbar drainage are assigned to the ICU or the critical care step-down unit in an attempt to improve and standardize evidenced-based care for this population. Because lumbar drains are a high-risk low-occurrence event on the step-down unit there was a need for an “in-time” reference tool. Description: The Neuro-Trauma Clinical Action Team (CAT) on the critical care step-down unit consists of 4 unit RNs, unit-based educator, clinical nurse specialist, and neuro-trauma nurse clinician who meet monthly for 4 hours. A goal of the group is to bring evidenced-based care to this population of patients. The team felt the most appropriate format for this tool was a 3-ring binder divided into sections. This reference includes sections for lumbar anatomy, indications for drain placement, postplacement care issues, CSF collection, complications, troubleshooting, order-set, and lumbar drain guidelines by the American Association of Neuroscience Nurses. Other sections contain 4x6 color pictures using a CAT member as the patient. The photographs provide a visual reference with set-by-step instructions in the care of the patient with a lumbar drain. Some pictures include, supplies, external drain and monitor system, patient positioning with head-of-bed restriction, clamping procedure during patient mobilization, leveling of drain to reference point, and changing the drainage bag. Evaluation/Outcomes: This quick and easy visual reference was eagerly anticipated by the step-down unit staff and has become an option for use with new employee orientation. Staff appreciate the photographs and say “a picture is worth a thousand words of description.” christine.katers@allina.com

The Weekly Wonder: Did You Ever Wonder Why? A Novel Approach to Staff Education

Leonard T, Xikis M; Stony Brook University Hospital; NY

Purpose: There is a constant need to provide education, which should start with the same base knowledge. From there the standards of care can increase. However, preceptors can share only their experience with the current patient population, not always the typical patient. Missed educational opportunities do exist. The Beacon Unit Award sets the standard of 5 hours per month in-service time. To meet the education needs of a busy cardiac catheterization staff, a bulletin board titled the “Weekly Wonder” was placed in a central hallway that all staff accessed at one point in their day. Description: The “Weekly Wonder” was created to provide an increase of education/in-services for the unit in a unified standard method. Every week different topics are presented. Initially, the topics concentrated on basic cardiac concepts, and later included some critical concepts such as ventricularized or dampened waveforms. Then low-volume, high-risk procedures were reviewed such as Flolan administration. Equipment overviews were also done, such as IABP checks, initial setup and timing triggers. Presentations are done in Power Point, ranging from 4–15 slides. The presentations review the current evidence-based practices, facility or unit policies, and include the correct staff action/response/role to the “idea/wonder.” Slides include actual pictures when possible to capture visual learners. Evaluation/ Outcomes: In a nonthreatening way, basic concepts are reviewed and expected staff responses can be corrected. Keeping information posted over a weeklong period allows staff to visualize information repeatedly, be introduced to evidence-based practices, reaching even the resistant. Some attending physicians review the weekly information, offering critiques. Presentations are expected, and staff requested specific information. Each presentation is saved in a binder, kept as a resource. Future presentations can come from surveys or unit based needs assessments. theresa.leonard@stonybrook.edu

Engage and Transform: Supporting Critical Care Certification

Lovasik D, Potersnak K; UPMC Presbyterian; Pa

Purpose: At UPMC Presbyterian, the flagship hospital of the University of Pittsburgh Medical Center, we support nurses who are seeking their national critical care nursing certification and believe certified nurses demonstrate pride in their work and validate their own competency in critical care. Description: UPMC has a sustained and sincere commitment to nurses who choose to certify in their specialty. Certification has been incorporated into our Clinical Advancement Program (CAP) as a prerequisite for advancement to the Senior Professional Staff Nurse position. In addition to creating a “culture of certification,” we support the nursing staff through education and preparation as well as financial incentives. This includes providing free certification classes, assistance with study groups, facilitation of scheduling for test preparation, and reimbursement for successful completion of certification. We recognize newly-certified nurses through a “congratulation” letter, the gift of a certification pin, unit-based celebrations and proudly announce their accomplishment in our nursing newsletter. Our certified nurses are celebrated through unit-based displays including plaques, galleries of certification awards and “Walls of Fame” that include photos of the certified nurses. Nurses’ Week is a unique time to celebrate nursing and the names of all of our certified nurses are prominently displayed. In addition, we provide an abundance of free continuing education materials and programs to assist with certification requirements. Evaluation/Outcomes: In 1999, there were 40 CCRNs in our hospital. Through our efforts, we have increased our CCRNs to 112 and added 4 PCCNs over a 6-year period. These nurses take great pride in their accomplishments and mentor/foster others to attain their certification. Certification fosters a culture of professionalism and dedication, and we are proud to work with these nurses on a daily basis. lovasikdj@upmc.edu

Using TEAM Teaching Strategies to Enhance the Cardiac Education Program

Marzlin K, Webner C; Aulttman Hospital; Ohio

Purpose: The Heart Center’s multilevel education program lacked optimal cohesiveness among its 36 bedside clinicians who serve as clinical instructors. The instructors individually planned their classes, but did not work as a team to create a flow between classes and workshops were often perceived as disjointed. Our goals were to increase the cohesiveness and synergy of the clinical instructors, maximize the effectiveness of the staff education program, and have fun on the journey. Description: A team teaching concept was implemented. Instructors teach on only one team and are able to focus on specific content for the developmental level of the curriculum. The team integrates the clinical content of their classes and develops creative teaching strategies throughout the workshops. A team challenge was introduced where teams compete for prizes based on team spirit, innovative teaching strategies and satisfaction scores. A detailed scorecard is used to track team results. The TEAM acronym is used to describe our philosophy: T (Together We’re Better), E (Excelling as Educators), A (Applying Knowledge to Practice), and M (Making a Difference). Evaluation/Outcomes: The overall effectiveness scores for the levels where team teaching was implemented improved significantly from 2004 to 2005. Level I score has improved from 8.9 to 9.4; Level II from to 8.4 to 8.7; and Level III from 7.8 to 8.5. The overall effectiveness score includes the developmental level of the class, instructor effectiveness, class content, and teaching strategies. Instructors have increased autonomy and increased synergy with the new team concept and this has led to increased effectiveness. In addition, there has been an improvement in the efficiency of logistical operation of the program because of new team accountability. Having defined team members and measurable outcomes can focus a team to achieve more and creating a sense of fun competition among teams can challenge and enhance performance. Keychoice1@yahoo.com

Quick Reference Cards: They’re Not Just for Drug and Assessment Information Anymore

Metersky S; Grant Medical Center; Ohio

Purpose: A method of obtaining simplistic instructions on the use of equipment was necessary to ensure patient safety. CCU is a widely diverse unit serving high-acuity medical and surgical patients. Numerous equipment is utilized; however, some equipment is not used on a daily basis but reserved for emergency procedures and high-risk, low-volume situations. Description: Many avenues have been employed in initiating and maintaining competency of equipment such as on-unit inservicing, on-unit library of operational manuals, and mandatory annual skills days. Even amidst efforts to maintain competency, staff continued to feel inadequate in their use of equipment that was used infrequently. Familiarizing oneself with equipment is a stressor especially when a patient’s status is unstable, when models of equipment vary within the institution, and when nurses are floated to different critical care units. The development of reference cards became an apparent need. Quick reference cards were created and are attached to the equipment with abbreviated instructions for set-up, use, and pertinent monitoring values. There is a designated location in the nursing station for placement of additional cards in case originally placed cards are inadvertently dislodged from the equipment. Examples of implemented equipment quick reference cards include defibrillator, MRI-compatible IV pumps, epidural infusion pumps, Refox PA catheter, VAC therapy, and hemochron machine. Evaluation/Outcomes: Utilization of equipment quick reference cards has increased the comfort level of the nursing staff and has added a safety level of proper equipment usage. These reference cards have proven to be time efficient by decreasing the need to find other staff members that are more experienced with the equipment and by having readily accessible instructions for “walk through” of the equipment set-up and use. In addition, staff have reported quick reference cards to be useful when orienting new nurses. smetersk@ohiohealth.com

Small BITES: Bringing Information to Every Staff—Delivering Education to Critical Care Nurses

Michalopoulos H, Taylor J; The University of Chicago Hospitals; Ill

Purpose: At the University of Chicago Hospitals there are 6 critical care units with a total of 63 beds. On any given day, there are approximately 70 nurses who care for patients in these units. The ideal, teachable moment is not always available to us as educators working in these busy settings. In the past, planned teaching sessions were difficult for nurses to commit to while on duty due to a number of factors, including workload, patient acuity, and time. However, as a basic necessity of life, nurses could usually find time to have a meal whether it was a cup of coffee or something quick to eat. Therefore, we targeted meal times as the perfect opportunity for teaching and learning. Description: Determining which educational methods worked well for our nurses was a challenge. Multiple needs assessments showed that most nurses preferred short, 30-minute education sessions along with inservices that included case-reviews as the preferred method of learning. Adapted from a previously successful teaching strategy, mealtime education sessions were introduced. Two 30-minute, “lunch and learn” sessions were provided for the day staff, followed by two 30-minute “teach at 10” sessions for the night staff. Based on feedback, topics were chosen to facilitate the nurses’ own educational needs. Posters were distributed advertising the sessions, and food was provided as an incentive. PowerPoint presentations were created which included case-reviews to facilitate the application and transfer of knowledge. Evaluation/Outcomes: Evaluations were distributed at the end of each session, and positive feedback was received from everyone who attended. Over 54% of the nurses working on the day of our first session attended the inservices. This was quite an achievement based on previously poor attendance results. Providing critical care nurses with opportunities for learning during meal times proved successful in our facility. Preparation for upcoming sessions is already in the works. helen.michalopoulos@uchospitals.edu

ECMO: Extraordinary Collaboration in the Midst of Opportunity

Mowry J, Holzhueter S, Shirato A, Remenapp R, Dean P, Ferguson A, Watts J; The University of Michigan Health System; Mich

Purpose: On May 17, 2005, nursing leadership of a 14-bed thoracic ICU learned adult cardiac ECMO (extracorporeal membrane oxygenation) patients would be cared for in TICU as early as July 1, 2005. Our goal was to formulate a comprehensive educational program, including competencies, presented by ECMO team colleagues to over 50 nurses; and be prepared to give exemplary care to adult cardiac ECMO patients within 45 days. Description: The TICU CNS collaborated with a senior ECMO nurse to develop an educational program built upon knowledge TICU nurses had of cardiac surgical patient care. Mandatory 1-hour staff education sessions occurred 4 times a day on both shifts, every other day, for 2 weeks, including weekends. Education was completed for 96% of the staff by June 25. Educational content included presentation of ECMO historical information, pathophysiology of ECMO patients, procedures, ECMO and TICU staff teamwork, troubleshooting the circuit, emergency situations and family-centered philosophy. ECMO circuitry was demonstrated and reference materials were provided. On-line competency instructions were given; results are forthcoming. TICU staff were encouraged to visit SICU and pediatric ICU to observe ECMO cases. Evaluation/Outcomes: The first cardiac ECMO case arrived in TICU on August 10, 2005. Nurses, ECMO staff and medical staff agreed this was an optimal first case related to early notification of the admission; the patient room had adequate space for ECMO equipment, a telephone, and computer; the same two 12-hour shift TICU nurses cared for the patient during his stay; and ECMO was weaned off successfully. The TICU staff involved in the direct patient care believed the preeducation was adequate preparation. In addition, ECMO nurses at the bedside were excellent teachers. The patient’s successful outcome and staff pride in a job well done was a result of extraordinary collaboration in the midst of opportunity. jole@umich.edu

Using Posterboard Games to Teach 12-Lead EKG

Fullo-Sheehan T, King M; Sharp-Grossmont Hospital; Calif

Purpose: Gaming is an instructional method requiring the learner to participate in a competitive activity to accomplish educational objectives. During a 12-lead EKG class, gaming was introduced after the lecture presentation to reinforce new information, and to stimulate learners to use problem solving and critical thinking strategies. The goal was for learners to win the game by applying their new knowledge and rehearsing old/new skills. Description: During the gaming portion of the 12-lead EKG class, the author used different types of poster board games such as Tic, Tac, Toe, Jeopardy, and the Mix and Match Board. The poster boards were eye-catching, attractive, and stimulating. The combined visual, auditory, and kinesthetic learning addressed the different learning styles. Students were divided into 2 groups based on the color of their nametags. One group played Tic Tac Toe, while the other group played Jeopardy. The team that gave the first correct answer to each question earned 5 points. If one of the answers was not correct the other team got a chance to steal the other team’s accumulated points. If neither team answered the question correctly, the instructor discussed the correct answer. Questions were asked in progressive order from simple to complex and most required a more in-depth group discussion. This strategy provided an opportunity to discuss alternate methods and techniques, share knowledge and skills, and promote group belonging. The team that earned the most points at the end of the game was declared the winner and received a group prize. Evaluation/Outcomes: Based on the evaluation summary after the presentations, 100% of the learners felt that gaming contributed to their learning of the 12-lead EKG concepts. These learners thought that gaming was a good teaching strategy used in combination with lectures, case studies, and demonstration/return demonstration and should be included in other classes. theresa.fullo-sheehan@shapr.com

Critical Care Nurse/Teacher/Mentor—Staff Driven Unit-Based Education

Stupak D, Cedeno L; Lehigh Valley Hospital and Health Network; Pa

Purpose: Embracing their role as teachers and mentors, critical care nurses developed a unit-based learning module program to facilitate staff orientation, continuing education and professional development. Description: A community hospital critical care unit underwent a major transition following the hospital’s merger with a large health network. Unit scope of services changed to include cardiac surgery, introducing a more intense level of care. In addition, staff moved to a newly constructed unit with state of the art technology and equipment. Experienced critical care nurses, along with inexperienced nurses joining this established team, were challenged with learning new skills and expanding their knowledge base. Two staff nurses recognized the need for unit based education and collaborated with the Patient Care Specialist to develop a learning module program. Modules are designed to promote independent and collaborative learning, familiarize the learner with Practice Protocols, review evidence based practice theory, and to foster critical thinking through case scenario discussion. Clinical topics addressed include critical care pharmacology, patient/family education, appropriate use of equipment and alarms, documentation, communication, and managing complications. Preceptors support staff in using the modules and facilitate case scenario discussions. The 2 coordinators developed the first module, then mentored colleagues in developing a second. All nurses who develop modules serve as mentors for future module development. Evaluation/ Outcomes: Learners evaluated individual modules and, based on feedback, changes were implemented as appropriate. Staff evaluation of modules and of the program has been positive. According to unit staff and leaders, “the program fosters nurse autonomy and professional development and provides nurses with an opportunity to explore roles as educator and mentor.” Staff has embraced the professional practice model, taking ownership of education and professional development.

Making It Last: Helping Staff Remember Skills Competencies Throughout the Year

Suntrup M; Barnes-Jewish Hospital; Mo

Purpose: In a busy cardiothoracic unit, there are numerous skills that must be validated each year. It is unrealistic to expect staff to remember all of the information that is covered in a 4-hour period. In the past, skills information consisted of multiple handouts placed folders, which were often misplaced. We sought a way to present the information in a format that was user-friendly and more accessible to staff when they needed it. Description: Information including policy and procedures, previous handouts and quick references from manufactures was compiled and condensed into easy to read formats. A 132-page book was developed and organized into major categories including cardiac, respiratory, assist devices, infusion pumps, medications, and miscellaneous equipment and procedures. The book was bound together using a comb binder and then distributed during our annual skills day sessions. Evaluation/Outcomes: The skills books were well received by staff. During skills day they provided easy access to information that was covered. Most staff keep their books available to use when needed. It has been reported that some have taken them to other jobs where staff have asked if they could get a copy. Additional books were passed out to new employees during their orientation. Ongoing revisions include additional categories and condensing information further. mas6678@bjc.org

A New Way to Earn Continuing Education Units

Walsh L; UC Davis Health System; Calif

Purpose: Our staff in the MICU have become accustomed to obtaining continuing education units (CEUs) through attending conferences and traditional classes. Some nurses are no longer able to attend lengthy conferences, so a new way for nurses to obtain some of their CEUs was developed. Description: A CEU survey was developed and attached to the time card for each of the 48 nurses working in the MICU. Seventeen of the surveys were returned over a 1-month period. The survey revealed that a majority of the nurses had only obtained CEUs through attending conferences and classes, and a number had let their CCRN certification lapse, some because of not obtaining enough CEUs. To introduce staff nurses to an alternative way of obtaining CEUs, a free CEU board was developed for the unit. A decorated bulletin board was put near the nurses’ station. Each month the CEU board nurse coordinator features 3 new free CEU offerings, some are written material with a test, and others are via Internet with explicit instructions on how to access the offering. Most of the offerings are for 1–3 CEUs, all are free and reviewed by this nurse prior to posting. Evaluation/Outcomes: Initial responses have been positive, some nurses were not aware of the many free CEU offerings that exist in written form and online. Many nurses would not have accessed these CEU offerings had they not been on the free CEU board. The topics covered are important in the care of medically complex patients, yet may not be covered in a traditional critical care class. A follow-up survey will be conducted in 6 months to determine how many nurses in the unit have taken advantage of the free CEUs and the number of CEUs the nurses in our unit have obtained in this manner. Lfridaywalsh@yahoo.com

CLIK: Cincinnati Learning Is Quick

Davis S, Williams J, Burns J; Barnes-Jewish Hospital; Mo

Purpose: In an emergency department that triages an average of 275 patients a day, it was evident that a rapid process was needed to increase the triage nurse’s ability to recognize potential stroke patients. The focus was the non-EMS patient, ie, drive in or walk in type, where the triage nurse is the first to perform an assessment. If a patient’s assessment was suggestive of a stroke, the triage nurse could quickly activate the stroke protocol process. This is important when the average ED wait can be over 3 hours and there is only a 3-hour window to treat the ischemic stroke patient. The process for identifying potential strokes needed to be quick and simple to implement, as 102 nurses needed to be trained. Description: Several standardized stroke assessment scales were evaluated for their ease to perform, time to assess, and ease of training. The National Institute of Health Stroke Scale (NIHSS) has multiple categories to score, 4 hours for training and can be time-consuming and difficult to use. The Glasgow Coma Scale also has 3 categories, can take up to 2 hours for training, and has several weaknesses. The Cincinnati Stroke Scale (CSS) consists of 3 questions or tasks, is used extensively in the EMS community, takes 10–15 minutes to train and is easy to complete. It was decided to use the CSS based on the ease for implementation and training. The emergency department educators completed the training of 102 nurses. Evaluation/Outcomes: All nurses were trained in a month and the assessment process was implemented. Most patients presenting to the triage desk are assessed for stroke. If any stroke symptom is recognized the stroke protocol is activated since patients with any 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke. Rapid recognition of an acute event can lead to early intervention for the ischemic or hemorrhagic stroke patient. The Cincinnati Stroke Scale has shown that learning is quick and gets results. sbd4906@bjc.org

The Big Freeze: Operationalizing a Therapeutic Hypothermia Team for Sudden Cardiac Death Patients

Hallinan W, Myers D, Lambert A; Strong Memorial Hosptial; University of Rochester Medical Center; NY

Purpose: Recent scientific papers have lead to the recommendation to induce hypothermia for comatose survivors of sudden cardiac death to improve neurologic recovery. The clinical protocol for such a treatment is multidisciplinary and can be emotionally difficult for families whose lives have been suddenly changed. Therapeutic hypothermia requires the initiation of cooling within 6 hours, cooling to 33° for 24 hours and maintaining effective paralysis during the period of hypothermia and rewarming. The challenge is to identify and rapidly evaluate potential patients, implement therapy in a timely fashion and care for families while they wait to see if their loved one awakes. Description: After several successful therapeutic hypothermia patients, Strong Hospital purchased the Artic Sun Cooling System. A process was developed to merge existing resources into a multidisciplinary team. An education initiative was undertaken with the emergency department to assist in identifying patients. A group page activation system created the “Artic Sun Team” that activates the MI team, the Stroke Team, and a cardiac critical care nurse. A competency and training program was undertaken for the cardiac intensive care nursing staff. The team responds to the emergency department and assesses the patient and begins therapy if necessary. Medical and nursing order sets were created specifically for hypothermia care, and a support process was created for families of patients undergoing hypothermia. Evaluation/Outcomes: The “Artic Sun Team” is activated 3–5 times monthly to evaluate patients for therapeutic hypothermia. The role of the critical care nurse has been extremely valuable as a coordinator, care provider and advocate. The team functions well together and has been able to foster a healthy working relationship with emergency medicine staff. Future directions include education of prehospital providers about therapeutic hypothermia and the early involvement of palliative care nurses. william_hallinan@urmc.rochester.edu

What Is a Clinical Resource Nurse and How Do You Develop Your Own?

Harrison C, Williams D; Barnes-Jewish Hospital; Mo

Purpose: To develop a team of nurses to assist in staff development. Description: Barnes-Jewish Hospital emergency department has more than 100 staff nurses and 45 patient care technicians. The nurse educator discovered the nursing staff was not getting important clinical information. It was difficult to contact all levels of nursing staff during different shifts. Clinical information was being distributed through email, bulletin boards, and mandatory in-services. The nurse educator wanted to make it easier for the staff nurses to get clinical information; she wanted to eliminate mandatory in-services and extra meetings. She tried completing in-services on her own, but soon discovered that for one person this was almost impossible with a staff this large and on this many different shifts. To facilitate communication of important clinical information and to clinically involve and develop more staff nurses, the nurse manager and nurse educator decided there should be a group of 4 experienced, clinically competent nurses. A mass email was sent out describing the new role and the job duties/expectations. Panel interviews were held to decide who would be best for the new role. The manager and nurse educator chose 5 individuals, and increased their pay, changed name badges to read “Clinical Resource Nurse,” and scheduled bi-monthly meetings. A detailed list of role expectations was also given to each new member. Evaluation/Outcomes: The development of this new team has helped achieve an increase in job satisfaction, empowered experienced RNs to achieve more and share their knowledge, and given staff more than just 1 “at-the-moment person” to contact for clinical questions. The staff now had clinical resources during all different shifts. crd5865@bjc.org

The Emergency Department Survival Guide

Williams J, Harrison C; Barnes-Jewish Hospital; Mo

Purpose: The CNS and nurse educator sought to create a complete department reference handbook for the nursing staff in the Barnes-Jewish Hospital emergency department. Description: Multiple reference tools were in use by the staff, most in the format of badge tags. Additional information on procedures, documentation, and processes were common requests from the staff. The goal was to provide a convenient reference book for all the staff that could be comprehensive and portable. A team was created to include 5 staff nurses, the CNS, and nurse educator. The first goal was to identify the appropriate content. The team met during a brainstorming session. All suggested topics were divided into categories. These included procedures, system specific assessments, documentation, triage, trauma and special patient populations. The team reviewed all the possible topics and determined the most appropriate list. Each of the team members had a specific body system or systems and procedures relevant to those systems. A 3-month period was given to review and research the assigned topics and complete the initial draft. Existing tools were modified for use in the new guide. All sections were then reviewed by the CNS and nurse educator, and edited for content and consistency of format. Once completed, the sections were converted to PDF format and taken to the publisher. The final product was provided to all nursing staff in the emergency department. Evaluation/Outcomes: The Survival Guide has been very well received by the staff. They have a small (3 inch by 5 inch) spiral bound guide that can be carried while working. The feedback has been positive with the following areas noted for improvement in future revisions: increase the size of the text, change the binding to allow for addition of pages or substitution of pages, create the same version to download on to a handheld PDA and place in on-line. jaj5264@bjc.org

Rapid Recognition and Treatment of the Septic Patient by the Development of a Nursing Protocol

Williams J, Harrison C; Barnes-Jewish Hospital; Mo

Purpose: Rapid recognition and treatment of the septic patient by the development of a nursing protocol. Description: The CNS and nurse educator sought to achieve successful implementation of the “Surviving Sepsis Guidelines” without the use of a special response team. They developed the Early Sepsis Recognition Nursing Protocol. It enables the nurse to screen every patient’s potential for sepsis, obtain diagnostic information, and begin resuscitation treatment if necessary. It screens each patient for the presence of 2 of 4 SIRS criteria and patient history for at risk conditions or current presentation of organ failure. Identified patients are enrolled in the protocol. A key support is the “sepsis pager.” All identified patients’ name, location, and arrival time are entered into a paging system that is used 24 hours a day. The CNS, nurse educator, and PharmD respond to the page as a resource for the nurses. During initial implementation, staff primarily asked for guidance with protocol specifics, equipment use, treatment algorithm questions, and antibiotic selection. The protocol provides standing orders for laboratory and radiology testing and fluid resuscitation. Patients may begin the fluid resuscitation from the protocol. Using a lactate level, patients with levels greater than 4 and nonresponsiveness to the fluid resuscitation are enrolled in EGDT. Evaluation/Outcomes: Using a nursing-driven screening tool to recognize potentially septic patients has significantly aided in implementing the surviving sepsis guidelines. It has demonstrated its effectiveness in early recognition of septic patients and therefore early initiation of treatment. In a comparison between pre- and postimplementation groups, key components of the treatment bundles are showing marked improvement. Obtaining serum lactate increased from 18% to 80%, administration of at least 20 mL/kg bolus of intravenous fluids increased from 51% to 80%. jaj5264@bjc.org

What Do We Do Now? An Innovative Nursing Approach, Assisting Families Through the Bereavement Process

Marin A, Spencer P, Lyman D; University Medical Center; Ariz

Purpose: The purpose of the quality improvement project is to improve bereavement support for the family, friends, and parents who lost a loved one at our hospital. A secondary goal of the project is to heighten awareness that nursing care in these circumstances often means shifting the focus from the dying patient to the living survivors. For the critical care nurse, this can often mean a paradigm shift in thinking. Description: Bereavement resources and materials for the survivors in our hospital were scarce. Traditionally, the only resources included a list of funeral homes as a part of the patient information death packet. Educational support for the staff on distributing the resources and opening communication related to bereavement was also limited. Evaluation/Outcomes: A multidisciplinary team of nurses, child life specialists, and social workers met to discuss the problem. Bereavement packets, now called “Next Steps,” were created and implementation was trialed in 2 critical care units, and individualized to the needs of the family. These packets include community resources, information on grief and loss, and information for children. Pragmatic information, such as guidance for funeral arrangements and financial concerns, are also provided. Keepsakes are offered to families if they choose. Responses from both families and staff have been overwhelmingly positive. The packets have provided nurses with a tool to acknowledge loss, provide support, and address important bereavement issues. Our vision for the future is to achieve consistent care of the survivors through bereavement support. The hospital-wide implementation of the bereavement packets and keepsake items is currently in progress. amarin@umcaz.edu Sponsored by University Medical Center

The Art of Palliative Care

Matzo M, Navarrette C, Tibbals S; University of Oklahoma College of Nursing; Okla

Purpose: In 2004, the National Consensus Project for Quality Palliative Care was published. These guidelines were developed through consensus of 5 major US palliative care organizations and describe the core precepts and standards for excellence in clinical palliative care. As we work to refine the healthcare system that includes a framework for the provision of palliative care, we fashioned a teaching strategy that addresses both the art and science of end-of-life care. Description: A creative framework for teaching these guidelines was required because of the vital necessity to incorporate palliative care content into an already full program of study for CNSs who will work in the ICU. In an effort to show ICU nurses what good palliative care looks like, we showed them movie clips from Hollywood videos depicting both the good and the bad delivery of end-of-life care by healthcare practitioners. These film clips were used to help nurses recognize and process in the classroom setting their own attitudes, feelings, values, and expectations about death and the individual, cultural, and spiritual diversity existing in these beliefs and customs. Our objective was to use film to promote the provision of comfort care to the dying as an active, desirable, and important skill, and an integral component of nursing care. Evaluation/Outcomes: After this class students verbalized an increased interest in learning more about palliative care and requested more time be spent on this content area. They were able to identify what could have been better practices by the healthcare practitioners in the scenes shown as well as observe good role models. This teaching approach helped these CNSs begin to embrace the value of the art of palliative care. mmatzo@ouhsc.edu

Creating a Healing Environment: Implementing Palliative Care in the CCU

Foytik L, Lewis P, Manojkumar S, Mengo P; The Methodist Hospital; Tex

Purpose: A healing environment of caring and compassion is the foundation of our culture. The purpose of the Palliative Care Program is to deliver personalized care to increase comfort and decrease pain and suffering to all patients in the CCU. Description: Palliative care programs are vital to quality patient care. Palliative care is the right thing to do for all patients and families in all settings, especially in critical care. In 2002, the Palliative Care Program was initiated in our hospital. Potential and actual barriers to initiating palliative care include education and a cultural shift in how to deliver palliative care to all patients and families. In order to overcome these barriers, staff are hired to the culture using behavioral interviewing and all staff are oriented to Palliative Care practices. We pride ourselves in the palliative care initiatives. These initiatives include personalized care, open visitation, child and grandchild visitation, family photos, photos from before this hospitalization in the patient rooms, phones in each room, pictures in each room, personal pet visitation, use of an end-of-life protocol, celebration of the patient’s life, taking patients outside the building, and the use of complementary therapies such as music and aromatherapy. We initiated AACN’s evidence-based recommendation to allow family presence during cardiopulmonary resuscitation. One nurse stays with the family throughout the code describing who is present and what is happening. When a patient is dying we offer to make the family a hand mold of the patient’s hand. This has been a special gesture that has been very meaningful for some families. We also send condolence cards to the families after a patient dies in our unit. Evaluation/Outcomes: CCU continues to have high patient satisfaction scores. Patients and families request to be admitted to or transferred to the CCU for care. CCU continues to have a high nurse retention rate and low vacancy rate.

Clinical Ethics Consultation—There Is a Better Way!

Fuerst D, Seckel M, Bincsik A, Mclaughlin J, Rodden T, Farber N, Goodill J, Essex M, Slease B; Christiana Care Health System; Del

Purpose: The goal of the Ethics Consultation Screening Team is to provide a timely response to requests for information or consultation, determine optimal course of action based on information gathered, and coordinate the consultation process as appropriate. Description: Our previous structure for ethics consultation did not provide for consistent 24 hour/7 day on-call coverage. Consultation was provided by physician members of the Ethics Committee, who also may have been consulted on the same patient in their primary role as palliative care physicians. This created a potential conflict of interest. An interdisciplinary team was convened to explore resolution to potential conflicts of interest while providing expanded coverage and decreasing response time. A model was developed which includes the education and training of a core interdisciplinary team of nonphysicians who are available and responsible for responding to requests for ethics consultation on a 24 hour/7 day per week basis. Guidelines and algorithms were developed to aid decision-making and data are collected to evaluate effectiveness. Evaluation/Outcomes: When ethics advice or consultation is sought, the request is answered by a trained consultant. Our current average response time is 6 minutes. 50% of calls have been converted to palliative care, 15% resulted in full ethics consultation, 35% have been resolved through facilitated communication. An interdisciplinary ethics screening team can avoid potential conflicts of interest, improve response times, and allow for better patient outcomes. dfuerst@christianacare.org

Leaving a Handprint Behind

Hellickson J, Houck V, Miers A; Mayo Clinic St Mary’s Hospital; Minn

Purpose: Making hand prints for families to create a memento and initiate the healing process of their loved one when death is imminent. Description: The neuroscience ICU developed a bereavement committee to explore options for a memento. Replicating the patient’s handprint using washable ink proved to be a creative and personable solution. When end-of-life care is initiated, the nurse offers the family the opportunity to make handprints of their loved one. Families often want to couple their own hand print with their loved ones. They frequently ask for multiple copies to share with family and friends. Evaluation/Outcomes: The hand printing process often sparks conversation and storytelling among the family. Consistently providing high quality end of life care is a priority in the neuroscience ICU. Hand printing has become successful in comforting families and is being duplicated throughout the institution. Hellickson.Jodi@mayo.edu

Merging Palliative Care in Critical Care: The Role of a Critical Care Nurse Liaison

Kelly J, Schwartz S, Kelly M, Radice P, Luck G; Boca Raton Community Hospital; Fla

Purpose: The critical care units in our hospital lacked a coordinated approach to assist patients/families with complex decisions. Thus, when developing a new hospital-wide consultative palliative care program, it was clear that the critical care units would be a potential source for referrals. However, there was confusion about what palliative care is, how it differs from hospice, and what services the program could provide. As a result, a critical care nurse liaison was included on the newly formed palliative care team as an educator about palliative care and facilitator of consults in the units. Description: An experienced and familiar critical care nurse from the SICU, assertive in advocating for patients/families at the end of life and with symptom management, joined the team. The liaison presented in-services to critical care units and respiratory therapists defining palliative care, the team’s role, and how to consult them. Physician education took place on a case-by-case basis. Having a nurse liaison directly in the units allowed earlier identification of palliative care patients. Patient/family conferences were coordinated on a routine basis with the palliative care physicians and psychologist. Availability as a resource hospital-wide during off hours allowed the nurse liaison to work with families only able to visit during these times and see patients with immediate needs. A data collection tool was instituted to learn more about palliative care consults in the critical care setting. Evaluation/Outcomes: 36% of hospital-wide palliative care consults came from critical care units. The main reason for referral was assistance with decision making. Time spent and decisions derived from patient/family conferences was the largest buy-in of the program. As the program has matured, critical care staff is referring patients earlier from admission and are being proactive in approaching physicians for palliative care consults. Satisfaction data about the program are currently being collected. jmkelly44@juno.com

Mindfulness, Meditation, and Coping With Death in the PICU: A One-Day Retreat for Professional Staff

Klatzker C, Loera T; Childrens Hospital Los Angeles; Calif

Purpose: Seeking a creative solution to the “compassion fatigue” of care-givers of critically and terminally ill children and their families, our unit Family Centered Care Committee created a daylong retreat for PICU nurses, physicians, respiratory therapists, social workers, unit assistants, and chaplains caring for severely ill and dying children. Description: Drawing in part on the “Being With Dying” curriculum of Joan Halifax, phd, we adapted Mindfulness Based Stress Reduction (MBSR) teachings of contemplative mindfulness for PICU use in a 1-day format. The retreat agenda includes experiential exercises, introduction to meditation techniques and relaxation, group support, lunch, and self-care activities engaging participants in a process of transforming their experience of death. To determine feasibility, we first interviewed a medical retreat coordinator in Los Angeles. An experienced facilitator with the necessary skills and motivation was then located. Retreat facilities off-campus were found. Community donations were collected to support this project. CEUs plus education time were arranged to allow caregivers to attend. Evaluation/Outcomes: There have been 3 retreats since October 2004. The fourth is planned for September 29, 2005. To date, over 85 health caregivers have participated. The retreat is now offered to cardiothoracic ICU, emergency department, and hematology-oncology. Feedback is anecdotal. Questionnaires collected before and after the first 3 retreats yielded evidence of subjective shifts in awareness, or mindfulness, which cannot be quantified. Greater cohesion on the job among retreat participants has been observed and reported, plus openness to expanded debriefings following deaths on the unit. Growing staff demand for more retreats suggest that this retreat format is useful in the PICU setting and may benefit caregivers generally who find the barrage of pediatric deaths takes an emotional, physical and spiritual toll. kate@klatzker.com

Collision Course: Nursing, Medicine, Patient: When Your Terminally Ill Patient Says “Do Everything”

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

Purpose: Transitioning the patient from curative to palliative treatment has become an integral part of high-level nursing in critical care. When current treatment will only prolong the inevitable yet your patient wants everything, conflict arises between patient, family, and the healthcare team. Facilitating the transition to palliative care requires not only excellent clinical skills but also core competencies that address effective communication, planning and hope for patient and family. Description: The Palliative End-of-Life Care program was initiated in 1999 as a quality improvement project of the Healthcare Ethics Committee concerned with the comfort, care, and transition of patients to palliative care.The End-of-Life Care Improvement Team of the Ethics Committee received approval to create the position of a full-time supportive/palliative care coordinator to collaborate with clinical staff and meet the needs of the more than 600 patients who die annually at the hospital. The program has expanded its services to address the needs of all seriously ill and dying patients. Some of these include the Supportive Care Pathway, the Advance Directive Admission Worksheet, the Palliative Medicine Consult Service, staff education, a staff support program, and the Pain Management Service. Evaluation/Outcomes: Project Impact reveals that Hoag is excelling in palliative and end-of-life care. In critical care where approximately 40% of all hospital deaths occur, 25% die on the Supportive Care Pathway. Patients on Comfort Care Measures at the time of death include 68% in our CCU as compared to 36% nationally and 76% in our ICU as compared to 38% nationally. Seventy-four percent have Advance Directives at the time of admission as compared to our peers whose results show 11% for CCU patients and 28% for ICU patients. In July 2005, Hoag became 1 of 3 hospitals nationwide to receive the American Hospital Association’s annual Circle of Life award for end-of-life care. dlepman@hoaghospital.org

Recycle: Transform Used Equipment to Help People in Need

Nievera C; Barnes-Jewish Hospital; Mo

Purpose: As a nurse from a third world country, the author is aware of the acute lack of supplies that foreign hospitals contend with as they try to care for many poor patients. Government aid is seldom enough to cover even the basic minimum that we consider essential in the United States. Many foreign hospitals rely on charities and donations from private businesses. However, the needs are greater than the resources. Description: Critical care units and operating rooms are the biggest generators of waste in a hospital. Clean but expired, or opened but unused supplies are often directed to the incinerator or to trash landfills because it is expensive to repackage or resterilize them. Some of this is regulated medical waste with very high disposal costs. Various rules in the United States limit which medical materials may be reprocessed. Diverting these supplies to people in need is a way both to save hospital disposal costs and to protect the environment. Old medical equipment can have a second life if sent to a country in need. Because of personal contacts overseas, this nurse works with our hospital to provide clean supplies and outdated equipment to several healthcare organizations in the Philippines. She also sends nursing magazines, journals, and books to help both nursing students and professional nurses update themselves with the latest issues and trends in American nursing. The costs of shipping the supplies are subsidized in part by the local chapter of the Philippine Nurses Association. Evaluation/Outcomes: This nurse has sent many cartons to the Philippines that contain older models of defibrillators and pacemakers. Expired but sterile pulmonary artery catheters, disposable operating room equipment for heart surgery and other related supplies have also made their way across the Pacific. Our hospital is spared the expense of disposing of these items as waste. Through this project we are able to show that we not only care about our environment but we also help people who are in need. charito54@yahoo.com

An Innovative Approach to Patient Care Rounds: Ethics Rounds in the CCU

Osayande E, Matura L; The Methodist Hospital; Tex

Purpose: The purpose of this program was to create an opportunity for nurses and the interdisciplinary team to learn how to identify and analyze ethical dilemmas at the bedside. Description: The coronary care unit (CCU) is an 18-bed medical cardiology unit. The patient population consists of patients with acute myocardial infarctions, heart failure, and dysrhythmias. Heart disease is the number 1 cause of mortality in the US; therefore, the CCU population is an area where complex patient problems relating to advance directives, surrogate decision making, and end of life are common themes. In May 2005, the CCU interdisciplinary team including nurses, physicians, pharmacists, respiratory therapists, and social workers, partnered with 2 bioethicists to implement ethics rounds. The rounds occur every 2 weeks, with each session lasting approximately 1 hour. Staff selects a patient to discuss. The nurse caring for the patient presents a brief history of the case and describes the actual and/or potential ethical issues. The team discusses the issues and possible interventions/solutions. At the end of the discussion, the bioethicist summarizes major points in the case and potential next steps to resolve or prevent the ethical situation. Discussed cases include medical futility, surrogate decision making to withdraw artificial support, decision-making capacity, and pain management. Evaluation/Outcomes: After 2 months of ethics rounds staff were surveyed. One hundred percent of staff surveyed found the rounds beneficial and wanted to continue. Some feedback included rotating the rounds to different areas of the unit, depending on the level of activity, for added staff participation. Ethics rounds have increased awareness and education about ethical issues at the bedside using case presentations. Interventions such as family meetings have resulted in decreasing conflict about care issues, improving communciation, and providing ethically competent care. esther_osayande@yahoo.com

Bridge Over Troubled Waters

Osborne K, Niemchak S, Spurney Y, Hanson J, Stillwagon M; Duke University Health System

Purpose: Withdrawal of support on a ventilator occurs primarily in the ICUs. Although this is recognized as a fairly common occurrence in the ICU, this did not happen with any regularity on our pulmonary renal step-down unit. We were supposed to be getting people ready to go home or to a rehab facility, not planning for their end of life. Description: Members of the healthcare team and leadership came together to facilitate the process of withdrawal of ventilator support on our step-down unit. Staff were questioned on their beliefs, and given different scenarios that promoted discussion amongst the care team members. The attending level physician spent time with each nurse caring for the patient to quell fears, answer concerns, and promote understanding. The palliative care CNS was called to assist staff in identifying learning needs and to answer questions from a “nursing point of view.” Questions about morale and ethics came to light. Educational sessions were held 1 week before the event covering topics including family support, patient support, drugs to use, symptom management, dyspnea, pain, anxiety. A withdrawal of support order sheet reminded the staff what needs to address within the 24 hours prior to withdrawal. Evaluation/Outcomes: Nursing and physician leadership recognized the importance of everyone being on the same page of understanding before removal of the ventilator. This process has helped build stronger relationships between our healthcare team members. Each withdrawal has been a learning experience in spite of the experience of many seasoned staff who had worked in an ICU in their past. The order sheet has helped to streamline the process in situations that did not provide for adequate discussion in preparing the staff for withdrawal of support situations. Staff have a better understanding of the process, the resources available for assistance, and the drugs and dosages used during this time period. osbor013@mc.duke.edu

The Going Home Initiative: Getting Level Trauma ICU Patients Home With Hospice

Babb B, Stadnicki B, Bulloch B, Jodka P, Whitten L; Baystate Medical Center; Mass

Purpose: A multidisciplinary ICU Palliative Care Committee team sought to develop and institute a caring process to transfer ICU patients home to die in the warmth of familiar surroundings. Description: Little literature focuses on transferring ICU patients home to die. Our multidisciplinary team, which includes staff nurses with hospice background, a CNS, an intensivist, and a hospice nurse, developed this process over 2 years based on particular assumptions. First, we felt that many dying patients wish to spend their final days in familiar surroundings, ie, home. Second, if a patient was stable enough to move home, we could work with hospice to get this person home. Third, if the patient was stable enough to be extubated and sustain the trip home, have a family support mechanism that could care for the patient at home, and desired to be designated “do not resuscitate/intubate” or comfort measures only, we could get the patient home with family supports. Working with nursing and house staff who selected potential “going home” patients, we developed a process that included 3 phases. The Work-up phase focuses on patient stability, talking with the family, contacting hospice for an “intake” visit with the family and patient, setting up the home environment, and contact with local hospice nurses. The Day of Transfer phase focuses on the ambulance and final home arrangements, contact with the hospice nurse, and timing of transfer events. The After Transfer Contact phase includes a call from the CNS or involved staff nurse to the hospice nurse. Evaluation/Outcomes: We have had 2 patients successfully transferred home. After a long stay in the unit, 1 patient with end-stage COPD was extubated and transferred 2 hours home. With his family by his side, he died in his favorite chair by his front window. His wife wrote us, “You gave us the greatest gift possible. Fred died Wednesday peacefully at home.” dqueen@charter.net

Spread the Love: Bringing Comfort to Patients and Families

Westphal C, Beltramo B; Oakwood Healthcare System; Mich

Purpose: By engaging the staff and community members, Oakwood Healthcare System (OHS) Family Matters and Spiritual Support Services initiated a program at Oakwood Hospital & Medical Center to provide handmade blankets to seriously ill and dying patients. Description: Soft, colorful, handmade blankets are a source of comfort to patients by providing warmth as well as tactile and visual stimulation. The blanket is presented personally to the patient with a message of hope that the blanket will bring comfort. A gift tag and a special label on the blanket reminds the patient and family that this labor of love is done by people who care about them. If the patient dies, the family takes the blanket home as a special remembrance. In “learn-to” sessions, experts who can knit and crochet have taught staff members how to create squares that are assembled by the experts into 3x4 love blankets. On the fourth Monday of the month, community volunteers join staff at lunch to teach new stitches or find those elusive dropped stitches. Staff and volunteers who possess even more time and talent have made complete size love blankets made from yarn, cloth or fleece. Evaluation/Outcomes: In the first 3 months of the program more than 100 love blankets have been donated with over 60 presentations. Over 70 nurses, physicians, and support staff have attended 4 after work “learn-to” programs, in addition to the Monday “lunch and learn” sessions. Other OHS acute care sites are now being mentored in developing the “Spread the Love” program. The many positive comments and anecdotal stories from patients, families and staff demonstrate how the “Spread the Love” program has made a difficult time a little easier. westphac@oakwood.org

Engaging Nurses to “Embrace Hope” and Transform End-of-Life Care in a Riverside Methodist Hospital Neurologic Critical Care Unit

Yeager S, Epting S, Patchen K, Jeffers D, Doust C, Thomas K, Ortman L, Newton B, Manche D, Indian C, Morris M; Riverside Methodist Hospitals; Ohio

Purpose: The goal of this group was to enable staff and families to “embrace hope” by creating a structured, multidisciplinary intervention around end-of-life (EOL) care in our neurologic critical care unit. Description: During a nurse debrief after a particularly difficult patient death, discussions began in the neurologic critical care (NCC) on how our team could create a multidisciplinary structure to manage death more consistently and respectfully. Wanting to support our patients and families in life and death, and desiring to expand the unique EOL skill set, the concept of an intervention to support families during death began. Building on the baseline information obtained from deceased patient’s loved ones (surrogates) and approximately 100 practitioners, an algorithm of care formed the foundation of the intervention. The intervention consists of educational information for staff and practical tools to support families. Four hours of educational content sensitized staff regarding symptom management, EOL communication, and phases of grief. To support the families of dying patients the committee developed a quilted envelope called the “Embrace Hope” packet. This huggable packet houses grief information, supportive verses, cards, symptom literature, and patient mementos (hair clipping, and hand tracing). Evaluation/Outcomes: Through this process, our goal to have patients/families, nurses and staff professionals feel a sense of comfort and support through the dying and death of our NCC patients has occurred. Emotional comfort based on education and knowledge for families, nurses, and multidisciplinary staff was obtained. A growth in the knowledge surrounding the dying process, grief, EOL stages, and structured protocol for all involved lead to favorable care decisions for all when involved in the dying process. syeager@columbus.rr.com

Improving Advance Directives: Ensuring Your Patient’s Voice Is Heard

Richter A, Hofmann A, Nolan E; University of Michigan Health System; Mich

Purpose: In critical care, machines can replace almost every bodily function. Examples of this are continuous renal replacement therapy (CRRT), cardiac assist devices, and extracorporeal membrane oxygenation (ECMO). Nurses often ask, “Are we sustaining life or prolonging death?” The bigger question should be, “Is this what my patient wants?” In our quest to put patients and families first and to meet federal regulations, we are striving to find out what the patients want while they can speak for themselves. In the second quarter FY 2003, 86% of the patients in our hospital were asked if they had an advance directive (AD), only 58% were offered information about how to obtain an AD, and of those with an AD only 35% were in the chart. We needed to improve. A CCU and progressive care telemetry unit teamed up to devise a way to ensure all our patients were asked about ADs. Description: Before our endeavor, the patient’s nurse asked about ADs during the admission assessment. If patients did not have an AD, they received a booklet on how to obtain an AD. With all the admission paper work, this form was frequently overlooked. Now, we partner with our unit host (nonnursing personnel who is responsible to follow up on all newly admitted patients). The nurses trained the unit hosts on the correct AD process. Each day hosts check the new charts. If the AD form is not complete, the host completes the form at the bedside with the patient. If the patient does have an AD, the family are asked to bring in a copy for the permanent record. Evaluation/Outcomes: This partnership proved successful. In FY 2005, 98% of our patients were asked about ADs and 97 % received information. However, we noticed a lack of improvement in getting families to bring in the AD. Therefore, we added a section, “substance of my AD,” to the form. Documentation of the substance of the ADs was 100%, while obtaining a copy of the AD from the families remained at 35%. This process was so successful that it was adopted throughout the hospital. atallmad@umich.edu

Intra-Hospital Transport of Critical Care Patients

Roberts M, Harris K; Poudre Valley Hospital; Colo

Purpose: To define the standard of care, emphasizing patient safety, for intrahospital transport of all critical care patients to include emergency department (ED) and operating room (OR) patients. Description: Organizationally, there was inconsistency in monitoring critical care patients between the ED, OR, and the critical care units. In 2004, the SCCM published specific guidelines delineating monitoring, equipment, and personnel requirements for safe transport of critically ill patients. This issue was addressed at the hospital Critical Care Committee, a multidisciplinary team, which determined the SCCM guidelines would be implemented. All critical care patients would have appropriate monitoring, medications, airway equipment, and a defibrillator during transport. All intubated patients would be transported using end-tidal CO2 monitoring. A subcommittee of the ED, OR, and Critical Care Medical Director and CNS discussed implementation of the guidelines, education, and equipment requirements for these areas to comply with the standards. This was quite a deviation from current practice. Collaboration was imperative. A procedure was developed and agreed upon after much discussion. Pharmacy created a consistent drug box with the necessary medications for all critical care departments. Staff education was completed with train-the-trainer methodology and Transport has been part of the critical care competencies in both 2004 and 2005. Evaluation/Outcomes: Organizationally, it is neither easy nor common to get the critical care units, ER, and OR to standardize equipment and care of patients. A standard of care for transfer of critical care patients was accomplished. Now, all critical care patients, regardless of where they originate in the organization, are consistently monitored and transported safely. mgr@pvhs.org

Transforming the Culture of Visiting Hours: Touched by the Family

Lanthorn C, Baisden S, Fahey A, Smith T, Dickerson L, Clark K, Dennis L, Metersky S, Birkefeld R, Thompson C; Grant Medical Center; Ohio

Purpose: Inconsistencies in visiting practices led to an insurgence of dissatisfied patients and family members. A change in the visitation policy was necessary because the customary tradition of rigid visitation in the CCU did not support best practice. Description: Staff were surveyed to determine their preference of open or restricted visitation. Seventy-five percent supported open visitation believing that restricted visitation was neither caring nor compassionate. Buy-in from those opposed to open visitation was essential to ensure successful implementation to necessitate the transformation of current belief. A team reviewed current literature and best practice standards. Suggestions were sought from peers and tools were developed for successful implementation. A visiting environment was created with visitation guidelines. To ensure consistency with information, a “Family Information Packet” was developed, which included a visitor expectation brochure and general information such as lodging and hospital services. Visitor expectations are an essential component of open visitation. Visitors need to be aware of how they can best benefit their loved one and how staff would communicate with them. The brochure covered details such as spokesperson, allotted visitors in room, confidentiality, and limited visitation during certain times of patient care. All staff were educated before implementing open visitation including scripting scenarios. Evaluation/Outcomes: Benefits derived from a stronger family presence include a more detailed insight of patient needs and more time to educate families about their loved one’s illness leading to a quicker understanding of diagnosis and management. Patients/families report that they are able to be more of an active participant in their care resulting in decrease stress and an increase sense of safety and support. Open visitation has increased patient/family and staff satisfaction resulting in increase customer service. clanthorn@ohiohealth.com

Improving the Family Experience of Having a Child in the Special Care Unit After Heart Surgery

Schlichting P; Maine Medical Center; Me

Purpose: A lot of stress is often placed on the family and parents of the child or neonate undergoing cardiac surgery. An unmet need was identified through feedback from a support group for parents of children with congenital heart disease. The parents asked if there was a way to supply bags that contain some basic items that can be given to the families of children undergoing heart surgery. Description: The idea of a basket was developed to a tote bag that could be used throughout the hospital stay. With input from a couple of parents who had just recently been though a hospital stay involving cardiac surgery. With their input and the assistance of the hospital development office the tote bags became a reality. The tote bags contain nonperishable snacks (such as peanuts, crackers, and juice), a gift certificate to the hospital cafeteria and a nearby sandwich shop, crossword puzzles, phone cards, small toys, and a Precious Heart’s brochure. Coloring books and crayons, sticker books, and books are also included if there are siblings. Evaluation/ Outcomes: In the first month after the supplies for the tote bags were obtained and assembled with all the contents, parent volunteers from the Precious Heart’s group or a staff nurse has distributed 10 tote bags. The reaction from the parents of the children undergoing cardiac surgery has been nothing but positive. They have expressed feelings of being grateful and thankful for the thoughtfulness of the staff and the Precious Heart’s group. After being introduced to the Precious Hearts through the tote bag, several parents have joined the group. Staff nurses in the unit have also expressed satisfaction with the program and being able to humanize the cardiac surgical experience. schlip@mmc.org

Effect of Family Centered Care on Patient/Family Satisfaction on a Progressive Care Unit

Vickers A, Towne G, Wells E, Lewis L; Carolinas Medical Center; NC

Purpose: To use the practice model of family-centered care to increase patient and family satisfaction on a progressive care unit. Description: The current practice model of family-centered care was reviewed by the staff in the Journal Club. This was the first introduction to this practice model for our nurses. In addition, Elizabeth Wells presented AACN’s Synergy Model and Standard of Care for her clinical ladder project. One of the AACN standards states “The plan is developed collaboratively with the team, consisting of the patient, family, and healthcare providers, in a way that promotes each member’s contribution toward achieving expected outcomes.” Also a survey was conducted to evaluate the staff ’s perception of increased family involvement in patient care. On the basis of the AACN information and results of the survey, the visiting hours were reevaluated. The decision was made to initiate a family-centered care practice model. This practice model allowed families the opportunity to be more involved in patient care, learning skills such as oral care, assisting with turning, skin care, and other skills as appropriate. In addition, a communication board, which was placed in each room, contained information about the plan for the day. Family members were encouraged to write other information they felt to be important. Patients and families welcomed this opportunity to be more involved in their loved one’s care. Evaluation/Outcomes: By shifting the practice model to patient and family-centered care, the patient and family felt they had more control over their hospital experience. This was evidenced by the increase in patient and family satisfaction and decrease in the use of restraints. On daily rounds with the patients and families, the nurse manager noted an increase in positive comments. Family members were more involved in the care of the patient giving them a sense of purpose and increasing the patient and family satisfaction.

Implementing Proactive Nursing Communication for Families in the ICU

Kimpel K, Shaffer D, Deivert M, Hummel J, Gochenour E, Clark K; University of Virginia Health System; Va

Purpose: Nursing communication with families in critical care is vital to successful patient outcomes, family health, and family satisfaction. The nurses in the surgical-trauma-burn ICU (STBICU) currently use a variety of styles while communicating with families. The purpose of this study is to determine whether a nursing communication plan built on family-driven preferences will enhance family understanding of patient condition, care delivery, and ultimately family satisfaction. Description: In an attempt to improve communications with families and ultimately family satisfaction, the STBICU nurses have designed a proactive approach to identify family communication preferences. Once the preferences are identified, a plan will be implemented to ensure that the focused family-desired communications are completed daily. Tools were designed to support a structured approach to introduce families to the concept of proactive communication. Using the pneumonic “ABCDE,” staff was prepared to negotiate the components of daily communication with participating families. Evaluation/Outcomes: Authoritative nursing references on the subject of communication with distressed families of critically ill patients are lacking. Multiple studies have identified the needs of family members of critically ill patients. We plan to evaluate the effectiveness of the newly implemented proactive nursing communication intervention negotiated with families rather than merely identifying family needs. We will survey families to measure their level of satisfaction with the nursing communication process to validate our proactive program. mmd3s@virginia.edu

“Quiet in the Halls”: An Interdisciplinary Approach to Control Noise

Connor K, Caro M, Cameron R, Donegan K, Hanks J, Hawkins D, Peck D, Reddick K, Reiland S, Nakata C, Wash D; Long Beach Memorial Medical Center; Calif

Purpose: Noise in hospitals is a major cause of sensory and sleep deprivation among patients. This also may affect the work stress to staff. The challenge of reducing noise in the patient care areas was addressed by the Memorial Heart & Vascular Institute Partnership Council. Description: The Partnership Council is composed of representative interdisciplinary team members of the entire Heart & Vascular Institute. The team began by discussing numerous concerns regarding noise on the units and had received a letter from a concerned physician. The team then met with the various departments such as housekeeping and engineering to evaluate how some extraneous noise could be contained. A campaign was launched to raise awareness with all colleagues. “Quiet in the Halls: Sleep Helps Heal” was chosen to be the slogan. Laminated signs were made for the nursing units. These listed some specific measures for the staff to take to help reduce the din. Included were: turning off TVs after 11 pm in double rooms; limiting the use of overhead paging; answering call bells in person and dimming the lights in the evening. Surveys were distributed to all disciplines on the units with a pen and card with the slogan. Approximately 150 surveys were returned and tabulated. A TV channel with meditative music had also was implemented by pastoral care. Notices of availability were placed in patient rooms. Finally, a letter addressed the physician’s issues. Evaluation/Outcomes: This effort was shared with the ICU Partnership Council and implemented in that unit as well. The physician wrote a complementary letter regarding the process. A video was made entitled “ The Shadow Knows …Quiet in the Halls” to represent the process in the system wide Partnership Councils video awards. This was shown at the award event. It won “Best Dramatization of a True Story” prize. Our patients, families and staff are more comfortable and happier now. kconnor@memorialcare.org

Shhhh…Quiet Please! Providing Improved Patient Satisfaction by Reducing the Noise Level in the Intensive Care Unit

Malonzo V, Hizon C, Holler P; University of California, Irvine; Calif

Purpose: All critical care units are challenging work environments that face many stressors and demands. In addition to providing exceptional nursing care, critical care nurses are challenged to work to improve healthcare delivery, patient care systems, and customer service. The noise level in the SICU can be intensified at any moment because of many factors. In attempt to reduce the noise level in the SICU and increase customer satisfaction, a team of critical care nurses developed an educational program. Description: Clinical nurse IV (CN IV) critical care nurses from the SICU attended a special leadership retreat for best practices. One goal from the retreat was to select a project that would improve the unit customer service. A special project was identified and implemented by the CN IVs. UCI Medical Center partners with Press Ganey Associates, Inc, to assess and improve customer and staff satisfaction. The CN IVs decided to use this survey score for their evaluation tool. A presurvey was given to 30 random SICU nurses that answered 14 questions regarding noise in the unit. The CN IVs provided in-services to educate staff and other healthcare professionals. The education included the results of the survey; research related to noise reduction in the ICU; and specific measures, interventions, and solutions to reduce noise levels. Evaluation/Outcomes: After the in-service education, staff has commented that there is a noticeable reduction noise in the SICU. The staff has made a conscience effort to keep the noise level down. Lastly, the recent Press Ganey survey results since the initiation of project indicated that there has been improved satisfaction from our recent patients discharged from the SICU.

Around the World in the SICU...Come and Get to Know Us

Ramirez M, Lane T, Woodard C, Gao Y, Fortich Z, Gonzalez A, Thomas S, Evbouwman E, Giglio C, Demura J, Luangrash K, Bernas K; The Methodist Hospital; Tex

Purpose: A need to increase cultural awareness and sensitivity amongst the SICU staff in a large metropolitan hospital was identified. Knowledge of divergent cultural issues has become increasingly important during times of critical illness. Improving cultural sensitivity in the changing healthcare delivery environment only serves to improve patient care. Description: To improve cultural sensitivity amongst the nursing staff of the SICU at The Methodist Hospital in Houston Texas, a wide range of interventions were implemented. Brief biographies of the ethnically divergent nursing staff were collected with emphasis placed on the unique awareness that each brings to the table. Each nurse’s cultural perspective was then featured and posted on a world map central in the unit. In addition, expert lecturers provided insightful talks that heightened each individuals ability to become more aware of cultural issues. Evaluation/Outcomes: Biographies are updated every 2 weeks and fellow team members and families eagerly await the opportunity to learn a new culture. Having intimate knowledge of other cultures enables the team to more effectively interpret patients’ needs during times of critically illness. In addition, a postintervention survey was collected from each participant to assess if the overall goal was obtained and served as a benchmark for ongoing training. micheleramirez@houston.rr.com

Open the Doors! Visiting Hours Revisited

Tovar S, Westemeyer W, Foltz L, Sargent J, Kacher D, Smith K, Bappe S; Mercy Medical Center; Iowa

Purpose: With the significant increase in literature supporting open visiting hours, the critical care unit council challenged themselves to change our unit culture and incorporate open visiting hours for our patients’ family members. Description: Historically, our adult critical care unit had gradually increased visiting hours from specified times to a consistent 9 am to 9 pm visiting time frame for family members. Recently, the staff defined the unit values as well as the motto of “Our level of care is only exceeded by our level of caring.” The staff lived this motto by posting it in the unit and developing shirts with the motto for staff to wear with their uniforms. With this culture change, nursing staff began to allow visiting after 9 pm as well as throughout the night and a sleeping room outside of the unit was created for family members to spend the night as needed. However, there was staff disagreement regarding the visiting hours and this created tension between nurses and confusion for patients’ family members. In August 2004, the unit staff council was created and one of the first agenda items was the discussion of an open visiting policy. The council worked on this by seeking input from staff with different perspectives and creating guidelines for open visiting. A unit brochure for visitors was developed, outlining the unit guidelines, and unit council members dialogued with individual staff over several months to finalize the brochure. Evaluation/Outcomes: In August 2005, the open visiting guidelines were instituted with minimal stress to everyone. The unit council continues to actively work through any changes needed and are working on incorporating the Caring Bridge e-mail program for families. Through timing, involvement of key staff members, and keeping staff engaged with the process, the unit council was able to change the environment and open the doors to our unit! stovar@mercydesmoines.org

Synergizing Healthy Work Environments: Moving Beyond Models… to Possibilities

Dixon J; Baylor University Medical Center; Tex

Purpose: Professional nursing practice occurs in a healthy work environment where patient needs are assessed and matched to nursing competencies. This synergy produces safe passage for patients. To achieve this goal, we merged the Synergy Model for Patient Care, Healthy Work Environment (HWE) Standards, and key nursing practice concepts to create our professional nursing practice model. We are translating this model into reality. Description: To make this model visible and an integral thread of everything we do, we began translating key elements into operations. Initial projects included revising the staff nurse job description and performance appraisal; creating A.S.P.I.R.E. (Achieving Synergy in Practice through Impact, Relationships, and Evidence), our professional nursing advancement program; and developing measures such as the Charge Nurse and Preceptor Outcomes evaluations and current state assessment tools for nursing units. One of our retreats was The Synergy Café built upon the World Café technique for idea generation. The Chief Nursing Officer led an assessment of nursing using the HWE standards and its critical elements. We are making strides to synergize other important supportive practices including orientation and continuing education, nursing’s research agenda, Synergy Care Rounds, Synergy Spotlights, documentation, patient classification, and interview questions for employee candidates. Evaluation/Outcomes: This model has been adopted by all nursing specialties across our healthcare system. We are using the model not only in the direct clinical environment but also as an essential foundation for various initiatives and nursing’s strategic plan and dashboard. By using this framework to link intentional nursing actions with outcomes, we are demonstrating how synergistic professional nursing practice makes a difference for patients and organizations, creates safe passage, and moves us to possibilities. johndi@baylorhealth.edu

Ensuring a Healthy Work Environment (HWE) by Improving Communication Patterns in a Surgical Trauma Burn ICU

Clark K, Bowles M; University of Virginia Health System; Va

Purpose: To improve our work environment by ensuring effective communication between all healthcare providers in the surgical trauma burn (STB) ICU. Description: AACN’s HWE standards delineate the critical importance of communication skills. In our 16-bed STBICU, the leadership believed that the unit staff regularly evidenced behaviors not conducive to a HWE. A HWE pledge, focusing on improving communication was developed and signed by 100% of our nursing staff and a majority of other ancillary unit staff. In addition, we sought to objectively evaluate the staff ’s perceptions of communications so that we could learn the specific areas that required attention and address them. We used a reliable and valid communication survey to accomplish this goal. The survey results demonstrated that conflict management, style of communication (eg, approachability), effective direct communication, and collaborative decision making were perceived deficits. On the basis of these results, an action plan was put into place by our HWE committee. The plan includes walking rounds every shift with communication “in the moment” and education to teach positive communication techniques. The HWE pledge is mounted in the unit to maintain awareness and motivational quotes are posted to encourage effective communication. As new staff and medical residents rotate to the unit they are educated on our HWE plan and informed that it is an expectation that these behaviors be exhibited. Leadership staff regularly follows up with unit staff to ensure healthy communication. Evaluation/Outcomes: By putting these key initiatives into place, a HWE may be realized. Our goal is for staff to feel empowered and supported to communicate honestly and effectively. It is an expectation of the staff that they will be committed and accountable. We have already seen positive changes in communication and morale as a result of our project. We expect that repeat surveys (6 and 12 months) will confirm this change. kwc3f@virginia.edu

The ENT All-Stars: Boosting Patient and Staff Morale With “Team Spirit Week”

Cox E, Rogers A, Johnson R; Barnes-Jewish Hospital; Mo

Purpose: Our ear, nose, and throat surgery unit has many patients with serious diagnoses and sometimes disfiguring surgeries. For the dual purpose of demonstrating appreciation for the staff ’s dedication and boosting the morale of the unit patients, our unit manager and assistants hosted “Team Spirit Week” in August 2005. Description: Throughout the week, we invited the unit staff members to wear their personalized “All-Stars” jerseys. These jerseys were specially designed to coordinate with their hospital uniforms and to recognize how much we value our hardworking team members. Our staff functions as an excellent team every day, and the jerseys stepped up the “look” of our team players during spirit week. We invited patients to be part of the team, distributing novelties like baseball beanbag toys and ball caps that the staff could sign with an inspiring message to the patient. Because many of our patients cannot speak and have to communicate with us by writing, we jazzed up the communication process with baseball bat pens. Several staff members set up a concession stand 1 day, serving sodas and hot nachos while cooking ballpark franks on an electric grill. Evaluation/Outcomes: Although something as abstract as morale cannot be truly quantified, “Team Spirit Week” resulted in a discernible rise in employee and patient satisfaction. A number of patients thanked the staff for the fun they brought to their hospital stays. The subsequent discharge surveys indicated that the patients had been pleased with the positive attitude that the staff projected. Employees enjoyed the light-hearted mood of the week as well as the gift of the jerseys in recognition of their dedication as members of the unit team. We plan to make “Team Spirit Week” a regular occurrence on our patient care unit.

Conflict Resolution: Communicate, Communicate, Communicate!

Elchos S; The Methodist Hospital; Tex

Purpose: To fascilitate open and honest staff communication through conflict resolution to foster a healthy work environment. Description: Direct communication between staff members when conflicts arise to address the issues face-to-face, was an essential teambuilding skill our MICU wanted to improve. In order to facilitate and build effective communication, we held several workshops where emphasis was placed on conflict management styles. The first session was a 4-hour workshop for our mentors. As respected leaders of the unit, it was necessary these professionals understood the various styles of communication before participating in conflict resolutions with their colleagues. We then held several 1-hour workshops for all staff, followed by role-playing; then as a group, the communication styles were critiqued. The last step was a formal interaction agreement that lists the specific rules (ie, timeliness and setting of communication) to adhere to during the communication. Evaluation/Outcomes: 95% of the MICU’s 89 staff members attended at least 1 workshop and all staff signed the interaction agreement. Our team has learned how to use tools for bringing potentially conflict creating issues to the front without blame, shame, or excuses while keeping professional relationships intact and ensuring a healthy work environment. selchos@tmh.tmc.edu

S.O.S.: The Duke Pediatric Intensive Care Unit’s Plan to ‘Save Our Staff ’

Ellis R, Vaughn J, Daugird D, Mericle J; Duke University Medical Center; NC

Purpose: A 16-bed pediatric intensive care unit (PICU) underwent renovations in 1998 from large 7-bed ward-style rooms with 2 isolation rooms to 6 semiprivate rooms and 4 isolation rooms all lining a long hallway. This greatly decreased overall visibility of the patients in the unit, which in turn decreased staffing efficiency. Subsequently, the new PICU layout created an unexpected problem for nurses trying to cross cover each other to get their breaks and lunches. It was further compounded by being understaffed. The result was hungry, discontented nurses whose job satisfaction was falling as bedside stress was increasing. Description: An innovative, creative solution was proposed by a group of senior staff nurses. This solution included using a portion of the vacant FTEs to help cover the staff for their lunch breaks. This position, called SOS (Save Our Staff ), also used creative scheduling, a 10 am to 3 pm shift, which allowed experienced staff that were no longer able to work the traditional shift to continue to work. Evaluation/Outcomes: The PICU has offered the SOS program for 2 years and we have remained within our budgeted guidelines. It has improved staff nurses’ satisfaction significantly because they have guaranteed lunch coverage while patient safety is maintained. The nurses working the SOS plan report improved job satisfaction because it offers flexibility while maintaining their job skills and it enables them to be valuable contributors to their PICU colleagues. ellis006@mc.duke.edu

Improving Nurse and Physician Collaboration: ICU Joint Practice

Hoaglund J, Brown T, Dusenka B, Eggersglus A, Halter A, Hanovich S, Kamara C, Slipy J, Susag-Maynard A, Whitney J; Unity Hosptial; Minn

Purpose: To build collegial relationships between nurses and physicians in the ICU and to improve patient outcomes through increased collaboration. Current literature describes the impact of ineffective communication between physicians and nurses on patient outcomes and staff satisfaction. Concerns had been raised about the communication styles of various physicians, as well as the lack of collaboration to improve specific clinical indicators. Description: The ICU medical director and other physicians practicing in the ICU were invited to attend a portion of the monthly meeting of unit staff that deals with operational, clinical, and quality issues. These joint practice sessions were cofacilitated by the nurse manager and medical director. A variety of topics were addressed. Physician and nurse practices that would improve clinical outcomes were identified and joint action plans developed. Sensitive topics like nurse-physician communication and respect were openly discussed. Nurses and physicians offered examples of frustrating or disrespectful interactions and problem-solved solutions. In some cases, scripts were developed for future situations. Lunch was often provided to promote a relaxed and collegial atmosphere. Evaluation/Outcomes: The sessions have prompted nurse and physician practice changes resulting in improved clinical outcomes, eg, blood glucose levels and ventilator times have decreased, and an agitation order set was created. Nurses and physicians enthusiastically report an increase in collaboration and in their subjective comfort and confidence level regarding nurse-physician communciation. judy.hoaglund@allina.com

The ICU Nursing Council: True Collaboration for Patient Safety

Hooker S, Samways D, Schmitz T; The Methodist Hospital; Tex

Purpose: Our Magnet-recognized hospital’s structure is service-line based, with our 5 ICUs divided among 3 service lines. The nursing leadership in the ICUs recognized the need for collaboration among all the units, and the ICU Nursing Council was created. The goal of the council is to provide a forum for developing and sharing best practices in patient safety, quality, and leadership. Description: ICU Nursing Council membership comprises staff nurses, directors, managers, APNs, and colleagues from other disciplines. We meet monthly to share ideas, solutions, and accomplishments. First, we standardized our “patient care guidelines” throughout all the ICUs, ensuring that all patients receive the same standard of care. We collaborated with Pharmacy to reduce the potential for errors in administering high-risk IV medication infusions. A colored label was implemented that visually alerts the nurse to the medication. We also changed practice to include a double check of high-risk medication infusions during change of shift. The ICU council coordinated the annual skills competency validation. ICU Clinical Mentors (the highest level on our career progression model) staffed the skills fairs 24 hours a day for 7 days over 5 weeks. Poster boards highlighting the National Patient Safety Goals, medication safety, and ICU care bundles (sepsis and ventilator-associated pneumonia) were displayed, and nurses completed written tests on these topics; 350 nurses attended the skills fairs. Evaluation/Outcomes: Attendance at our monthly meetings is consistently high, with comments after every meeting from staff and management about the value of the meetings. Positive changes in practice resulting from collaboration include glycemic control, decreased medication errors, standardized protocols (sedation, sepsis, ventilator weaning), daily goals and rounds, and guidance on Beacon Award applications. Two Methodist ICUs are now recognized as Beacon units. sjhooker@tmh.tmc.edu

Let’s Get Out to Prevent Burnout

Kagel E, Barto C, Perry T, Doolin S, Bailey M, Hensley J, Dickerson L, Lanthorn C, Metersky S; Grant Medical Center; Ohio

Purpose: A staff-driven retreat individualized to improve the quality of worklife in the CCU by developing awareness of unit/hospital goals and providing tools for personal and professional nurturing. Description: Due to the increased acuity of patients, influx of caring for different patient populations, increased end-of-life care situations, and high level of stress of nurses, a committee of staff nurses was formed to create a work retreat encompassing all CCU staff members to promote both self renewal and teambuilding. Although CCU management has embraced the importance of annual retreats for teambuilding, this year’s retreat theme of self-renewal was chosen by the staff as a recognized need. The all-day retreat was held at a Metro Park lodge, nestled away from the stressful intensive care setting, further enhancing the creation of a restful environment. Self-renewal exercises, such as massage and aroma therapy, meditation, and healing touch were offered throughout the day, in conjunction with an environment created to support socialization with peers. Teambuilding was also encouraged through identification of stressful incidents and discussion of critical stress debriefing techniques. To unify staff and bring out cultural diversity, each staff member was asked to bring a favorite food stemming from their culture or heritage. Evaluation/ Outcomes: Included in the day of relaxation, a formal process for critical incident stress debriefing was created. The staff also developed personal goals for each team member to manage stress levels and engage in coping mechanisms when difficult situations present. Staff was surveyed upon leaving the retreat and reported a high level of satisfaction with techniques learned. In addition, evaluation comments confirmed that the retreat was beneficial to foster a more nurturing work environment. ek7456ek@yahoo.com

Talk Is Cheap: Put Your Words Where Your Mouth Is!

Samways D, Knaack K, Nicasio M, Sullivan R, Reardon M, Krinock S, Clark T, Rupert C, Langdon J, Espada R, Masud F; The Methodist / DeBakey Heart Center; Tex

Purpose: Healthcare team communication has a major impact on safety. The American Association of Critical-Care Nurses (AACN), Society of Critical Care Medicine (SCCM), and Joint Commission on Accrediation of Healthcare Organizations (JCAHO) have all started initiatives on communication and work environments. True collaboration occurs when respect and civilit are the norm. Description: Like many other critical care units nationally, our unit has communication challenges. Communication in this tense, high-energy environment often becomes strained leading to hurt feelings. Using AACN’s Healthy Work Environment standards, SCCM’s Critical Connections, and the Josie King Foundation information on patient safety, the unit set out to partner with all disciplines and improve communication. With a focus on delivering safe care, all egos were checked at the door and an outside facilitator was brought in to assist. The first outcome achieved was a poster agreement between all staff. The poster listed simple, common sense approaches of respect and communication, and putting it in writing and posting it in the unit has been powerful. Future classes on communication are planned. The class focus will be healthy conflict, not taking things personally, not responding with emotion, and how to stay out of the middle. Evaluation/Outcomes: We have already raised the awareness through the poster. Monitoring of physician satisfaction, staff satisfaction, and overall unit patient satisfaction will be the markers of success. kknaack@tmh.tmc.edu

Oh My Aching Back: The Use of Lift Equipment in Critical Care

Lanthorn C, Campbell T; Grant Medical Center; Ohio

Purpose: Providing patient care in the critical care arena is physically demanding related to environmental obstacles among staff workforce and patient population. Traditional patient lift/transfer methods have been ineffective in preventing staff injuries. Implementation of lift algorithms became necessary to promote injury prevention. Description: Environmental obstacles encountered in delivering patient care include aging, obesity, declining staff workforce, and increased patient acuity. These obstacles lead to a high rate of muscular skeletal injuries with sometimes permanent residual deficits, and generate a dissatisfied workforce. Consequences are felt with the lost productivity of injured staff. Also, the unit loses staff ’s valuable knowledge and leadership skills when staff are forced to pursue careers that are not physically demanding. To address injury prevention, a workteam was formed to focus on creating a less physically demanding environment by incorporating evidenced-based practice. A minimal lift policy was created outlining the number of staff needed per patient’s weight and supplemental lift equipment was purchased. Algorithms were created outlining use of a lift team and lifting interventions with appropriately designated lift equipment based on patient weight and type of repositioning needed (ie, reposition in bed, transfer from bed to chair). Commitment to safety prevention was accomplished by orientation of staff to lift algorithms and proper use of lift equipment/lift team. In addition, an occupational therapist taught staff proper body mechanics and stretching exercises when manual lifting is required. Evaluation/Outcomes: There has been an 85% reduction in staff injuries since implementation of the lift algorithms, which incorporates lift equipment, lift team, and proper body mechanics. Staff awareness has increased promotion of proactive injury prevention techniques by use of appropriate resources. clanthorn@ohiohealth.com

Promoting Healthy Work Environments: The ICU Advisory Council

Read J, Scruth E, Homen S; Kaiser Permanente San Jose; Calif

Purpose: An advisory council was established in the ICU to promote staff involvement in decisions affecting the work environment. The advisory council provides a forum for open dialogue between staff and management. Description: A unit-based staff advisory council was established to work on issues that affect the work environment in the ICU. Before implementation, a planning team drafted by-laws and established a nomination and voting process. The multidisciplinary council includes staff RNs, a respiratory therapist, managers, the clinical educator, and the medical director. The council initiated their work by brainstorming and prioritizing unit issues on which the council would work. Evaluation/Outcomes: The success of the council is the active participation of patient care staff in generating ideas and formulating plans for improvement. The ICU management team has mentored staff members in assignments such as agenda planning, minute-taking, and leading discussion. Council members have demonstrated newly acquired organizational, communication and computer skills. Staff members have taken on leadership roles that have fostered their professional development. The advisory council sponsored a hospital Critical Care Awareness and Recognition week in May. This week featured a lecture series, a public awareness booth, and executive leadership shadowing RNs in the ICU. Staff response was so positive it will become a yearly event. In response to staff concern about the lack of clarity of the charge RN role the council conducted a revision of the role description. The council’s next project will be revision of the ICU visiting policy incorporating evidence-based practice to promote patient and family centered care. The ICU Advisory Council has been successful in facilitating open communication between members of the multidisciplinary care team. The effectiveness of this communication is essential in contributing to a healthy work environment in the ICU. julie.read@kp.org

Interdisciplinary Collaboration: Nurse-Physician Peer Review

Noe C, Williamson D, Duran D, Young K, West C, Johnson L, Mehta J, Ungarino T, Rao R, Dodd D, Vildibill H; Phoebe Putney Memorial Hospital; Ga

Purpose: The Healthy Work Environment Standards were designed to promote and foster excellence in patient care. We felt that incorporation of the standards in daily work life was just a start. Therefore, we revised our Critical Care Medical Staff Peer Review Process into a joint Critical Care Nurse-Phyisician Peer Review Process. The Nurse Physician Peer Review Process allows clinicians to honestly communicate and collaborate in a safe environment, and determine the effectiveness of the decision-making processes that occur in the care of our patients. Description: The Critical Care Committee at Phoebe Putney Memorial Hospital made the commitment to review sensitive cases collaboratively in order to explore areas of concern involving specific patients or clinical issues. Each month, one or more team(s) consisting of a nurse and a physician are paired together to review specific cases. Cases maybe chosen based on a DRG code or a specific outcome. The reviewers analyze the record together to determine appropriateness and timeliness of treatment, application of evidenced based practice, appropriate monitoring, timeliness and response to communication, etc. They then present the case and their analysis to the Critical Committee consisting of nurses, physicians, and leaders each month for discussion and recommendations. Evaluation/Outcomes: Though each group had concerns about a joint review process, it has proven to an enlightening and valuable collaborative. Physicians have been impressed with the knowledge of the nurses in decision making and nurses have gained greater understanding of application of evidenced-based practice and medical staff concerns. As a result, we are collaboratively developing and revising standards of care for the unit based on current evidence; physicians have volunteered to do more educational programs for the nursing staff; and we have all developed a better understanding of each other’s point of view by working closely together for the betterment of our patients. cnoe@ppmh.org

Establishing a Healthy Work Environment Through Shared Decision Making

Oldham S, Dembowski J, Horner S, Watson F; Memorial Medical Center; Pa

Purpose: Traditionally, only unit leadership was part of the interviewing and hiring process. There was no staff level involvement in the decision-making process. In an effort to establish a healthy work environment, we redesigned our hiring process for our newly created charge nurse positions. Description: Two senior staff members with demonstrated clinical expertise and a desire to improve teamwork within the department were selected to be part of the hiring team. The nursing director and unit manager led the team. Each applicant for the charge nurse position submitted a cover sheet, resume, and letters of recommendation. The nursing director mentored the senior staff members in interviewing skills and techniques and assisted them in developing interview questions. The interviewers were asked to prepare their own responses to the questions. During the interview process each member of the interviewing team presented a question to the applicant. This allowed the applicant to interact with all members of the interview team and helped to alleviate some of their anxiety. After the interviews were completed, each team member had 1 week to review the applicant’s responses. With the assistance of the nurse manager, the responses were weighted according to a predetermined scale. At the end of the week, all team members met and a candidate was selected after consensus was achieved. Evaluation/Outcomes: Involvement of senior staff members in the interview process and hiring decisions has proven to be a success in our unit. Because the staff had input into the hiring decisions, the charge nurse role has been well received. The inclusion of experienced nurse’s opinions and perspectives has allowed our unit to lay the foundation for establishing and sustaining a healthy work environment. oldhamcash4@aol.com

Lose to Win

Niemchak S, Barker L, Osborne K; Duke University Health System; NC

Purpose: Nurses, physicians, and other healthcare workers provide physical, emotional, and spiritual care to those around us everyday. The attention that we give others often leaves us little to provide to ourselves. Unwanted pounds accumulate, which increase health risks. It was time not only to help our patients and families but to help ourselves achieve a better lifestyle. Description: Posters were placed around the unit and a memo was sent to all staff inviting each to join the lose to win event. Everyone who joined paid $20. A scale was purchased and the remaining money went into a cash pool. Each individual picked a number that remained anonymous to all others. The contest lasted 4 months. Participants had to weigh at the beginning, once a month and at the end of the contest. Participants who gained from their start weight paid $4 per pound, which were collected in the cash pool. This payment for gaining weight was to deter participants from adding on the pounds. Several designated people documented the weights, which gave a sense of accountability to all the participants. At the end of the 4 months, individuals who had lost the most percentage of body weight won the cash pool. The cash pool was $320. Evaluation/Outcomes: Increased morale was noted in the early stages of the win to lose event. Stairs were climbed up and down, walking on breaks and better lifestyle choices were being made. A total of 157.5lb were lost. The winner lost 12.2% of body weight. The contest promoted unit moral, increased self-esteem, and increased health benefits. One winner took home the money; however, everyone who lost weight won. Lose to win was very popular in our unit. We have shared our success with other units who have also used this module to help improve the health of their staff and fellow comrades.

Creating a Healthy Work Environment

Scheutzow M, Slaughter K, Idemoto B; University Hospitals of Cleveland; Ohio

Purpose: As an interdisciplinary performance improvement project, the SICU developed a Code of Conduct to promote a healthy work environment. The goal is to support a professional workplace and to improve job satisfaction, patient satisfaction, and nurse retention. Description: In the demanding environment of an ICU in a large academic medical center interactions between people were becoming increasingly ineffective. Nurses and other members of the healthcare team began to verbalize their distress at having interactions that communicated disrespect or that were of an antagonistic or even argumentative nature. Over time these types of behaviors were almost becoming an accepted norm in communication. The unit’s performance improvement committee decided to take action. The advanced clinical nurses and staff nurses were encouraged to enter into the process as well. The resulting Code of Conduct is consistent with both the University Hospitals Health System mission “To Heal, To Teach, To Discover” as well as the AACN Standards for sustaining healthy work environments. To communicate the message we have included this document on our SICU Intranet Web page and have displayed the Code in the unit’s entry hall. Orientees receive a copy of the Code in their orientation folders. Evaluation/Outcomes: The Code of Conduct was introduced at nursing staff meetings and as part of the SICU resident orientation. A preliminary survey of the nursing and medical staff indicated approval of the concepts in the Code as well as initial improvements in communication behaviors. Ongoing review will demonstrate the effectiveness of the Code of Conduct and changes will be made as necessary after review of formal data collected quarterly. The Code demonstrates teamwork in action! maria.scheutzow@uhhs.com

Automating Referrals From Admission Assessment Screening

Furukawa M; UCLA Medical Center; Calif

Purpose: Referrals to ancillary departments when patients require specialized assessment is a part of the admission assessment process that was not always consistently done. We needed to improve compliance with making required referrals to ancillary departments and also create a way to verify that the ancillary department responded to the referral. Description: UCLA Medical Center is moving from a paper-based documentation system to a computerized clinical information system (CIS). We felt that automating the admission assessment screening and referral process would improve compliance with making referrals. We worked with our CIS vendor to create a special script to automate referrals from the admission assessment note. Once nurses check “yes” to any referral trigger statement in screens for nutrition, abuse, social services, or infection control, an automatic referral is generated to the ancillary department and a referral note is made in the patient chart. The ancillary staff chart in the CIS after they see the patient, which closes the loop on the referral process. Evaluation/Outcomes: Once the script was running, ancillary departments found that they received too many referrals because their triggers were too broad and vague. We made our referral triggers more specific, which ensured that appropriate referrals were generated. Compliance with making required referrals greatly increased with the automated referrals. With ancillary documentation in the same system, it is clear that they evaluated the patient. We were able to show JCAHO surveyors that required referrals to ancillary departments were consistently made and that they responded to the referrals in a timely manner. MFurukawa@mednet.ucla.edu

NURSENET: An Internal Nurse Developed, Web-Based Solution to Enhance Communication, Education, and Professionalism

Rose T, Merrill A, Jones S, Craig C, Rother L; Council Of Nursing Excellence, INTEGRIS Baptist Medical Center; Okla

Purpose: Identified as a concern on the employee survey in 2004, the NurseNet Web page was developed to address problems with communication of all types within the organization. Description: The 2004 Council of Nursing Excellence created the NurseNet Web page as a tool for disseminating information to employees throughout the organization. Focusing on nursing issues, the initial home page had 13 navigation pages (NPs) to information ranging from just-in-time news and the nursing newsletter, to education and career opportunities and nurse recruitment and retention initiatives. It has now grown to more than 48 NPs, with new pages addressing research and evidence-based practice and the hospitals Magnet journey. The research/evidence-based practice site provides information about ongoing nursing research efforts within the facility as well as best practice topics. The Magnet journey page address the 14 forces of magnetism and our evidence supporting each of those forces within the organization. It also addresses the accountability of each nurse during the Magnet quest. The NurseNet Web page is used not only to inform and educate, but also to encourage increased professionalism on the part of the nurse. Links are provided to the ANA Code of Ethics, the Nurses Bill of Rights, and the ANA Standards of Practice. Links to numerous professional organizations are also provided including the state board of nursing, the Oklahoma Nurses Association, and many specialty organizations. Evaluation/Outcomes: Since its inception 1 year ago, the NurseNet Web page has received more than 24 000 hits. The Council of Nursing Excellence continues to solicit input regarding new information for the site and how to make it more user-friendly. This has become such a prominent part of the communication system for nurses that during nursing computer training, it is the page from which all orientation is initiated. Access to this site is available on every computer within the organization. tara.rose@integris-health.com Sponsored by: INTEGRIS Health

Mentoring: Rekindle the Passion for Nursing!

Bonuel N, Leonard J, McKnight R; The Methodist Hospital; Tex

Purpose: In the quest for excellence, a mentoring strategy was developed to assist clinical mentors in their professional development. Description: Clinical mentors are the third level of the Nursing Clinical Career Progression Model. Fully supported by the chief nursing executive, 8 nursing directors, 2 nurse educators, and a CNS developed a mentor program curriculum based on mentor needs assessment survey. Modules highlighted 6 key areas: performance improvement, evidence-based practice, communication, meeting management, resource management, and professional development. CNS, nurse educators, directors, and an organizational development specialist collaborated to teach the classes. The program is 16 hours, and classes were taught concurrently to accommodate class time and clinical practice. Upon class completion, each module has a definite outcome and limited timeframe for project completion. Completed performance improvement projects will be displayed in the hospital lobby in February 2006. Monthly nursing grand rounds were organized to showcase unit evidence-based practices. Mentors will provide written reflection of communication effectiveness and successful meeting facilitation to director; recommend 1 cost-effective intervention to improve unit operation; and develop either a poster in-service or initiate a journal club. Invigorated after the class completion, one mentor started a performance improvement project on “Patient Satisfaction on Food,” presented a positive outcome during the research resource council meeting. The mentor was complimented by the CEO in his weekly e-mail. Participation in the nursing grand rounds has reached a fever pitch. Evaluation/Outcomes: Mentor Program benefits extend beyond clinical quality. When nurses take ownership of their unit issues, finding evidence-based practice solutions, implementing and evaluating outcomes, they find practice enjoyable and fun. Mentor Program invigorates practice environment and increased enthusiasm to the nursing profession. The passion lives on! nbonuel@tmh.tmc.edu

Between Orientation and Competence, Where on the Path Does ECCO Belong?

Correll-Yoder N, Willems P; Queen of the Valley Hospital; Calif

Purpose: The level of readiness for critical care education in the orientees from both progressive care and ICUs was tracked between the initial orientation period and the first year of employment to determine readiness for the Essentials of Critical Care Orientation (ECCO) program. Inserting ECCO at the right time into the orientation of the new graduate RN in the high-stress critical care environment is crucial to orientee cognitive development and retention. Description: The orientation and education of new employees in the critical care units (progressive care and ICUs) is managed collaboratively by the Clinical Orientation Coordinator and the Critical Care CNS. Orientation classes had historically always been offered for large groups and early in the orientation period. New graduate nurses frequently complained of the class content being “too much” or “too overwhelming.” Staff nurses 1–2 years out from orientation complained that they were unable to remember and retain the information learned in orientation. An orientation pathway was developed and the ECCO program was implemented to replace the classroom education. Staff were tracked during the orientation process and surveyed after each ECCO module to evaluate the orientation and education process. Evaluation/Outcomes: Staff in both the progressive care and ICUs expressed satisfaction with the changes in the orientation process and the institution of the ECCO program. Staff were surveyed as to when in the orientation process ECCO should be initiated. The consistent feedback from the survey was to begin ECCO after completion of the preceptor orientation and approximately 6 months after hire. Based on staff feedback, the progressive care and ICU orientation and education plans were separated and 2 pathways were developed. Natalie.Correll@stjoe.org

Communication Tree: Talk to Me

Gryglik C, Davis M, Kinsey D, Scott K; Baystate Medical Center; Mass

Purpose: A cohesive management team on a 44-bed surgical intermediate care unit developed a means of consistent, effective communication to inform staff of changes in policy/procedure/ protocol and new information technology enhancements that affect the ability to provide excellent patient care. Description: With healthcare changes occurring at the speed of light, it is difficult at best on a busy unit with high patient turnover (275 discharges per month) to keep over 100 nursing staff informed of current information from multiple sources. A highly motivated clinical nurse manager, 2 assistant nurse managers, and a CNS are all actively involved in the unit’s Clinical Practice Committee where all nursing practice decisions are made. 2005 ushered in 3 major institutional undertakings: system-wide conversion to new computerized medical record/physician order entry technology; JCAHO survey using new tracer methodology; and an ANCC Magnet Site Visit. With each challenge, clinical staff involvement and commitment was key to its success. To facilitate these processes, a Communication Tree is used where 13 current and aspiring RNIII’s (highest level on Clinical Recognition Program) function as facilitators to pass along information expeditiously. Each RN facilitator has 4–7 staff members in their respective tree. Packets of new policies, computer downtime information, new forms and other types of information are placed in mailboxes of facilitators when appropriate and disseminated within each small group. Questions, comments, and feedback are directed to the management team to address. Evaluation/Outcomes: Although monthly staff and Clinical Practice Committee meetings are a great forum for information exchange, it is clearly not enough. Using the communication tree for expeditious information sharing ensures a clear, consistent message reaches all staff members. Facilitators also acknowledge the importance of their role in unit managment. Christine.Gryglik@bhs.org

Developing Frontline Leaders: One Strategy for Healthcare Success

Holtschneider M, Robinson J; Duke University Health System; NC

Purpose: Coaching and mentoring bedside nurses to become nurse leaders is fast becoming a critical necessity for the survival of the healthcare industry. Internal leadership development, particularly from the frontline staff, is a proactive solution to an evolving predicament. In conjunction with our Chief Nursing Officer, we participated in an intensive practicum, “The Center for Frontline Nursing Leadership.” Description: At our health system, structured leadership development sessions focused on improving and sharpening the intuitive skills of the frontline nursing staff. The practicum timeline spanned over a period of 3 to 4 months. Each nurse was assigned to a team of 4 to 5 other frontline members and guided by a coach, usually a manager or clinical nurse educator. A project, chosen by each individual frontline nurse, was implemented and evaluated. In designing the project, the nurse was asked to account for time constraints, identify required resources, and develop strategies to overcome personal barriers. Each nurse’s project was to be aligned with a common health system strategic objective with a focus at the unit level. Four team meetings were held during the practicum process to provide the nurses with the opportunity to obtain feedback on their progress and receive guidance from the coach and their fellow team members. Evaluation/Outcomes: Bedside nurses were given the opportunity to identify areas where they felt improvement was needed in their various work environments. They then planned and implemented projects geared for improvement. Three major projects were implemented on the health system level as a result of the coaching experience. These included: FAQ sheet on pharmacy-related concerns; Discharge Instructions Pocket Brain to help with patient teaching; and a Common Errors in Electronic Documentation PowerPoint presentation. Internal leadership training programs enable consistent follow-up and attention to needed changes. holts001@mc.duke.edu

ICU Nursing: Not Just a Job but a Lifestyle

Houseworth T, Elliott A, Johnson L, Mitchell S; The Methodist Hospital, DeBaKey Heart Center, CVICU; Tex

Purpose: In an era of nursing where the profession of nursing and the entire nation are facing a nursing shortage, hospitals have had to develop or add creative ways of not just training but retaining nurses. According to an AACN public policy statement on the nursing shortage, “the three major contributing factors to the nursing shortage can be best summarized in three categories: supply and demand, retention and workplace issues, and recruitment and image of nursing.” On the basis of the tenet of staff retention and workplace issues, the staff in the cardiovascular ICU collaborated on a life skills course. Description: Originally developed as an adjunct class for all new graduates in the cardiovascular ICU at The Methodist Hospital and later expanded to all new graduates in the hospital, the goal of the life skills course was to help the new graduate navigate and cope with the tasks of scheduling, working overnight shifts, balancing full-time nursing, and full-time families. Two presenters were selected and consisted of a nurse who primarily worked on the day shift and had over 20 years of nursing experience and a nurse who primarily worked the night shift and had a year and half of nursing experience. A power point presentation was given for two hours and then several games were played such as “Night Shift Jeopardy” and a mock self-scheduling game. A question and answer period was provided and the director of our unit was also present to answer questions and provide another perspective to the participants. Evaluations were given to each participant at a 6-month and a 12-month follow-ups. Evaluation/Outcomes: This class was particularly rated very highly by the participants of the residency program. According to the 12-month evaluations, 17% of the participants were very satisfied, 50% were satisfied, and 33% were neutral. The residency program at The Methodist Hospital had an 88% retention rate compared to the national average of 50%. tinahouseworth@hotmail.com

Accelerated Orientation of Nurse-Paramedic Critical Care Flight Crews Using High-Fidelity Simulation

Lavelle B, Denning S, Ihnken L, Benney A, Loberg N; HealthPartners Simulation Center for Patient Safety at Metropolitan State University/North Memorial Air Care; Minn

Purpose: Faced with orienting 20 critical care RNs and paramedics to medical air transport within 6 weeks, educators used high-fidelity simulation to accelerate learning of critical processes, thinking skills, communication, and teamwork. Description: Educators and managers identified critical aspects of the flight academy orientation curriculum that could be enhanced through standardization and simulation. They drafted 6 scenarios with specific skill, customer service, and communication objectives. Each scenario involved 1 RN orientee and 1 paramedic orientee acting as the flight crew. Experienced staff performed as patients’ family members or other healthcare providers. The remaining orientees watched the simulation via live feed video in a nearby classroom. Two debriefings occurred after each scenario—one between the crew and one among all orientees and the manager. Evaluation/Outcomes: Simulation/debriefing was an efficient, safe way to streamline orientation, providing “experiences” of high risk/high frequency. Active involvement of the manager provided clear behavior and skill expectations as well as increased bonding of the new employees with their supervisory staff. Each orientee crew, paired during the scenario as they would be in practice, perceived the simulation as a strong foundation of the bonding critical in actual medical air transport runs. Incumbent staff observed that this group of new employees demonstrated higher confidence, skill and communication behaviors than previous groups. Months later, the newer employees are still talking about the simulation training saying, “It is just like you said it would be!” The faculty involved with the development of the simulation curriculum noted the quickly enhanced situational awareness and more rapid movement of orientees to intermediate level practice. Given the positive outcomes, simulation will be used in future training events. elizabeth.lavelle@metrostate.edu

He’s Real! Using High-Fidelity Simulation in Critical Care and Progressive Care Orientation

Lavelle B, Sullivan D, Dahl W; HealthPartners Simulation Center for Patient Safety at Metropolitan State University/ Regions Hospital; Minn

Purpose: As a result of the need to orient larger numbers of critical and progressive care nurses while maintaining patient safety, high-fidelity simulations were incorporated into the orientation process. Description: Since February 2005, a minimum of 8 hours of patient simulation has been integrated into critical and progressive care orientations. Scenarios ranging from high volume (eg, AMI, CHI, hemorrhage shock, multiple trauma, ischemic stroke) to low-volume/high-risk (septic shock, pediatric trauma) require critical thinking and action on the part of the participant. Since each has been built with objectives, cues, and multiple layers of complexity, they are versatile and can be adjusted to individuals’ skill levels. Selected aspects of National Patient Safety Goals, new evidence-based practices, issues related to communication, cultural awareness, and ethical/legal dilemmas are able to be layered onto scenarios. Orientees rotate through scenarios in small groups so each can have hands-on experience. Simulations are video recorded to allow immediate feedback and facilitate debriefing with faculty and peers. Depending on performance, the next scenario can be leveled to become more difficult or more basic. Evaluation/Outcomes: The standardization of selected critical experiences has been an efficient way to expose orientees to many situations that would take months to observe in the clinical setting. There are opportunities to observe behavior under stress, intervene for learning, or to allow mistakes to be made and watch the effects without jeopardizing patient safety. 100% of orientees rated the content as “directly applicable to my job.” Comments included: “very helpful,” “would have liked more class time with this group at the sim center; too much info, so little time!,” and “a great teaching tool.” Future outcome measures may include confidence levels in routine and high-risk patient situations and rate of advancement to higher levels of expertise. elizabeth.a.lavelle@healthpartners.com Sponsored by: Minnesota Job Skills Partnership Program

The Apprentice: Engaging and Transforming Baccalaureate Nursing Students Into Highly Trained Critical Care Nurses

Rempher K, Manger R, Walker L; Sinai Hospital of Baltimore; Md

Purpose: Recruitment and retention of graduate nurses is paramount in the effort to provide consistent, high-quality, safe care to critically ill patients. The purpose of this poster is to explicate the role of the “special assistant,” a transitional role that cultivates graduate nurses for clinical practice in critical care. Description: For many reasons, recruiting and retaining graduate nurses for critical care has become increasingly difficult. In an effort to meet this challenge, nurses at Sinai Hospital of Baltimore have developed the role of special assistant (SA) for baccalaureate nursing students. The role, based on the “mentor model” was designed to enhance basic nursing and critical synthesis skills while acclimating the SA to the culture of the unit that upon licensure as an RN becomes their “home unit.” Under the guidance of an assigned RN mentor, SAs conduct routine assessments, review medications, and perform basic nursing functions. Additionally, SAs learn to navigate organizational systems which subsequently decreases anxiety and promotes efficiency when transitioning to the RN role. A primary benefit for the SA is the flexed schedule. From the employer perspective, the role allows shorter “employee” orientation and enhanced “clinical” orientation during transition to RN. Nurses in units where SAs are mentored benefit greatly from the experience by sharing knowledge, influencing socialization, and helping to retain future colleagues at a time when having consistent staff is essential for safety and quality of care. Evaluation/Outcomes: Outcomes are measured by evaluating the retention, performance, and employee satisfaction of those who have made the successful transition from SA to RN. To date, 4 RNs have successfully moved through the SA process, clearly demonstrating that engaging student nurses, and transforming them into proficient critical care nurses is indeed a good thing for themselves, our hospital, and most of all, our patients. krempher@lifebridgehealth.org

Essentials of Critical Care Orientation (ECCO): A Retention Tool?

Roberts M, Harris K; Poudre Valley Hospital; Colo

Purpose: To provide critical care nursing staff with the training and tools needed to provide world-class, compassionate care using a combination of bedside clinical orientation, ECCO, and skills review classes. Description: In late 2003, we evaluated our current orientation process and determined the presentation of information was overwhelming in both content and timeframe. With the advent of ECCO program availability, we proposed changing the orientation process for critical care nurses and preceptors. All new critical care nurses will complete ECCO as part of orientation and the preceptors will use ECCO to prepare them for their new role. The orientee and preceptor focus clinical orientation on the same content as the ECCO module the orientee is completing. The clinical experience and ECCO knowledge are brought together in the skills classes to fill in gaps, reinforce specific standards of care, and highlight the most important information. Evaluation/Outcomes: Addition of ECCO to the orientation process was evaluated in 2 ways: exemplars from all ECCO participants, and the subjective assessment of the educators and CNS. The exemplars were overwhelmingly positive. Positive comments include: defined expectation of base knowledge, reinforced ECCO content with clinical experience, ability to learn at own pace, and an ongoing resource when a new patient experience presents itself. An unexpected benefit was retention. Before ECCO implementation, 58% of critical care orientees stayed longer than 2 years. Since ECCO, we have 100% retention at 18 months. Of the preceptors who participated in ECCO, only 1 person has left in the past 18 months, and that was due to family obligations. Several of the preceptors who participated in ECCO commented how valued they felt that the organization would provide them with the opportunity. mgr@pvhs.org

Batter Up—Hitting a Home Run With ECCO Implementation

Sturgis G, Mcnatt P, Jones S; Integris Baptist Medical Center; Okla

Purpose: AACN’s Essentials of Critical Care Orientation (ECCO) program was chosen as the foundation for the graduate nurse (GN) internship program in our healthcare system. The goal of the coordinators for this program was to introduce and implement ECCO in an exciting, visual, and goal-oriented format. Description: Deciding on a baseball theme, the players (GNs) were divided into teams based on their specialty. Each team was assigned a coach (clinical educator) and a team color. On “Opening Day,” a welcome breakfast was held for all 98 participants. The hospital was decorated to reflect the baseball theme. ECCO modules were divided into 4 groups and completion dates were set. These deadlines were labeled 1st, 2nd, 3rd base and Home Plate. After each of the “base deadlines,” the coach held a “batting practice” (BP) with their team members. BPs gave players a forum for questions about the modules, time to practice skills and receive unit specific coaching. Coaches were responsible for managing their team roster, following their team members with unit visits, monitoring module completion progress, reviewing weekly feedback reports, and communicating the player’s progress to the clinical directors. The conclusion of the BPs was “the race for the pennant.” Each player earned a MVP pin, and certificates of completion for the internship program and ECCO modules. Evaluation/Outcomes: We have completed our second season using this theme. Postseason internship evaluations demonstrated a 92% satisfaction rate among critical care nurses; 85% felt that ECCO built competencies and 84% would recommend the ECCO program to others. The managers have appreciated such a positive impact from “batting practice” that they have now requested that this continue beyond the initial orientation period well into the first year. Gayle.sturgis@integris-health.com Sponsored by: Integris Baptist Medical Center

Which Way Do We Go? Orienting Staff to a Brand-New Unit

Suntrup M, Thomas-Horton E; Barnes-Jewish Hospital; Mo

Purpose: Our cardiothoracic unit was faced with a move to a brand-new unit in a new building of the hospital. We more than doubled our size, going up to 22 000 square feet, and expanded from 17 to 21 beds. The hospital purchased new monitors from a different company, which were installed with the move. Boom systems were designed for our patient population. Our unit practice committee identified the need for an orientation plan to ease the staff during the transition into the new unit. Description: Two-hour orientation times were scheduled for all staff in conjunction with a 4-hour monitor class before the moving date. During the orientation, staff were given a guided tour and shown how to operate new systems that had been installed. These included the boom system, nurse call system, telephone system, security door operation and lighting operation. Two brochures were developed to pass out during this time. One brochure had a blueprint of the new unit, a scavenger hunt, new phone numbers, and equipment lists for frequent procedures. The second brochure contained frequently asked questions that had been compiled as the move was anticipated and was divided into nursing, patient care tech, secretary, and general categories. Evaluation/Outcomes: Attendance was 100% for orientation. The brochures were well received by all staff and encouraged discussions and insured that important topics were reviewed. During the orientation, staff were able to make suggestions, some of which were implemented before the move. Staff felt more confident about the move after the orientation. The brochures are now being passed out to new employees during their orientation. Another unit has used our model of a brochure to give to their staff after their unit was remodeled. mas6678@bjc.org

Standing on My Own Two Feet: Developing a Mentorship Program for Novice Nurses in the ICU and CCU

Whitcomb R, Truman B, Dennis L, Woodham M; Grant Medical Center; Ohio

Purpose: To develop a mentorship program for novice nurses in the ICU and CCU to improve patient care, enhance learning, and increase RN retention. Description: Our critical care team identified a need for post-orientation guidance of newly hired RNs in our ICUs. New RNs stated they frequently felt overwhelmed and insecure without the support of an assigned preceptor after orientation. Based on this feedback, our team decided to develop a formal mentorship program that would help novice RNs feel more comfortable in their new role. Additional benefits of this program include increased job satisfaction, decreased turnover, a more cohesive team, and contribution to Grant’s mission of “improving the health of those we serve.” Initially, our team elicited staff feedback regarding the ideal mentor and their characteristics. Novice nurses were surveyed about what would have been beneficial for them after orientation. Based on this feedback and insight from the management team, mentor qualifications were defined and a mentorship program was designed. Our Mentorship Program will be a continuation of our current comprehensive 3-phase orientation process encompassing a 12-week unit specific orientation. Formal mentoring will begin at phase 4, lasting 3 months. During this time, the novice will closely follow their mentor’s schedule. Phase 5 will be individualized on the basis of the novice nurses’ needs to support their professional growth. The time frame of this phase will be determined based on the new RNs’ progress and comfort level. Evaluation/Outcomes: Mentors and the novice nurses will complete a survey at the end of phases 4 and 5 to evaluate the program. A team consisting of the mentors, unit educators, and management team will meet quarterly to evaluate feedback obtained from these surveys. Success of the Mentorship Program will be evaluated based on this information and changes made as needed to improve our process. rwhitcom@ohiohealth.com

Creation and Implementation of an Orientation Process for Physician Residents in the Intensive Care Unit

Zettl J, Becker C, Sramek D; Wyoming Medical Center; Wyo

Purpose: This project arose from an expressed desire for ICU RNs to discover the informal yet important role they play in the education process of the University of Wyoming Family Medicine Residency Program. Thus the idea of an orientation for residents was born. Three objectives were identified: 1) implement an RN-directed ICU orientation day for first year residents; 2) promote ICU RNs as resources to residents throughout residency; and 3) promote an atmosphere of trust/education versus mistrust/criticism. Description: Wyoming Family Practice (WFP) yearly welcomes a small group of doctors to their residency program at Wyoming Medical Center (WMC). To provide quality resident physician training and optimal patient care, WFP desired to foster an atmosphere of communication between ICU RNs and residents. ICU RNs at WMC traditionally experienced frustration and skepticism with WFP due to residents’ newness to critical care practice and ICU protocols. The RNs desired to improve nurse-physician relationships and assist first-year residents with clinical practice. We began with an informal orientation to ICU facilities by an RN. Each resident then spent 5 hours with a bedside RN. Each was inserviced on protocols, flowsheets, equipment, and were introduced to staff. At conclusion, RN and resident completed an evaluation. Evaluation/Outcomes: Written evaluations stated this program was successful and useful due to its informal nature. It gave residents opportunity to ask questions and learn without added burden of organizing patient care. RNs and residents began building rapport, opening doors to effective communication and interdisciplinary teamwork. This program’s success lead WFP to add second year residents to the orientation program and restructure the first year residency to include orientation during the first month, rather than spreading it out over a year. We discovered that a simple, proactive approach helped us to meet and even exceed our goals. jzettl@wmcnet.org

Collective Opportunities to Decrease Cardiac Surgery Infections

Hartwig J, Doran K; Mercy and Unity Hospitals; Minn

Purpose: An interdisciplinary team strives to prevent sternal wound and graft site infections by providing appropriate care based on current research. Opportunities of impact include normoglycemia, normothermia, and appropriate antibiotic timing. In review of data, it was noted appropriate antibiotic timing fell below 90%. In addition, a system was required to identify potential diabetics (fasting blood sugar >110 and an A1C >6.0), use of insulin drips perioperative with a transition postoperatively, proper preparation of skin before surgery and attaining a body temperature above >96.8 upon return to the unit. Description: The team members, include a CV surgeon, cardiologist, anesthesiologist, infection control nurse, pharmacist, clinical nurse specialist, and nursing staff have developed key activities: 1) revision of preprinted orders to denote exact timing of antibiotics, perioperative, and postoperative insulin use; 2) involvement of a diabetic educator and a registered dietician for patients with an admission fasting blood sugar >110; 3) development of patient education on proper skin cleansing and updating of preoperative teaching; 4) revision of hospital and patient pathway; 5) endoscopic vein harvesting; 6) body bear huggers initiated in the OR; and 7) staff education on identified strategies with available resources. Evaluation/Outcomes: Data indicate there is consistent improvement in the redose of antibiotic in surgeries greater than 4 hours and the discontinuation of antibiotics within 24 hours of surgery to 98%. Use of perioperative insulin drips for diabetic patients is at 100%, a structure for patients with preoperative blood sugars >110, including a diabetic educator and dietician. All preoperative and postoperative preprinted orders, pathways, and teaching forms have been revised. New body bear huggers are being used in surgery and in the immediate postoperative period. Implementation of these strategies have improved the care for our cardiac surgery patients. jodi.hartwig@allina.com

Reducing Incidence of Skin Breakdown in One University Burn Unit

O’Connor A, Taylor J, Davy D, Quinney M; University of Chicago Hospitals; Ill

Purpose: Research shows that the number of patients who develop pressure ulcers is estimated in the millions, costing approximately $1.6 billion annually. Because burn patients are at an increased risk for developing pressure ulcers, the purpose of our project was to reduce the incidence of pressure ulcers in our burn unit. Description: Capitalizing on weekly wound rounds, an interdisciplinary team consisting of nurses, an occupational therapist and physicians, performed in depth pressure ulcer assessments. We looked for the opportunity to prevent skin breakdown. Anticipatory guidance was a major focus of our project. For example, patients who were going to the operating room for a period of greater than 2 hours received thin Duoderm to bilateral heels and Gel-e-donut for their head. All patients who were intubated for greater than 24 hours received a Gel-e-donuts and Heelbos. This anticipatory approach also included posting flyers in the burn unit and one on one discussion with nurses on how to use the appropriate healthcare products needed to prevent pressure ulcers. Evaluation/Outcomes: Data were analyzed on 158 patients for evidence of pressure ulcers. In the first 6 months of our project we had 101 patients who had 2 head pressure ulcers, 13 heel pressure ulcers and 6 sacral pressure ulcers, the incidence of pressure ulcers was 33%. However, after our planned approach our burn unit had zero head, heel, or sacral ulcers. Ongoing proactivism, staff support and education proved to be essential in reducing the incidence of pressure ulcers in our burn unit. annemarie.oconnor@uchospitals.edu

Moving Evidence-Based Practice From Theory to Reality

Jenkins J, Marchiondo K; Central Missouri State University; Mo

Purpose: To make evidence-based practice more than a buzzword for nursing students. The project selected has a 2-fold purpose: 1) to provide nursing students the opportunity to evaluate a practice question, review literature regarding issue, and to recommend a practice solution; 2)to work with clinical agency to address actual patient care problem. Faculty hoped to enable students to recognize the need for a strong theory foundation and to introduce the tools necessary to support clinical decisions. Description: In order to make the project more meaningful, faculty moved from classroom to a patient care setting. Students work in conjunction with acute/critical care units to identify priority practice change topics. In small groups, students first gather evidence related to the problem. Research studies, professional organizations, and published guidelines are used to identify best practice. Research studies are critiqued using established guidelines. After gathering available evidence the students make recommendations for clinical practice. Their recommendations include steps necessary to launch new procedure/policy, products needed to implement change, and education necessary for implementation. Students then present recommendations via a poster. Both recommendations and posters are shared with clinical setting. Evaluation/Outcomes: Students have been very positive about the project, stating that working with real problems enables them to see benefits from their work. The clinical settings have also been very positive and have used elements of student projects. This assignment has not only provided student learning, but has positively influenced patient care and staff perceptions of feasibility of implementation of evidence-based practice. jenkins@cmsu1.cmsu.edu

“Sweet Success”: Embracing Change in Progressive Care Hyperglycemia Management

Mowry J, Pesenecker J, Bekele J, Eathorne J, York T, Mitgutsch L, Tucker C, Allis D, Gianchandani R, Prager R; The University of Michigan Health System; Mich

Purpose: A large surgical progressive care unit implemented tight glycemic control, including an insulin infusion protocol, to improve patient outcomes. Further goals were to develop glycemic control discharge education for diabetic and nondiabetic patients and to work with ambulatory care staff to provide consistent care for patients requiring hypoglycemic agents after discharge. Description: Maintaining euglycemic blood glucose (BG) levels after surgery has been shown in research studies to decrease surgical wound infections, bacteremia and complications that may lead to longer LOS. Using the hospital’s insulin infusion protocol as a guide, progressive care nurses learned titration of insulin infusions and transition to subcutaneous basal and bolus insulin therapy to maintain BG levels between 100–150 mg/dL in cardiac surgery and lung transplant surgery patients. Staff nurses, assistive personnel and advanced practice staff attended inservices led by the Hyperglycemia Consult Service. Documentation audits determined where further educational coaching was needed. A collaborative team provided ongoing staff education. Information resource boards contained pertinent BG control information for staff and patients. Job aids were created to organize insulin orders. “Super-users” were implemented to reinforce change. Evaluation/Outcomes: A tool was developed to evaluate specific aspects of the tight glycemic control program; staff ’s perceived workload and level of comfort with insulin therapy, and attitude and inclination for following the protocol. Anecdotally, teamwork, equipment issues, and multiple insulin orders were identified as major issues by the staff. Accomplishments to date are decreasing trends in deep surgical wound infections and bacteremia in the past several months. Adjustments in staffing models, the purchase of more glucometers, and creative staff education techniques contributed to our “Sweet Success” and improved patient outcomes. jole@umich.edu

Pediatric Patients With New Tracheotomies— Innovative Solutions for Safe Patient Care

Veator R, Pelletier M, Horn M, Gray S; Children’s Hospital Boston; Mass

Purpose: Our goal was to decrease unnecessary variation in the nursing care provided to pediatric patients with new tracheotomies. To accomplish this we first formed a Tracheostomy Group that is cochaired by 2 pediatric ICU (PICU) staff nurses and includes a pulmonary CNS and RNs from throughout the institution. We then created and disseminated nursing standards for tracheostomy care across our pediatric institution. Description: We did this by designing numerous tools that would be helpful to staff nurses. For example, we developed a laminated card that includes 10 key points of tracheostomy care, a revised bedside information sheet, and a management plan that includes information about the critical airway of a newly tracheotomized patient. In the PICU a tracheostomy teaching bag was created which contains different styles and types of trach tubes, different types of dressings and ties, and a doll on which nurses can practice changing tracheostomy tubes and parents can practice changing dressings, ties, and skin care. The group also continues to teach monthly tracheostomy orientation classes to all newly hired nurses in general hospital orientation. Our resource books have been distributed to all inpatient clinical units and our 10 questions on tracheostomy care have been adapted to a Netlearning format and is made available to all nurses throughout the institution. Evaluation/ Outcomes: Our staff nurses’ innovations for standardizing care have resulted in more confident and knowledgeable PICU nurses, and therefore, safer tracheostomy care to medically complex patients. Furthermore, the availability of these solutions to nurses throughout the institution has helped to ease patient transition from the PICU to the acute care units. Improvements with the delivery of care will also continue as the Netlearning tool will be able to evaluate and help the Tracheostomy Group address the learning needs of nurses throughout the institution. rosamond.veator@tch.harvard.edu

No Ifs, Ands, or Buts

Richter A, Dammeyer J; University of Michigan Hospital System; Mich

Purpose: To promote health and safety our Health System is a smoke free environment. New programs are in place to enforce this culture, using policy education and counseling. No standard nicotine replacement therapies (NRTs) were available to offer patients for nicotine withdrawal symptoms. Many patients went “cold turkey” while also recovering from an illness or surgery. Many nurses lacked the knowledge to counsel patients about smoking cessation and the NRT available. From January 1 through June 29, 2005, there were 26 inpatient smoking occurrences recorded in the adult hospital. This puts everyone at risk for smoking safety issues related to fire. Description: A multidisciplinary team coordinated the development of a NRT Order Set. Upon admission and when a patient responds “yes” to smoking within the last year, the nurse consults the Tobacco Cessation Counselors and notifies the physician that the NRT order set was placed in the chart. The patient is given a letter stating the hospital smoking policy. The NRT appears on the medication record daily for the nurse to offer the patient. If the patient refuses NRT, the orders are not discontinued thus available when the patients’ withdrawal symptoms peak, usually at 48–72 hours. Within 24 hours of referral the patient is seen by the counselors. Evaluation/Outcomes: Evaluation of this program is being done using various methods. The number of orders placed in the charts versus those patients who answered “yes” to smoking and those orders actually initiated and signed by physicians are being tracked. The patients’ evaluate the program by completing a discharge feedback form asking such questions as, was NRT offered and was the staff knowledgeable about smoking cessation. Nurses’ scores on pre- and posttests regarding comfort level with smoking cessation and facts related to NRT are compared. Security Services data about smoking occurrences will be compared before and after implementation. Safety is reinforced by implementing a culture of No Ifs, Ands or Buts! dazy@med.umich.edu

Body Substance Isolation Plus (BSI+) Model for Eliminating Multi-Drug Resistant Acinetobacter

Hamilton R; Harborview Medical Center; Wash

Purpose: To eliminate the transmission of Acinetobacter bacteria in the critically ill patient at Harborview Medical Center. A resistant form of Acinetobacter was introduced to Harborview 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: Harborview implemented the W.A.S.H. (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 patients (intubated, open wounds, or transfers from another facility) who are admitted to the ICU are given surveillance cultures upon admission and once a week while in the ICU. A patient testing positive for Acinetobacter becomes a BSI plus (BSI+) patient. BSI+ is noted with an orange wrist band, orange stickers on the patient’s chart, and 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 BSI+ 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 five new cases of Acinetobacter were reported daily. After initiating the BSI Plus 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 one 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. rhamilo@comcast.net

Time to Wake Up: Improving the Quality of Assessment and Documentation of Pain as Part of a Minimum Sedation Protocol

Harvey E; Veterans Administration Medical Center; Va

Purpose: Optimal pain control in critically ill patients centers on accurate pain assessment and interventions that minimize sedation while effectively treating pain. Consistent documentation of pain assessment is essential to a coordinated team effort to the management of pain. Over a 3-month period, in a 14-bed medical intensive and progressive care unit, the Critical Care CNS identified a standards compliant pain assessment in 9% of cases with a 63% compliance with every 4-hour pain reassessments. Description: The Critical Care CNS and pharmacist convened a multiprofessional team including an intensivist, nurse manager, respiratory therapist, and staff RNs to develop an evidence-based minimal sedation protocol incorporating daily wake-up with pain, anxiety, delirium, and ethanol withdrawal assessment. To improve the quality and compliance of pain assessment documentation, a system was developed incorporating templates within a computerized patient medical record for assessment of pain in verbal and nonverbal patients. Staff, resident and physician education in regards to the minimum sedation protocol and documentation standard occurred. Ongoing individualized patient application of the protocol by the Critical Care CNS and pharmacist occurred during daily multiprofessional team rounds. Evaluation/Outcomes: Three months following implementation of the protocol and documentation system, with sustained compliance over a 1-year period, a standards compliant pain assessment was identified in 98% of the computerized medical records. Every 4-hour pain reassessments rose from the baseline of 63% to 97% and early morning wake up with pain assessment of sedated mechanically ventilated patients rose from a baseline of 13% to 81%. Application of a minimum sedation protocol woke up a multiprofessional critical care medicine team to consistent evidence-based assessment and documentation of pain in a critical care setting. moandaba@yahoo.com

Smoother Transitions: Development of the ICU to Acute Care Transfer Checklist

Johanson R, Bachman C, Gibran N, Blayney C; University of Washington Regional Burn Center, Harborview Medical Center; Wash

Purpose: To create a smooth transition of ICU patients as they move to an acute care setting, our multidisciplinary team developed a comprehensive tool in the form of a checklist and letter given to patients and families. The checklist is to ensure that vital information is passed on to the receiving nurse and as a double check that the patients meet acute care criteria. The letter explains that their loved ones now need a different level of care and details what to expect in the receiving unit. Description: As a patient becomes readied for acute care the ICU nurse begins to review the transfer checklist making sure that appropriate orders are obtained, that the family is aware of the transfer, and that belongings are tracked and documented. An individualized care plan is updated in the computer and is passed on directly to the receiving unit. Evaluation/Outcomes: This process has strengthened the relationship between the ICU and acute care teams, and has prevented misunderstandings on the part of families regarding change of status. Important details such as medications, meals, code status, and family dynamics is passed on. Families appreciate having the transfer letter that validates their loved ones improvement and answers many questions in advance. This decreases anxiety and lets them know what to expect in the acute care setting. Our transfer process has become more efficient and standardized, and we have anecdotally noticed a decrease in the number of patients returning to the ICU as a result of omitted care issues. johanson@u.washington.edu

Continuous Insulin Infusion Therapy: It’s Not Just for ICU Anymore

Jonas M, Beckett R; St. Luke’s Hospital; Iowa

Purpose: Research has shown a positive correlation between glycemic control and a decrease in morbidity and mortality rates of critically ill patients. For some patients, the need for tight glycemic control extends to the general medical-surgical (M-S) unit. By integrating a standardized insulin infusion protocol (IIP) with a simplified insulin dose calculation and documentation tool, our facility has moved the IIP outside of the ICU, for use house-wide. Description: For critically ill patients in the ICU, glycemic control has been accomplished through the use of the IIP. When the ICU implemented multidisciplinary rounds along with bed utilization, it became evident that the IIP needed to be expanded to the general M-S areas. To ensure patient safety, protocol compliance, and accuracy, the IIP was converted from a 7-step computer program to a 3-step pen and paper format. To make the IIP self-controlled, the order set includes guidelines for insulin dose calculations, and special actions allowing for immediate treatment of episodic hypoglycemia, dosage adjustments for changes in glucose intake, and for converting to long-acting insulin. Using small-steps of change, the revised IIP was trialed in ICU. Once finalized, a plan to educate one M-S unit every 2–3 weeks was created. As the inpatient units began using the IIP, an ICU RN was identified to serve as the resource person for any questions or concerns the M-S RN may have about the IIP. Because of the simplicity of the IIP, the intensity of the education, and support given to the nursing units, we are now able to use the IIP on all adult M-S patients. Evaluation/Outcomes: The educational component of the IIP was completed in February 2005. Initial data shows 39% of the glucose results are within the target range of 80–130 mg/dl. In phase 2, a more aggressive version of the IIP has decreased the time to target range from 18 hours to 8 hours. House-wide implementation is planned for October 2005. Phase 2 outcomes will be presented at NTI. jonasmm@crstlukes.com

Welcome to the Future: Transform Your Meeting Format to Engage Virtually Every Staff Member

King K, Olson D; Duke University Health System, University of North Carolina, Chapel Hill; NC

Purpose: Nurses transform the environment of care by participating in unit-level committees and work groups. Conventionally, a team of staff nurses meets once each month to develop and review policies and procedures. Projects typically require 4–6 months for completion. The hectic pace of the ICU leaves little time to attend meetings, and time off is a precious commodity. Often, nurses are asked to come in for meetings on a day off. The purpose of our project was to increase nurse participation in policy making without requiring additional administrative time commitments. Description: We created a password-protected virtual conference room on the World Wide Web. A total of 31 staff members participated in this project. They were able to access the Web site and participate in a virtual policy discussion forum 24 hours a day. This forum provided the opportunity to engage in a continuous dialogue that facilitated nonstop policy development. In addition, each new updated version of the policy was regularly emailed to members who would review the document and suggest changes through the discussion forum. Evaluation/Outcomes: The team completed the project in 35 days; evaluating 18 different versions of 2 policies. All 31 members participated in the discussion. The original budget of 6 meetings of 7–10 staff members was not required, which saved the hospital approximately $13 000 in additional labor expenses that would have been spent developing these policies in a conventional manner. Staff accessed the Web site at various times, some during short 5- to 10-minute breaks at work; some from the comfort of home. Discussion threads were moderated by the project chair to facilitate quick resolution of key points. Staff reported that the discussion threads were user friendly, and the use of email for document exchange was convenient and kept up the momentum. The virtual meeting environment was determined to be less costly, more inclusive, and significantly more productive. King0108@mc.duke.edu

Overcoming the Obstacles: Screening and Providing Immunizations for Patients in the Acute Care Setting

Biba S, Sellers P, Poston L, Nedd A, Warren M; St. Luke’s Episcopal Hospital; Tex

Purpose: Each year in the United States up to 60 000 adults die from vaccine-preventable diseases or their complications. Both JCAHO and CMS have set forth initiatives to encourage hospitals to screen and provide vaccinations for patients admitted with pneumonia. Despite the pathway and order set for pneumonia being updated to encourage vaccinations, consistent screening was not being completed. A protocol was developed and piloted to assist in the screening and immunization of all patients discharged from the hospital. Description: The pilot unit was a 32-bed general medicine floor. Two staff nurses, pharmacy, an APN, and the management team developed a process to implement the protocol. The protocol was placed in the medical record upon admission. Close to discharge, the patient was screened by the RN and immunizations were provided as needed. Patient education material was included with the medication for easy access. A floor stock level of 2 was kept on the unit as to not delay discharges. The unit secretaries completed a quality monitoring tool as the patient was discharged. Evaluation/Outcomes: 132 patients were discharged during the 22 day pilot. An average of 6 patients was discharged per day. The most number of vaccines given per day was 2 and only 1 delay in discharge was reported. The protocol was present in the chart 99% of the time. The screening rate was 79%, and the administration rate was 13%. Reasons for not giving included: patient declined, physician declined, patient current with immunizations, and patient did not meet criteria. Based on the pilot data, the decision was made to go house-wide with the protocol. The staff was educated and reminders were placed at the bedside charting areas. Vaccination status was also added to the admission database and to the discharge instructions. Currently, the original pilot unit continues to monitor compliance. The screening rate has been > 90% for the past 3 months and the provision rate has been 100%. mwarren@sleh.com

Critical Care Workteam: Improving Our Patient Outcomes

Woodham M, Barto C, Kagel E, Dennis L, Clark K, Thompson C, Dixon K, Dolan S, Truman B, Anthony T, Metersky S; Grant Medical Center; Ohio

Purpose: A staff driven workteam uniting our critical care units to collaborate, standardize nursing practice, and address patient care issues in the critical care setting. Description: The Critical Care Workteam, chartered in 2004, is chaired by the critical care Outcomes Manager, an advanced practice nurse, and champion critical care nurses. Goals of the workteam include: working collaboratively with the multidisciplinary physician- lead Critical Care Clinical Process Improvement Team (CPIT) to develop practice protocols/guidelines, providing suggestions and recommendations for change, and evaluating patient outcome data. Additionally, the team identifies opportunities for improvement, develops solutions for change, and drives implementation of process improvement initiatives. The workteam seeks feedback from CPIT regarding current projects and potential opportunities for future projects. One of the first projects the workteam was instrumental in was the development of the Daily Goal Sheet, formed to guide physicians and nurses in setting goals and identifying potential issues during rounds. The Daily Goal Sheet encompasses the JCAHO ICU core measures allowing for assessment and implementation of best practice standards. A Patient Worksheet was also designed to provide an accurate shift-to-shift report, as well as ensuring continuity of care. This worksheet is implemented upon admission and includes the patient’s medical history, current medical issues, a list of consulted physicians/disciplines, and a brief narrative of events. The workteam has also revised the nursing flowsheet to meet JCAHO requirements related to patient education and pain documentation. Evaluation/Outcomes: Since the formation of the workteam, patient outcomes have improved as evidenced by an increased use of DVT/GI prophylaxis and decrease in VAP rates. The Patient Worksheet has streamlined shift-to-shift report by reducing time and increasing nursing satisfaction. Michellewoodham@yahoo.com

Shear Discovery

Nasenbeny K, Higashi D, Glenn T, Ranum K, Sisco K, Wong K, Lendrum W, Lawson L, Ching J, Rydberg D, Greco S; University of Washington Medical Center; Wash

Purpose: Identify the etiology and risks of skin injuries in the ICU and develop a feasible standardized prevention program to be integrated into practice. Description: A Pressure Ulcer Prevention (PUP) team of ICU nurses and consultants (ICU and wound CNSs, nurse researcher, nursing QI) was created to develop strategies to decrease the prevalence of skin injuries in the ICU. Based on the literature and expert input an audit tool was developed to identify prevalence, type/mechanism of injury (pressure vs shear) and risk factors. Audits were conducted on 143 ICU patients during 4 monthly surveys. Baseline data provided the PUP team with targets for intervention. The highest risk sites were heels and sacrum. Top causes were shear (29%); device related (26%), pressure related (19%), and combined (16%). No clinical states/interventions (shock, dialysis) were significant risk factors. The Braden score was the only factor predictive of injury. Most patients had Braden Scores < 16, but a Braden score < 12 and subscores r/t moisture, friction and activity were most predictive. The results were shared with staff. The etiology of shear injury was discussed and high-risk patients were identified (HOB elevated for VAP prevention). Evaluation/Outcomes: Based on the data an intervention was designed to prevent friction/shear injury. Specifically, transparent film is placed on the heels/sacrum of all ICU patients (unless ambulatory). Skin protection packets were placed on the admission cart to make it easy to implement the strategy. Compliance audits r/t transparent film application and heel elevation were performed at 2-week intervals with a target of 80%. Initial compliance was 78%. PUP champions followed up with all nurses; compliance target met. Follow-up audit: decreased prevalence (achieved benchmark goal). Respiratory care and the PUP team partnered to develop strategies to decrease injuries due to ETT securing devices. Further interventions may include a silicone based barrier to decrease moisture related injuries.

Stopping VAP Using the AACN Practice Alert

Correll-Yoder N, Thompson E, Bruneau J; Queen of the Valley Hospital; Calif

Purpose: Following the publication of the AACN Practice Alert on Ventilator Associated Pneumonia, the ICU staff changed their practices around oral care and head of bed elevation resulting in a drop in the ventilator-associated pneumonia (VAP) rate. Description: The VAP rate was climbing in the ICU population over the last 3 years. The critical care leadership team in the ICU decided to make a change in practice following the release of the AACN Practice Alert for Ventilator-Associated Pneumonia. All RN staff received a copy of the practice alert for VAP at staff meetings. At the biannual skills fair, head of the bed elevation and oral care standards and their impact on VAP were reviewed with RN and respiratory care staff. Quarterly audits were performed to evaluate staff compliance with the changes in the practice standards. Staff compliance with the changes was 95%. Evaluation/Outcomes: VAP rates for intensive care patients dropped by 42% after the implementation of the head of the bed elevation and regular oral care. RN and respiratory care staff continue to work collaboratively promoting these 2 initiatives to reduce the risk of VAP. The critical care leadership will continue to monitor the literature and look for additional interventions to reduce the VAP rate to 0%. Natalie.Correll@stjoe.org

Declaring War: A Battle Plan for Defeating Catheter-Related Blood Stream Infections

Asleson A, Jacobs L, Madrid P, Farber M; Mercy Hospital; Minn

Purpose: Following a huge success in our fight against ventilator-assisted pneumonia (VAP), the nurse manager of the Mercy Hospital ICU set her sights on catheter-related blood stream infections (CR-BSI). With a goal of reducing and hopefully eliminating CR-BSIs in the unit, a multidisciplinary team now assesses the policies and procedures surrounding central lines, including steps in inserting, accessing, and maintaining central lines. This team consists of ICU and IV therapy nurses, an internist, and an infection control practitioner. Description: The team determines where the greatest risks for infection occurred and makes changes to diminish those risks. An issue of particular concern was the procedure regarding in-room storage units (nurse servers) in cases of contact precautions. Protocols were created addressing what would be done with the nurse servers in the event a patient is admitted with known precautions vs. being placed in precautions after being in the room for any period of time. Also, noting the marked decline in VAPs after the ICU adopted a vent bundle, the committee created a CR-BSI bundle. Full barrier is used every time a central line (including a PICC) is placed; daily discussion with physician about continued need for central line is required on every patient; bio-patch dressings were purchased, and are routinely put on a central line if the line has been in place for 7 days; central line dressing changes are routinely done every three days by IV therapy nurses. Staff education on correct accessing and dressing of central lines was done in several different ways. A critical event review is done and posted in each case of CR-BSI in the ICU. Evaluation/Outcomes: The immediate outcome has been increased staff knowledge of the risks related with central lines and infections as well as greater compliance with sterile technique with inserting central lines and aseptic technique in accessing and maintaining central lines. As of submission, the ICU has only had 2 CR-BSIs this year! amy.asleson@allina.com

Does Primary Nursing Alone Provide the Best Continuity of Care for Patients? A New Approach to Patient/Nurse Synergy

Armstrong D, Keith C, Bobotas L; Children’s Hospital; Mass

Purpose: To develop a system for delivery of nursing care that would provide continuity for patients while maintaining primary nursing. This system would create more consistent nursing balance for patients with various acuity levels and length of stay. Description: A task force evaluated current primary nursing practice used in a 24-bed level III NICU with 106 nurses providing patient care. Goals were to increase continuity of care; match patient needs with nursing expertise; educate families and staff on new system; balance patient acuity, and maintain shift and scheduling flexibility for staff. Nursing staff was divided into 3 teams and patient care areas were geographically designated. Nursing experience and schedules were considerations for team assignments. In addition, every nurse has 1 primary patient. Evaluation/Outcomes: The Continuity of Care Index (CCI) was used to measure the number of different nurses a patient experienced over a designated period of time. Three months after the model was implemented, the CCI reported a decreased number of individual nurses per patient whose length of stay was greater than 14 shifts. The CCI of patients with shorter lengths of stay did not improve significantly. Further evaluation is required to monitor trends long-term. Although a formal survey to parents has not been done, parents voiced that they “liked the team approach and getting to know a smaller group of nurses is better” and “the nurses on the team got to know my baby and her problems well.” A staff survey will be done after 1 year of implementing the new consistency care system. donna.armstrong@childrens.harvard.edu

Implementation of Early Goal-Directed Therapy for Sepsis at a Community Hospital Through a Multidisciplinary Approach

Atkinson M, Cerone P, Chesney S, Cowen J, Hashemi T, Hodgman T, Joffe A, Lidsky N, Nixon D, Ruiz C, Ryzner D; Northwest Community Healthcare; Ill

Purpose: Early Goal-Directed Therapy (EGDT) for patients presenting with septic shock is strongly supported in the Surviving Sepsis Campaign guidelines and by the Institute for Heathcare Improvement. The sentinel study by Rivers et al was conducted in an optimized environment, which included a specialized mini-ICU located within the ED. This has resulted in much concern and debate in the critical care community regarding the ability to overcome the impediments that prevent timely implementation of EGDT in a community hospital setting. Therefore, we developed a protocolized approach to early identification and treatment of patients with septic shock who presented to the ED. We also sought to identify any process issues that could impact upon timely implementation of EGDT and the other components of the “sepsis bundle.” Description: The EGDT and “sepsis bundle” protocols were developed by the Critical Care Multidisciplinary Evidence-Based Practice group. A multidisciplinary sepsis team was then developed to educate the ED and ICU staff through lectures, in-services, and reinforcement at departmental meetings. Staff nurses were recruited as “Change Champions” to promote and encourage compliance with the evidence-based guidelines. We also designed sepsis-specific doctor’s order sets and an ICU flow sheet to both optimize patient care and data collection. A computerized database tool was developed to capture traditional outcome measures as well as numerous process variables inherent in the achievement of EGDT. Evaluation/Outcomes: The sepsis team approach reduced the time to initiation of EGDT. It is possible to effectively implement, in a timely manner, EGDT for patients with septic shock in a community hospital setting. This can be accomplished through reorganization of existing resources and formation of a dedicated sepsis team. Data collection and review of process issues is an essential component of this ongoing effort. matkinso@nch.org

Critical Care Turn Team

Barcelos K; Community Regional Medical Center; Calif

Purpose: To address issues related to the increasing acuity and severity of illness of our patient population, aggravated by the current nursing shortage, there was a need to develop a creative solution to focus on care provision. The goal of creating a critical care turn team was to improve the quality of care provided to patients, prevent work related injuries, better use RNs time to focus on duties requiring licensure, and to aid in nurse recruitment, retention and satisfaction. Description: There were 2 main objectives with the implementation of a turn team. The staffing was changed to assign 2 patient care assistants (PCAs) per shift (previously 1 PCA per shift) for a 20-bed critical care unit. In addition, the job description and primary duties of the PCA now includes repositioning/turning and oral care rounds on all patients every 4 hours. These rounds, include oral care for all patients (intubated and nonintubated), based on the RN’s assessment of the oral mucosa. Once the job description was changed and approved, additional staff was hired to fill these newly created positions. The critical care educator created a training/competency program to educate and verify competency of the PCAs (newly hired as well as existing PCAs) to facilitate acceptance by the RN staff. The program was implemented April 2004. Evaluation/Outcomes: The implementation of the critical care turn team had astounding results when data were reviewed 12 months after implementation in May 2005. The critical care unit was fully staffed and was not using temporary RNs (Travelers/Registry). There were no work-related neck or back injuries in critical care. The ventilator-associated pneumonia (VAP) rate went from 10.2 to 5.7. This was a 44% decrease in the VAP rate, prevented 17 VAPs, and an estimated cost avoidance of $685,000. The Critical Care Turn team proved to be extremely successful! kbarcelos@communitymedical.org

Bugs Off With Handwashing

Barto C, Kagel E, Woodham M, Trees J, Deeg B, Whitcomb R, Coakley J, Bowdish C, Krueger T, Bossart K, Doles J; Grant Medical Center; Ohio

Purpose: To heighten awareness and educate the multidisciplinary critical care team about the importance of hand hygiene, JCAHO’s Patient Safety Goal #7, and their role in the prevention of hospital-acquired infections. Infection rate for possible hospital-acquired VRE was 2.5% in CCU, 2.3% in ICU, and 4.3% in BSU, illustrating an increased need for education and awareness of proper hand washing technique. Description: Under direction of the Patient Safety Council, the Infection Control Committee and the Critical Care Clinical Process Improvement Team identified this as an opportunity for process improvement. An audit tool was created in April 2005 to monitor physicians, residents, interns, physical/occupational/respiratory therapy, and nursing staff. Audits for hand washing were completed in April 2005, followed by staff education. An unidentified observational data collector was assigned to randomly observe in each unit. The audit tool monitors hand hygiene after hands-on patient contact and/or removing gloves. Results are broken down into 3 areas including use of a waterless hand rub, use of soap and water, or inappropriate use. Inappropriate hand hygiene was defined as handwashing for less than 15 seconds, not allowing the handrub to dry, and/or wiping the handrub off. Once the monitoring was complete, data were compiled and analyzed. Those staff members who were observed correctly participating in hand washing were rewarded with “wash your hands” tee-shirts acknowledging their appropriate use of hand hygiene. These shirts are frequently worn by staff in the critical care units promoting an ongoing culture of hand hygiene and patient safety. Evaluation/Outcomes: Following education and heightened awareness, a follow up audit was completed illustrating increased staff compliance with hand hygiene. Infection rates for possible hospital acquired VRE decreased from 2.5% to 0% in CCU, from 2.3% to 0% in ICU, and from 4.3% to 0% in BSU. cbarto93@hotmail.com

Controlling Pain While Maintaining Safety for High-Risk Cardiac Surgery Patients: A Clinical Challenge!

Bérubé M, Nguyen D, Lemay S; Jewish General Hospital; Canada

Purpose: Around the clock analgesia (ACA) is used for cardiac surgery Patients in our ICU and step down unit (SDU). However, our team noticed that cardiac surgery patients above 75 years of age and/or presenting several comorbidity factors developed side effects related to this therapy. Consequently, a clinical project to control pain effectively and safely for high-risk cardiac surgery patients was initiated. Description: 60 nurses from ICU and SDU were asked to fill up an adapted version of the McCaffery & Ferrell pain questionnaire. The monthly journal club was used to provide teaching on the relationship between risk factors and the development of side effects associated with the administration of analgesics. Also, an algorithm aiming to enhance nurses’ decision making for a safer administration of ACA was presented during the sessions. The algorithm provides with guidelines on parameters to evaluate before the administration of analgesics. Afterwards, nurses were asked to complete a modified version of the Pain Assessment and Interventions Notation (P.A.I.N.) tool while taking care of cardiac surgery Patients. Meanwhile, physicians reconsidered their approach to prescribe analgesics. Finally, a process of ongoing data collection was established. Evaluation/Outcomes: After 2 months of data collection, results revealed that no patient developed side effects associated with ACA. 3 patients obtained a score below 4 on the Riker scale, but were receiving a sedative agent. The CNS observed during data collection that nurses followed the algorithm. Also, physicians adjusted the dosage and type of analgesics according to patients’ risk factor(s). In summary, this clinical project shows how interdisciplinary work and educational interventions can lead to modifications in clinical practice towards better outcomes for patients. mberube@nurs.jgh.mcgill.ca

The Buck Stops in the E-ICU: Increasing Compliance With a Sepsis Bundle

Blakesley D, Fahey F, Hannah R, Tucker K, Roberts G; OhioHealth; Ohio

Purpose: Recognizing that early intervention and treatment is crucial to the success of sepsis management, the electronic ICU (e-ICU) at Ohio Health developed a strategy to improve the rate of compliance with a sepsis bundle that had been implemented by 2 critical care units from Riverside Methodist Hospital (RMH) in September of 2004. Description: After reviewing the “Surviving Sepsis” guidelines published in Critical Care Medicine, March, 2004, and many other research articles, sepsis “bundle” was created for implementation in 2 large medical/surgical critical care units at RMH. The “Sepsis Bundle” consists of the following components: glucose control, early assessment for Xigris, random cortisol levels if hypotensive, ARDSnet protocol if on the ventilator, and receiving the 1st dose of antibiotic within 2 hours of the order being written. The e-ICU was established as the initial contact if a patient was suspected of having severe sepsis or septic shock and care of the hospital sepsis pager was transferred to the e-ICU. The nursing staff in the e-ICU was empowered with protocols to assess patients for the sepsis bundle components and to obtain orders for any identified deficiencies in the sepsis bundle. Financial and quality outcomes for this patient population were tracked by entering these patients into a “Sepsis Registry.” Evaluation/Outcomes: When the e-ICU was implemented in January 2005 the 2 units’ compliance with the sepsis bundle was 17.4%. With the e-ICU involvement in assessing patients for the sepsis bundle, the compliance has increased to 44.4%, and mortality has decreased dramatically. Having a central location to screen and assess patients for the sepsis bundle has improved their identification and treatment. debboralynn@yahoo.com

Early Referral for Organ Donation

Crawford L, Blackmon D, Carlson E, Parker M, Taylor C; Mission Hospitals; NC

Purpose: Organ donation saves lives every day. To increase the number of potential donors, this organization decided on a proactive approach by developing a method for promoting early screening of ventilated patients prior to “end of life protocol” initiation. Description: A multidisciplinary team developed criteria to assist critical care nurses in determining when to make an early call for organ donation screening. A pilot was initiated in three out of the 5 adult ICUs. A bright green sticker with “early referral indicators” and call information was placed on the chart of every ventilated patient. Employees were educated on the new process via staff meetings, receiving packets of materials and by colorful posters placed in the units. During daily rounds, each case was evaluated for early referral based on the new, early call criteria. If criteria were met, a call was placed (to LifeShare of the Carolinas) and a representative screened the patient for organ donation. Evaluation/Outcomes: The pilot was concluded after 16 weeks. The team made minor revisions to the chart sticker and process based on evaluations from the pilot. With continued support from the team, the program was then implemented in all of the adult ICUs and the emergency department. Remarkably, the number of referrals jumped from 77 to 216 following implementation of the Early Referral Program. To further facilitate the early referral process, a prompt was added as part of the computerized nursing assessment documentation to remind the nurse to make a call if the patient is in the ICU, on a ventilator and is unresponsive. The end result is that the number of organs recovered has more than doubled in our organization, a significant contributing factor to saving lives! linda.crawford@msj.org

Project Excellence: Engaging Staff in Patient Satisfaction

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

Purpose: The patient satisfaction scores from our thoracic surgery patients were slipping. The clinical nurse manager received good feedback about the staff from patients as she made rounds, but organization-wide patient satisfaction scores did not reflect this. Our highest score possible is excellent, but survey scores were far below. The manager was determined to do something different to improve the scores, and recognize the staff for their commitment to patients. Description: The manager created an introductory packet for patients on the division. The first page states “Your excellent care is being provided by the staff of thoracic surgery.” It gives the names of the managers and invites patients to contact them. The managers make rounds to talk with patients personally and to intervene early. Our goal is to ensure that all problems are fixed promptly. The second page invites the patient to tell about their stay on the unit and to name the employees who provided excellent care. There is a self-addressed envelope for those who prefer to mail their comments. A “Project Excellence” book holds all the letters received from patients about their excellent care. Employees love to check the book for notes from patients. Every month the names of employees recognized are put in a pool to be drawn for the Service Excellence Employee of the Month. The winners select prizes that are meaningful to them. Evaluation/Outcomes: Gaining staff commitment to Project Excellence was difficult at first because using the word “excellent” was not part of their vocabulary. It has taken root as patient satisfaction is discussed at monthly unit meetings. The manager challenged the staff to achieve a target satisfaction score—and they did! Over 3 months the mean score rose more than 12 points. They celebrated with parties on all shifts. There have been no complaints on the unit since implementing Project Excellence. They employees take pride in doing the right thing for patients and they receive recognition for doing so. adl5362@bjc.org

To Eat or Not to Eat—Dysphagia Assessment

Loehr L, Edmiaston J, Davis S, Burns J; Barnes-Jewish Hospital; Mo

Purpose: In preparing for our disease-specific primary stroke certification survey stroke care across the continuum was evaluated. It was identified that dysphagia screening was not being initiated consistently before a patient was given anything by mouth. The process has been that a speech pathologist must evaluate all stroke patients before any oral intake may be ordered. Performance improvement issues that were identified were the lack of screening in the emergency department and that patients had remained NPO for greater than 24 hours. Patient satisfaction surveys have also indicated that not being allowed to eat until seen by speech pathology was upsetting. Description: A literature search was performed and other stroke centers queried about their dysphagia protocols. Finding no evidence-based guidelines that could be used, speech pathology developed a dysphagia-screening tool to be used by physicians and registered nurses when speech therapy is not available. The tool was approved for use and inservices have been completed for all neuroscience divisions, physicians and emergency department nurses. The tool is based on basic neurological assessment parameters that are performed on every stroke patient. Evaluation/Outcomes: This tool has enhanced patient satisfaction by empowering the physicians and nurses to screen each stroke patient for risk of aspiration in the absence of the speech pathologist. Looking at those patients screened, there has been no evidence of aspiration. sbd4906@bjc.org

Beat the Clock—Improving Times From Door to Primary Coronary Intervention

Derby B, Brown S, Clark B, Erickson T, Hemann G, Schaad P, Soukup M, Tannenbaum M, Verhey M; Mercy Medical Center; Iowa

Purpose: To improve the process within Mercy Medical Center to decrease the mean door to primary coronary intervention (PCI) time. Description: A multidisciplinary team worked to establish and implement an evidence-based protocol to treat individuals with ST elevation myocardial infarctions (STEMI). A baseline of 122 minutes door to PCI was established over a 6-month observation period (N=53 patients). Based on ACC/AHA guidelines and the JCAHO standard for acute myocardial infarction (AMI) time to PCI of less than 120 minutes, we focused on ways to reduce our time. A level 1 Heart Attack Protocol was developed to establish inclusion criteria and identify the critical time guidelines that needed to be met. Vital timetable information included onset of symptoms, ED arrival, time to ECG, protocol implementation, initiation of call system, ED exit, cath lab entry, and time of PCI. We then worked to educate the emergency department staff and streamline our processes. Evaluation/Outcomes: Data collected from January 2005 to July 2005 have shown the mean door to PCI time has decreased to 61 minutes (N=96 patients). We are currently working with emergency medical services throughout Iowa to implement a prehospital protocol for STEMI patients before arrival. An added bonus of early identification and treatment of these patients has been an increase in compliance with AMI core indicators, including 100% compliance of these core indicators form October 2004, to March 2005 (N=295 patients).

Striving for Perfection-Working to Achieve 100% Compliance of Acute Myocardial Infarction Core Measures

Derby B, Birchem S, Bosch M, Clark B, Erickson T, Porter C, Schaad P, Soukup M, Tupper R, Verhey M; Mercy Medical Center; Iowa

Purpose: Mercy Medical Center’s multidisciplinary Cardiac Medical Steering Committee challenged itself to provide “perfect care” to its acute myocardial infarction (AMI) patients. Description: Since January 2003, monthly data indicated Mercy Medical Center were consistently able to accomplish 100% compliance with 6/7 core measures but 7/7 was eluding. The committee worked to increase awareness and provide education to cardiologists, coronary care unit staff and emergency room physicians and nurses. Changes were made to the standard coronary care orders. A multidisciplinary team worked to develop and implement a Level 1 Heart Attack Protocol for ST elevation myocardial infarctions (STEMI). Daily goal sheets were developed and used in the coronary care unit to address all core measures. Evaluation/Outcomes: The increased awareness and education resulted in Mercy Medical Center achieving “perfect care” or 100% for all 7 core measures for 100% of all AMI patients for six consecutive months from October, 2004 to March, 2005 (N=295 patients). We missed one data point in April, 2005 achieving 100% for 6/7 measures (N=45/46 patients). We have returned to 7/7 “perfect care” for May and June, 2005 (N=112 patients). We have learned that only when you aim high, do you fly high!

Getting to the Bottom: An Innovative Unit Approach to Decreasing Hospital Acquired Pressure Ulcers

Doolittle T, Toole B, Sullivan-Fernandes K, McCormick S, Gray T, Perkins A, Cheng J, Brindley M, Branom R, Flores R, Buska L, Andersen S; Sharp Grossmont Hospital; Calif

Purpose: Hospital-acquired pressure ulcers are a recognized nursing sensitive outcome contributing to patient discomfort, length of stay, and expense. In the final 2004 quarterly prevalence study, our unit had a facility high 13.5% prevalence rate of hospital-acquired pressure ulcers. An initiative was launched to decrease this occurrence to meet or surpass the 4% national benchmark rate. Description: Using Deming’s Plan-Do-Check-Act model, a collaborative team was formed and strategies proposed to decrease this ulcer rate. The nurse manager, educators, advanced clinicians, and resource nurses composed the team. Team members made rounds 2 times per week on identified high-risk patients. Rounding tools included a supply cart; a data collection form for tracking interventions, patient progress, and RN communication; and dressing and mattress reference materials. During rounds the team assessed, photographed, and treated skin breakdown. If indicated, specialty mattresses were ordered and consultations initiated with the Wound Ostomy Continence Nurse specialist (WOCN) and dietician. Individualized interventions were based on the pressure ulcer treatment algorithm, wound dressing decision tree and specialty mattress linen guide formulated by the WOCN and skin team. The patient, family and nurse were educated on the interventions. In concert with the WOCN, staff education also emphasized preventive measures. Evaluation/Outcomes: Subsequent prevalence studies have shown marked improvement. After a promising first quarter 2005 rate of 6%, the plan was checked and further actions implemented, including daily assessment by the team for specialty mattress needs. Second quarter results were exceptional with zero ulcers found. Early detection and heightened awareness of prevention by the entire nursing staff generated these results. Based on these notably improved outcomes, many of our new strategies for pressure ulcer prevention have been adopted hospital wide. tammy.doolittle@sharp.com

To Shoot or Not to Shoot, That Is the Question

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

Purpose: Pneumonia and influenza are the 6th leading cause of death in the United States with pneumonia being in the top 5 hospital DRGs nationally even though vaccines for pneumonia and influenza have been shown to be highly effective. Pneumonia is a high-volume diagnosis at Hoag Hospital with an average of 600 patients a year. When the hospital’s pneumonia data for 1999–2000 werer reviewed, Hoag met all Medicare standards with the exception of only 5% of patients screened for pneumococcal vaccine and no patients screened for influenza vaccine. Description: This project organized a Vaccination Task Force. Research was conducted into CDC Guidelines and the use of in-hospital immunization functions at 2 major medical systems (Mayo Clinic and Intermountain Health Care). Our model for improvement was based on the information obtained. The goal was to immunize all adult patients hospitalized at Hoag, based on a nurse-screening protocol. Applicable eligibility criteria were obtained from CDC. Nurses screen patients against preexisting eligibility criteria at the time of admission. If eligible, the orders are transmitted to the Pharmacy. Pharmacy places the order on the Medication Administrative Record (MAR) to administer the vaccine upon discharge, and subsequently sends the vaccine to the patient’s unit. At the time of discharge, the nurse administers the vaccine(s) and hands the patients a yellow vaccination card. Monthly compliance reports are provided to all units. Evaluation/Outcomes: After implementation in the medical surgical units, it was moved to the ICUs in January, 2005. The Q1-2005 and Q2-2005 compliance rate was 50% for patient assessment. Based on these data, a process change occurred requiring the charge nurses to perform a daily survey with the objective of improving our rate of screening. With continued monitoring and reinforcing the goals of the project, we will ensure the delivery of proactive, preventative care. MHewett@hoaghospital.org

The Roadrunners—Rapid Response Team

Hewett M, Lepman D, Furman W; Hoag Memorial Hospital Presbyterian; Calif

Purpose: Adverse cardiac events are a common and serious complication among hospitalized patients. Recent studies show that most patients who have a cardiac arrest in the hospital have identifiable signs of deterioration before their arrest. Despite advances in treatment for cardiac arrest, only 17% of patients who experience a cardiac arrest survive to discharge. Using the Cerner Project Impact Critical Care (CC) database, with sudden emergent transfer from the floor to ICU, the average hospital mortality was 31% compared to 16% for patients admitted directly to ICU, thus a 2-fold increase in hospital mortality if patient became unstable while on the general care floors. Description: At Hoag, staff nurses can call the Rapid Response Team (RRT) “anytime they feel uncomfortable about a patient.” The RRT members (a respiratory therapist supervisor and a critical care nurse) will respond to a patient’s room within 10 minutes. The goal for the RRT is not to “take over” the care of the patient at the bedside, but to work with the nurse at the bedside in a coaching role. The intensivist in CC can be accessed by the team as needed. Evaluation/Outcomes: For the 2nd quarter 2005, 53% of cardiac arrests occurred outside of CC (16 of 25). Our hospital rate of arrests is 3.1 per 1000 discharges. The overall hospital mortality of patients who transferred to ICU from the floor after arrest has been reduced to 21.9% (mortality index of 0.84). CC length of stay after arrest is 2 days while hospital stay is 8 days. The average response time of the team was only 4.2 min, illustrating the teams trust in the validity of the RRT calls. At inception, 80% of the RRT calls requiring transfer to CC. With an inference that calls were being made late, further education resulted in a drop to 42%. The next steps will be to create a council with representation from all the units and respiratory department for case reviews and monitoring the team’s progress. MHewett@hoaghospital.org

Core Measures 101: Ten Easy Steps for Implementation

Hofmann A, Leggett S, Richter A, Nolan G; University of Michigan Health System; Mich

Purpose: To provide nurses with the knowledge and skills to achieve best practice through core measure monitoring using 10 easy principles (steps). Description: Our Cardiology Department leadership was committed to providing best practice through evidence-based principles and decided to implement the Guidelines Applied in Practice (GAP) process to improve outcomes of hospitalized ACS and CHF patients through rapid cycle improvement. Success was pivotal on the selection of a physician “champion” who would promote the project within the medical community and the assembly of a dedicated team to develop the process and provide daily monitoring. Quality indicators were adopted and performance goals set, and “tools” were developed for nurses and physicians to insure that the indicators were addressed. We created a multidisciplinary system to insure that all patients in these categories were captured. The process of daily monitoring was introduced to determine the use of tools and compliance with the indicators, and continuous feedback in performance was provided to physicians, staff, and monitors. Multidisciplinary collaboration was required to achieve and sustain this system of monitoring and feedback. Once the elements of the project were defined, staff were educated in the process and their vital part in its success. The development of this process has been guided by goals and principles that we condensed into ten easy steps that can be used by nurses wishing to implement quality improvement measures in their workplace. Evaluation/Outcomes: The GAP process has been successful in our department through the improvement of all the quality indicators. In addition, it has cultivated a collaborative relationship between the disciplines as we work toward a common goal. Through an incentive program from a third party payer the hospital has been given significant monetary rewards over several years which sustains administrative support for this vital project. ahofmann@umich.edu

Safety Summit: A Commitment to Patient Advocacy, Caring, and Excellence!

Kusic S, Essary E, Remolona G, Rinon J, Sohi M; The Methodist Hospital DeBakey Heart Center; Tex

Purpose: In response to to the 2004 JCAHO National Patient Safety Goals, our cardiovascular ICU challenged its staff to decrease medical errors and promote effective team communication as a commitment to patient safety and advocacy. Description: Discouraged by strained relationships and workplace errors, our cardiovascular ICU challenged its staff to tackle some of the unit’s most perplexing issues. How do we decrease medication errors, mislabeled specimens, and unhealthy communication? Consequently, a group of dedicated staff members collaborated to improve unit safety goals and effective communication, thus “The Safety Summit Group” took shape. Several work groups emerged, and unit protocols examined. “Hot spots” were identified and modifications arose. For example, mislabeled specimens were increasing. As a safety modification, at least 2 patient identifiers must be used before sending a lab specimen. In addition, 2 RNs must cosign on all lab requistions. As a system modification, additional label printers were purchased and placed at decisive locations within the unit. Another grappling issue presented: How do we improve our interpersonal communication skills among our team members? The staff formed another workgroup, “The CVICU Relationship Committee,” which is composed of various members of our team—RNs, physicians, and pharmacists. The group discusses aspects of skilled communication, relationship building, and respectful dialogue. Members share accounts of difficult interactions with the team and collaborate to increase confidence, and interpersonal skills. Evaluation/Outcomes: The Safety Summit proved to be a successful plan. Our JCAHO survey was positive and our incidence of workplace errors have decreased. We continuously strive to perfect team communication, thereby dedicated to patient advocacy, caring, and excellence. SKusic@tmh.tmc.edu

You Can’t See Us, but We’re Watching… The Design and Implementation of a Centralized Telemetry Surveillance Unit (CTSU)

Miller W, Erickson C, Mehlbrech M; VCU Medical Center; Va

Purpose: VCU Medical Center currently has 94 non-ICU, monitored beds among 7 inpatient units. Before November 2004, only 2 of the units, representing 48 beds, had individuals assigned 24 hours a day to observe cardiac rhythms. The remainder of the units relied upon alarms generated by central monitors at the nurses’ station that were frequently neither seen nor heard and critical changes in heart rhythms were often missed. It was not unusual for patients to become disconnected from their monitor without staff being aware which had the potential for a negative patient outcome. Finally, having unit based monitoring staff on 2 of the units, represented an inefficient use of personnel resources. Medical and nursing staff, equipment manufacturers, and architectural consultants collaborated to design and create a CTSU to be staffed by cardiac monitor technicians (CMT) around the clock. Description: To enhance the communication between the CTSU and the caregiver, multiple communication pathways were established. These included integration of the nurse-call system with hospital based cell phones, the creation of an automatic alarm-sending interface between the cardiac monitor and the cell phones and a back-up system to monitor the functioning of each component. Communication was also established through overhead paging to all of the monitored units from the CTSU. Evaluation/Outcomes: Caregivers are now notified immediately by the CMT’s of significant changes in cardiac rhythms. In addition, there is an instantaneous, automated notification of life-threatening rhythms and patient disconnects. Despite increasing our monitoring capacity from 48 to 94 beds, the number of required CMT FTE’s has decreased, resulting in a positive financial impact. Over the past 8 months, there have been no negative patient outcomes. These enhancements have brought our organization into compliance with JCAHO standards regarding audible alarms and notification to caregivers. mmehlbrech@mcvh-vcu.edu

Saving Young Lives: Reducing Medication Errors in the PICU

Mulloney J, Moloney-Harmon P; Sinai Hospital of Baltimore; Md

Purpose: Using a PSDA approach, PICU staff sought to reduce the number of medication errors occurring in a pediatric ICU. Description: According to the Institute of Medicine, medication errors are the most common reason for harm for pediatric patients in the hospital. In addition, pediatric patients have a higher risk of death as the result of medication errors. However, medication errors are preventable. A multidisciplinary group in the PICU consisting of nursing, medicine, and pharmacy was convened to examine how medication errors occur and to develop a program to prevent them. The group first outlined each step in the medication administration process, starting from when the medication is ordered to the time it is administered to the patient. The steps were identified and areas of potential breakdown were recognized for each step. Once the areas of breakdown were identified, interventions for each area were developed and implemented. A pediatric-specific medication administration policy was developed. Focused education for all providers took place. A double check process between 2 nurses was developed for certain high-risk medications, including those used for epidural analgesia. An annual competency for mathematical calculations was developed since miscalculation is a major cause of errors. An Excel program for checking complicated medication calculations, such as epidural analgesia was developed, which gives a red box warning if the calculated dose is outside the appropriate range for the child’s weight. If a medication error does occur, it is treated as an educational opportunity with the staff involved in the error providing multidisciplinary education. Evaluation/Outcomes: Since the implementation of this program, the number of medication errors has decreased; since January 2005 there have been no medication errors. Of note, many potential administration errors have been avoided by the double check system. jmullone@lifebridgehealth.org

Sleepless in Seattle: Preoperative Screening for Sleep Apnea in Heart Surgery Patients

O’Connell K; Hoag Memorial Hospital Presbyterian; Calif

Purpose: Sleep disturbances have a major impact on an individual’s physical functioning, emotional well-being, and quality of life. By identifying and treating heart surgery patients who have sleep apnea we hope to: improve respiratory outcomes in the immediate postoperative period, decrease the hypoxemia which may contribute to the development of future atherosclerosis, and decrease the patient’s sleep disturbance and therefore improve their quality of life. Description: The Hoag Cardiac Surgery Team and the Hoag Sleep Center collaborated to improve the care of the cardiac surgery patient with sleep apnea. We implemented a process to identify these patients preoperatively and intervene as needed. Starting in 2003, all elective heart surgery patients were screened for sleep apnea by the advanced practice nurse (APN) using a simple tool. Patients who met the high risk criteria for having sleep apnea were considered for CPAP mask in the postoperative period. They were eventually referred to the Sleep Center for a formal consultation with a sleep apnea specialist and an overnight sleep study. The APN also counseled patients who had previously refused to wear their CPAP mask or were lax about completing their overnight sleep study. Evaluation/Outcomes: Before implementing our screening process sleep apnea was frequently underdiagnosed or not even considered. The few patients who had been diagnosed preoperatively did not understand the significance of repetitive hypoxia on their heart disease. Many of these patients were not wearing their prescribed CPAP masks. Currently, over 90% of the elective heart surgery patients are screened by the APN for sleep apnea using the Sleep Apnea Assessment Tool. The screening process immediately “red flags,” patients who would likely benefit from a CPAP mask postoperatively. We have improved our process for detecting and treating sleep apnea in this patient population by implementing this systematic approach. Koconnel@hoaghospital.org

Race for Safety! 100% Compliance With JCAHO Safety Goals

Payne H, Freeman S; Poudre Valley Health System, Surgical Neuro Intensive Care Unit (SNICU); Colo

Purpose: The surgical neuro intensive care unit (SNICU) safety star program was developed to facilitate the mandatory 100% compliance with the JCAHO safety goals. Description: In an attempt to institute the 100% compliance benchmark established by JCAHO for the national safety goals the SNICU Continuous Quality Improvement Committee (CQI) developed a Race for Safety program. The CQI committee agreed on a predetermined number of observed and consistent behaviors that would establish practice change with each staff member for each safety goal. Each safety goal was designated by a different colored star shaped pin. It was the expectation that all SNICU staff members would receive all pins indicating compliance with all safety goals. The time frame for this initiative was 4 months. The charge nurses and members of the CQI committee directly observed these behaviors and recorded them in a safety star notebook. For example, it took 20 observations of consistent hand washing within the JCAHO guidelines to earn a black star pin. The pins were awarded at each monthly staff meeting and worn on the staff members’ name badge. The progress was tracked on a large bulletin board with a race car theme. Each staff member had a race car labeled with their name and the car progressed around the track according to the number of stars earned. After the 4-month period 99% of the SNICU staff members had achieved all pins and the remaining 1% completed the program after an additional month. The 100% compliance was rewarded with a pizza party at a staff meeting. Evaluation/Outcomes: The safety star program created an initiative based competitive atmosphere with positive reinforcements to establish changes in nursing practice. Data obtained using an audit tool verified the compliance rate of staff proving that the safety star program was useful in creating habit changes. We are now proud to be 100% compliant with JCAHO national safety goals. hap2@pvhs.org

Can You Hear Me Now? Transforming Care Through the Use of Voice Technology in a Progressive Coronary Care Unit

Rempher K, Bethel-Warner J, Schrank S; Sinai Hospital of Baltimore; Md

Purpose: Effective communication is essential in providing, safe, high-quality patient care. In an effort to return nurses to the bedside and improve electronic communication among healthcare providers, nurses at Sinai Hospital of Baltimore have turned to Vocera, a novel telephonic, wireless communications system. Description: The Vocera Communications System is a form of wireless, interactive, voice-response technology that uses a small badge to allow healthcare providers to communicate with each other. Nursing, telecommunications, and operations improvement specialists at Sinai Hospital of Baltimore enlisted this technology in early 2005 as one mechanism to optimize communication, increase productivity, enhance teamwork, and improve customer service. The badge’s lightweight and hands-free design allow the healthcare providers from various disciplines to page, leave messages, or speak directly to colleagues. Additional time-saving features include 3-way calling, conference calling, emergency break-through calling, and call forwarding/transferring. The primary benefits for Sinai nurses include time saved by no longer having to search for personnel, and improved ability to respond to patient needs in a timely manner. In addition, noise levels on nursing units has been reduced as a result of fewer ringing telephones and decreased overhead paging. Evaluation/Outcomes: The success of the Vocera technology has been evaluated using a combination of quantitative and qualitative methods: 1) pedometer measurements post-Vocera compared to baseline, 2) pre- and postassessment of central paging requests, and 3) assessment of attitudes and beliefs about the impact of Vocera technology on the clinical care. krempher@lifebridgehealth.org

Every Nurse Has a Name: Bedside Nurse Name Cards

Rowland K, Litzenich D, Murry M, Becker C; Barnes Jewish Hospital; Mo

Purpose: Nurses participate actively as advocates and coordinators in their patients’ care.One way to help patients understand this key role is to be sure that all patients and families know their nurses’s name. We discovered during a patient satisfication survey, that few patients or families knew the name of the nurses assigned to them each shift. Description: We formed a committee to find a solution. We created a “Bedside Nurse Name Card” intended for each patient. The name card sits in a 5 x 7 inch plastic holder on the patient’s overbed tables. The card’s design has the nurse’s name in easily readable print. It is tall enough to be seen above other table items. Each nurse has a supply of reusable name cards to put into the holder at the beginning of the shift. At the end of the shift, nurses collect their name cards from the holders. We piloted the name cards on a cardiac unit and a neurology floor. Before and after the pilot study, we surveyed 60 patients and families to test the effectiveness of the bedside name card. Evaluation/Outcomes: Patients, families, and staff members find the nurse-card holders very useful in identifying their nurses’s name on each daily shift. Analysis of our pre- and postpilot study data showed good improvements. On admissions, 40 of 60 participating patients and families had to ask for their nurses’name. After the pilot, 15 said this was a still a problem. We expanded the name card holders to more of our in-patient units and noted similar improvements in helping patients know the name of their assigned nurse. An added benefit for the staff was that since families and patients knew their nurse’s name, time and energy was saved by other staff in locating the patient’s nurse when a patient needed assistance. ksr1799@bjc.org

Misidentified Laboratory Specimens: From “Analysis Paralysis” to Results

Schmitz T, Gaskin P, Lewis P; The Methodist Hospital; Tex

Purpose: Mislabeling of laboratory specimens by nursing staff can result in extra cost, delays in care, and harm to patients. For years, data were collected and distributed to managers at our large, urban, academic medical center hospital, with little change in the frequency of errors. We queried the University Healthsystems Consortium and found that all institutions were similarly struggling. Description: A multidisciplinary Performance Improvement Team was established with representation from laboratory, ICU, acute care, emergency department, and Performance Improvement. A formal process was used to identify current practices and desired practice. Staff nurses from all the clinical areas with a high volume of laboratory specimens contributed invaluable input in this process. We agreed on a consistent process, educated and retrained, used technology to assist us, made “work-arounds” difficult, and improved the type of data collected. Reports were distributed to the units promptly. Constant positive reinforcement was provided. Staff nurses participated in designing processes, and in developing competitions and incentives. We used stories to emphasize the importance of this “routine” task. A staff nurse capitalized on a story about a patient who died as a result of a mislabeled type and crossmatch specimen. With the mantra of “We should treat drawing blood just like we treat giving blood,” she proposed a “buddy system” for double-checking labels. This is now our recommended procedure housewide. Evaluation/Outcomes: In 2 years, we have moved from “analysis paralysis” to results. We implemented a successful program to analyze the causes of error, change our processes, and alter staff behavior. This has resulted in a sustained 2-year downward trend in our incidence of mislabeled specimens. In just the past year, our rate of misidentified specimens (measured by number of misidentified specimens per 1000 equivalent patient days) has decreased 40%. tschmitz@tmh.tmc.edu

Love Your Patient’s Skin! Development of a Pediatric S.K.I.N. Bundle

Simpson V; Children’s Hospital of Austin; Tex

Purpose: Prevention of pediatric pressure ulcers has been a hot topic in recent years, yet there is little literature regarding the pediatric population. Our institution sought to develop a “bundle” of interventions that could be initiated on pediatric patients considered at risk for development of pressure ulcers. Description: Until a year ago, our institution had nothing in place to address prevention of pediatric pressure ulcers. To address this, a pediatric skin policy was developed and the Braden Q Pressure Ulcer Risk Assessment scale was chosen as our risk assessment. Nurses were trained in the use of the Braden Q. More recently, we have developed specific interventions based on the S.K.I.N. mnemonic developed at an adult institution in our healthcare network. S stands for “support surface,” K stands for “keep turning,” I stands for “incontinence management,” and N stands for “nutrition” as these are all key components in pressure ulcer development. Patients with a Braden Q score of 23 or less are considered at risk of pressure ulcer development. A resource sheet was developed for nurses to refer to based on the patient’s specific problem areas that could contribute to pressure ulcer development. Nurses were educated on all bundle elements. All interventions emphasize basic nursing care. For example, if the patient was scored below 23, and was immobile and incontinent, the nurse could look at the reference sheet and refer to the “S”, “K,” and “I” sections of the resource sheet to determine what interventions to use to prevent pressure ulcer development. Evaluation/Outcomes: Before policy implementation, there was no tracking of pediatric pressure ulcer incidence in our institution. Tracking of pediatric pressure ulcers began after policy implementation and our highest monthly incidence was 1.2 per 1000 patient days with an average of 0.4 per 1000 patient days since implementation. Unexpectedly, reporting of pressure ulcers also increased after policy implementation. vssimpson@seton.org

From CQI to Research: Reducing Ventilator-Acquired Pneumonia in CCU Patients

Stone B; Middlesex Hospital; Conn

Purpose: This presentation demonstrates the results of a 4-year interdisciplinary effort to reduce the occurrence of ventilator-acquired pneumonia (VAP) in critical care adult patients and the collaborative research project it has generated at our hospital. Purpose: A common and potentially fatal complication of mechanical ventilation, VAP include MRSA, gram negative, gram positive, and P. aeruginosa infections that further compromise critically ill patients. In 2001, our VAP rate was 11.7/1000 ventilator days, above the national benchmark established by the National Database of Nursing Quality Indicators (NDNQI) of 8/1000 ventilator days. Description: An interdisciplinary team began an extensive review of the literature as the first step in addressing the problem, including the 2004 AACN Practice Alert on VAP. The team included RNs, physicians, infection control experts, and respiratory therapists. The team goal was to reduce our VAP rate by instituting standardized, evidence-based interventions. Several practice changes made over the course of 4 years are presented. Interventions addressed new mouth care policies, head elevation guidelines, and equipment changes. Evaluation/Outcomes: Results indicated gradual improvement. These are illustrated graphically in a time series of pie charts. In 2004, the VAP rate had dropped below benchmark to 2.7/1000 ventilator days. While first quarter 2005 results are quite promising (0/1000 ventilator days), the team recognized the need to evaluate the effectiveness of several oral care products to reduce treatment variation. Consequently, the team has developed a research proposal to conduct a randomized control study to investigate the relationship between select oral care agents and occurrence of VAP. The randomized control study design is presented at the conclusion of our presentation. Barbara_Stone @ midhosp.org

Assuming Responsibility and Accountability for Practice and Patient Outcomes: Nursing Professional Practice Council

Truman B, Donaldson D, Whitcomb R, Bossart K, Dixon K, Hand T, Seiler R, Troyer R, Dolan S, Yowell K, Naber E; Grant Medical Center; Ohio

Purpose: Nursing care of critically ill patients should reflect best practice guidelines and use current literature to improve patient outcomes and decrease LOS. Committed to this philosophy, our nursing staff developed a shared governance committee to monitor and evaluate nursing practice in the ICU. Description: The Nursing Professional Practice Council (NPPC) was developed in 2003 to oversee nursing practice in our trauma ICU. This team is chaired by an ICU RN and composed of staff nurses with voting privileges, a manager and a critical care outcomes manager as resource support. The NPPC meets monthly and reviews literature; evaluates nursing practice; collects, reviews, and analyzes patient outcome data; identifies opportunities for improvement; and implements process changes to promote best practice. Council members are assigned a designated number of staff and are responsible to disseminate information. This promotes a culture of open communication, accountability, and consistency of nursing practice in our ICU. The NPPC works in collaboration with the multidisciplinary Clinical Process Improvement Teams. Projects include skin care initiative, medication safety monitoring, redefining the charge nurse role, multiple nursing audits, Point of Care testing, prevention of blood culture contamination, AACN certification drive, and development of the ICU Balanced Scorecard. The blood conservation initiative involved implementation of Point of Care (POT) testing in the ICU. POC testing equipment was placed near the ICU, POC labs were identified and incorporated into preprinted physician orders, nursing education was completed, and compliance was collected and reported to the NPPC and nursing staff. Evaluation/Outcomes: Since the formation of NPPC, multiple practice changes in the ICU have resulted in improved patient outcomes. The POC initiative resulted in reduced blood loss and decreased turn-around time for laboratory results thus decreasing delay in clinical decision making. btruman@ohiohealth.com

Unraveling the Ventilator Bundle: Improving Outcomes in Patients Requiring Mechanical Ventilation

Bishop C, Curtin K, Warren M, Stewart E, Treige N; St. Luke’s Episcopal Hospital; Tex

Purpose: Recent studies on aspects of care in the mechanically ventilated patient have demonstrated improved outcomes including decreased days on the ventilator, decreased length of stay, decreased cost per case, decreased mortality and complication rates, and decreased ICU utilization. These aspects of care are collectively known as “Ventilator Bundling” and include use of deep vein thrombosis and peptic ulcer disease prophylaxis, daily sedation holiday, intensive insulin therapy, daily screening for readiness to wean and head of bed elevation. Several process improvement activities were developed to assist in meeting compliance with Ventilator Bundling. Description: ICU admit orders were developed to include several aspects of ventilator bundling. A sedation protocol for mechanically ventilated patients and ventilator weaning protocols were developed to incorporate appropriate dosing of sedation, a sedation holiday, and ventilator weaning trials. Insulin protocols were also developed and implemented. In addition, multidisciplinary rounds were conducted and ventilator bundling was addressed with the primary RN and RT. Unit based pulmonary resource nurses (PRNs) were identified and served as resources for the education of staff and implementation of new protocols and aspects of care related to ventilator bundling. The PRNs also initiated quality monitoring on ventilator bundling to enhance communication among providers and improve compliance. An 8-hour pulmonary workshop was offered to explain rationale and educate the multidisciplinary team on ventilator bundling. Evaluation/Outcomes: In reviewing data for patients requiring tracheostomy with mechanical ventilation over a 9-month period (N=187), several improvements in outcome measures were seen: 32% reduction in cost/case; 24% reduction in overall length of stay; 23% reduction in ICU length of stay; 23% reduction in ventilator days; and 31% reduction in mortality rate. cbishop@sleh.com

Placing Ownership for Quality in the Hands of the Staff

Dematteis J, Werstler J; Aultman Heart Center; Ohio

Purpose: A unit-based Quality Dashboard and Newsletter was developed to provide staff with results of monthly key performance improvement indicators. Using this information, all staff is expected to make a personal commitment or offer suggestions to improve results. Description: Staff involvement in the performance improvement process is imperative for goals to be achieved. Participation in the PI process has always been an expectation of staff, but difficult to ensure informed collaboration by all staff. The newly developed quality dashboard provides the vast amount of PI data in an accessible format, including goals, year to date, and current results, and provides a visual gauge of thumbs up or thumbs down performance. Indicators included patient perception (Press Ganey), adverse drug events, pain documentation, falls, hand hygiene compliance, IV pump cleaning compliance, hospital-acquired skin breakdown, ST segment monitoring, patient education, smoking cessation education, and AMI core measures. National Benchmark Data are used where available. The visual representation of thumbs up and thumbs down provides easily viewed information on the performance of our unit. Staff is expected to review the Monthly Dashboard and submit in writing actions they personally will take or offer suggestions they may have to improve an indicator. Staff suggestions are given to the appropriate team-based committee and shared in the Quality Newsletter and in Unit meetings. Evaluation/Outcomes: Initial feedback has been positive. Staff is more aware of the indicators and how the unit is performing. Personal commitments are being made and staff is suggesting actions to improve indicators with thumbs down results. One staff suggestion being implemented is keeping bleach wipes and IV cleaning stickers at the nurses’ station in addition to the dirty utility room. jwerstler@aultman.com

Who’s in Charge Here: Building Leaders at the Bedside

Smirch V, Kissell M, Arackal G, Knaack K; The Methodist/DeBakey Heart Center; Tex

Purpose: Ensuring a strong, empowered nurse at every bedside is crucial to good outcomes and safe care delivery. A nurse who is accountable for driving care needs the knowledge, clinical skill, as well as communication savvy to maneuver systems. The leader at the bedside also needs the support of unit leadership and must have a voice in unit operations/decisions. Description: A well-defined Nursing Clinical Career Progression Model (NCCPM) that matches staff skill to patient’s acuity was a starting point. Unit shared governance looked at the skill level of practitioners and what patients at different levels of acuity required. The council staff was then able to determine the needed competencies and unit specific requirements and match them to the existing NCCPM. Shared governance has been essential in education and decision making in the unit. Staff has the ability to rise to the level of responsibility they desire. Their unit involvement is directly connected to the NCCPM and level of responsibility. Unit shared governance has driven the staff annual competency assessment as well as the unit promotions within the NCCPM. The unit council has played a key role in empowering staff to work as a team and holding one another accountable to a high standard. Leaders at the bedside are empowered and confident knowing they drive practice and decisions. Evaluation/Outcomes: Pay for performance, staff driven promotions, and bounses based on patient satisfaction ensure staff holds one another accountable to a high standard. Staff satisfaction and low turnover rates ensure qualified staff at every bedside. kknaack@tmh.tmc.edu

Utilizing Staff Retreats as an Opportunity for Staff Retention and Rejuvenation

Braungardt T; Harborview Medical Center; Wash

Purpose: In a busy level 1 trauma center, there is never an opportunity to sit down together with your entire ICU staff and discuss unit issues, policies, and social activities for the unit or institution. The creation of innovative retention strategies, such as a staff retreat day, will be a major focus for nursing administration as a shortage of nurses recurs and turnover of staff becomes a problem. Recent studies provide information on which to formulate retention strategies and findings suggest that retention strategies, to be effective, need to be targeted specifically to particular conditions of the nursing staff, eg, educational preparation and the clinical service on which staff are functioning. Description: At Harborview Medical Center, we have employed the use of 8-hour and 4-hour annual staff retreats to create opportunities for staff discussion, administrative updates, team building, clinical education, and overall morale enhancement. Administrative involvement and support has been a critical element in developing these days for our nursing staff. All 7 of our ICUs, PACU, and float pool now hold annual retreat days with their entire staff. Evaluation/Outcomes: Feedback was collected from our nursing staff via evaluations of each staff retreat. Evaluations measured our overall effectivesness in reaching critical objectives for the day including education content, team-building, and key institutional program concepts. In addition, we trend our nursing vacancy and turnover rates. Our current hospital nursing vacancy rate for ICU is 1.72%, and total vacancy rate is less than 3%.We believe the addition of this program, although just one element, has enhanced all of our efforts around staff retention as we continue to see a downward trend in both of these areas. tlbraun@u.washington.edu

Retreat but No Surrender, a Retreat That Led to Positive Creative Change

Farley T, Kessenich A, Patterson A, Bride W, Boggs P, Mcfeely T; Duke Medical Center; NC

Purpose: Identifying problems is easy but our goal was to engage staff to move beyond identifying problems to solving them. It is important to identify problems in a constructive manner to facilitate dialogue and problem solving. Description: The cardiothoracic floor was going through some monumental changes. Leadership had some major vacancies within the Heart Center and staff were feeling more and more like problems continued to pile up but the solutions were not easily found. It was evident that action was needed, and quickly. Two nurses from each of the 3 units on the cardio-thoracic floor went on an all day off campus retreat. Problems were formally identified and placed in 5 categories. The group then formed 5 subgroups to tackle the issues, the groups where: Work Culture, Orientation, Charge Nurse, Work Redesign, and Support Services. Staff led these groups who then pulled in additional staff from each unit to work on specific issues identified. Evaluation/Outcomes: The groups came up with creative ways to deal with the issues such as team-building parties, decreasing the number of patients a orientee and preceptor cares for, charge nurse classes, decreased RN/patient ratio, and an effective communication plan with support services. This has lead to an increased staff satisfaction as evidenced by increased retention. farle001@mc.duke.edu

Creative Staffing Solutions: The Art of Self-Scheduling

Macapagal R, Clark T, Klahn S, Smirch V; The Methodist Hospital; Tex

Purpose: Staffing our 40-bed cardiovascular ICU 24/7 is a challenge. Juggling schedule requests of 130 nurses with different staffing options such as 8- or 12-hour shifts plus weekenders and balancing the numbers to ensure adequate coverage for a high-acuity unit is a full time job. To address this major issue, our director formed a scheduling committee to create a balanced 4-week schedule throughout the year that will satisfy both our patient and staff needs. Description: Eight nurses, 4 from days and 4 from nights comprise the group. Each pair is assigned and rotated for specific periods of the year. Guidelines were developed for nurses to follow when making their sechedules. These emphasized weekends, holiday requirements, vacation requests, call in procedures and staffing grids (number of nurses needed on a given day). Three weeks before the next schedule is due, nurses fill out a request form. The schedulers look at all requests to ensure the guidelines are followed, return if not or ask the staff to consider switching days to meet the grid. Nurses can make changes on their requests within 2 weeks before the final posting. If the request is late, our director makes the staff ’s schedule based on the needs of the unit. Once the final schedule is posted, a charge nurse or a scheduler can make changes to meet the dynamic needs of the unit. Since everyone wants to be off during the holidays, the committee decided on posting “Christmas in July” wish list. Options are listed for the staff to choose which holidays they want to work. This gives the schedulers an idea of what to work on and enough time to prepare for these hectic periods. Evaluation/Outcomes: While we continuously strive to improve our methods, staff satisfaction is high as they have an input in the scheduling process. We eliminated the use of agency nurses and reduced the need of float pool staff to 1%. Foremost, coverage is ensured to meet our patients needs. rmacapagal@tmh.tmc.edu

Steering Committee: An Empowered Workforce

Sohi M, Kusic S; The Methodist Hospital; Tex

Purpose: Implementation of a staff-driven workforce to develop and support an environment that promote clinical and optimal patient outcomes through accountability and shared governance. Description: In 1998, the CVICU Steering Committee was conceptualized in line with the institution’s mission and hospital-wide shared governance. The unit-based shared governance was developed in an effort to promote a positive work environment, as well as serve as a forum for improving unit practice and standards of care. RNs of different clinical levels and all support staff collaborated initially to start the process; goals evolved and the council was restructured to meet the unit needs. The unit director served as facilitator; a chair person was chosen by majority vote and bimonthly meetings were initially held. Staff members were encouraged and given opportunity to participate in the unit decision-making process and were made accountable for their patient care. Every idea and suggestion was valued and respected. Workgroups were formed as needed to address pressing issues and concerns. Constant collaboration and improved communication between colleagues soon transpired. Evaluation/ Outcomes: For the first time ever, staff members verbalized that they felt empowered and their morale was enhanced. Staff members are now actively participating and are involved in unit activities. Most importantly, employee satisfaction and retention dramatically improved leading to better patient outcomes and increased patient and family satisfaction. The positive outcome was also evident in the institution’s achievement of the Magnet Award. Due to its success, the CVICU unit-based governance council serves as a model for other ICUs at the Methodist Hospital. msohi@tmh.tmc.edu

Positive Action—Balancing Act

Mou S, Hannon P, Lankford B, Knight A, Harmon D, Miller K, Brown-Jones S; Emory Crawford Long Hospital; Ga

Purpose: Unit 41 and 41 CCU had experienced high turnover rate for past few years. Positive Action program was developed and implemented to balance recruitment and retention efforts and to reduce cost of using travel nurses and cost of hiring new RNs by retaining existing or experienced nurses. Description: “Positive Action” program for retention and recruitment was unit specific and inspired by cable-stay bridges, especially the newly erected one that spans across Cooper River in Charleston, S.C. The bridge was designed and built by engineers to make it well balanced and allows traffic to run smoothly. The “Positive Action” program focuses on retaining existing or experienced nurses and also on attracting potential candidates. To balance both retention and recruitment efforts several projects were created and implemented in past few years. 1) Encourage staff to exercise positive action and give constructive input. 2) Create a thank-you card to reward positive attitude and creative solution with cards and gift certificates are drawn monthly. 3) Organize social events in the unit as well as outside the hospital. 4) Acknowledge staff birthday by putting up birthday poster boards in both units. 5) Provide opportunity for staff to joint various committees and utilize their talents. 6) Encourage staff to attend conference or seminar and expenses are reimbursed. 7) Provide opportunity for staff to develop their leadership potential by leading in-services and working as charge-nurse. 8) Sign-on and recruitment bonuses are given by hospital. 9) Work closely with area nursing schools, provide nursing students with clinical experiences and recruit potential candidates. Evaluation/Outcomes: 1) On average 20 thank-you cards were received monthly. 2) Four gift certificates were drawn each month. 3) Six social events were scheduled and well attended by staff. 4) Turn over rate for new hired was below 15%. 5) Retention rate exceeded 85%. 6) reduced use of travel nurses and use of overtime or on-call. selmamou@hotmail.com

Miracle Grow for the Nurse: Revitalizing the Potted Plant

Niemchak S, Osborne K, Spurney Y, Hanson J, Harris M, Stillwagon M; Duke University Health System; NC

Purpose: Tremendous resources are spent on the recruitment of nurses. Were more time, money, and effort invested in existing human resources, logically retention would improve, and recruitment efforts minimized. Our seasoned nurses expressed concern over the lack of efforts surrounding rewards and recognition, and behaviors often deteriorated as a result. Description: As chief retention officers, our leadership group chose to become a more positive force with the bedside nurse. Inspirational leadership became our mission, as our visibility on the unit increased and our open door policy became utilized more and more. Daily attendance during morning rounds keeps us involved on an individual level, facilitating spontaneous contact with each staff member, patient and family. Calls are made during odd hours to check in with unit staff; encouragement and support is given to attend educational sessions, and professional development has become a priority. Our new Pay and Performance System provides 360-degree annual evaluations, where peer feedback is obtained on all staff, including Managers and Directors. Individual performance is based on personal behaviors, self-evaluation, managerial and peer feedback as well as unit specific balanced scorecards. The revised Clinical Ladder includes specific tracks related to administration, education, and clinical practice. Multiple methods of advancement are included in each track, and interested staff are groomed to climb the ladder. Evaluation/Outcomes: Experienced nurses have been rewarded for their behaviors, as well as their longevity. Retention has increased, our units no longer require the use of temporary agency nurses, and labor costs have decreased. Customer Service scores have improved, and are among the highest in the nation. The work culture is positive, optimistic and supportive. A healthy work environment has bloomed! niemc001@mc.duke.edu

Guess Who Is Coming to Dinner—Guest Nurse Program

Zemansky P, Staneva I, O’ Hearn N; University of Chicago Hospitals; Ill

Purpose: Staffing the ICU adequately is a daily challenge. It frequently involves floating ICU nurses to other units or the use of agency. For many critical care nurses floating to another unit is often a source of dissatisfaction. The critical care leadership team came up with a novel approach to give a positive spin to floating and change the negative perception to a positive one. Description: We implemented a program titled “An invited guest.” This implies a welcoming attitude towards the individual who has been reassigned. This RN will enter into a receptive, positive environment. The invited guest also commits to enter the environment with a good attitude, treat all staff with respect, and respect the unit. The benefits of this program include: changing the mindset of “floating” to an invited guest; developing rapport with staff outside of the home based unit; providing continuity of care to every patient by the nurses at UCH; improving consistency of documentation by using UCH RNs versus agency RNs; broadening the nurse’s knowledge base by providing experience outside of the specialty area; decreasing agency usage; creating a positive attitude by rewarding the invited guest for his/her support to nursing excellence. Each guest nurse receives a “Be our guest” gift certificate for five dollars and a thank you card. Every unit budgets funds for staff recognition. The responsibilities of the charge nurse on the receiving unit as well as the guest nurse are posted and discussed. At the end of the shift, the guest nurse fills out an evaluation. Evaluation/Outcomes: Since the initiation of the program, the Critical Care Center has been able to increase staff satisfaction and reduce fear and resistance related to floating to another ICU, decrease agency usage, and promote unity and collaboration among the different ICUs. iliana.staneva@uchospitals.edu

Picture This... Nurses Highlight Their Work in Photo Journals

Thompson T, Carroll C, Hensinger B, Siggens L, Winters M; The University of Michigan Health System; Mich

Purpose: In 2005, the current nursing shortage entered its eigth year. Healthcare organizations look to retention of the existing RN workforce as a key component to solving the nursing shortfall. Many studies report a positive relationship between nurse retention and acknowledgement of the critical work performed by nurses. Recognizing that not all nurses can define their work in scholarly articles, research projects, or public forums, this project used creation of a photo journal as a method for conveying professional pride. The initiative addresses RN retention by highlighting nursing roles in a creative and professional manner. Description: Basic journal materials were sent to every nursing unit or site. RNs used their own creativity to enhance journal pages. Nurses were encouraged to express the reasons they entered and have stayed in nursing. After 1 month, the pages were retreived and placed in binders by retention committee members. The journals were displayed during 2005 Nurse Week activities and are being used by the University of Michigan Health System (UMHS)Nurse Recruiters. Evaluation/ Outcomes: Of the 3017 nurses at UMHS, photos of 2379 are included in this journaling project. Many positive comments were heard during Nurse Week activities and throughout the preparation time. Nurses voiced affirmative feelings related to their professional role. Many related that working together to create an expression of their ideas about nursing was fun. Moreover, they reported a sense of renewal as they acknowledged the satisfaction gained from being a nurse. This project served as a way to recognize and reinforce the valuable contribution of nursing.

Footnotes

Presented at the AACN National Teaching Institute in Anaheim, Calif; May 20–25, 2006.