be a champion for excellence: improving outcomes while...
TRANSCRIPT
Be a Champion for Excellence: Improving Outcomes While Empowering Nurses
By
Glenda Riggs RN, VHA-CM, CNL (C)
Objectives
� To discuss projects designed, implemented or managed by the ICU CNL candidate
� To explore specific outcomes influenced by CNL � To explore specific outcomes influenced by CNL candidate in ICU
� Review the steps to empowering the nurses
� Review the Iowa Model for EBP
Pieces to the Puzzle
� Nursing Education
� Empowering the nurses to identify problems and pilot solutionssolutions
� Implement EBP into the culture : easier said than done
ICU/SDU
� The challenge: Organize chaos
� RN Vacancy Rate and Impact
� Bed closures
� Surgical delays� Surgical delays
� Financial strains
� Unacceptable infection rates
� The solution: Implementation of the CNL
� Is there one simple answer to the problem
No No
� Education: Developing and initiating a comprehensive education program for new graduates and seasoned nurses to increase nurse’s knowledge base and establish standard work.
� Orientation: Develop and initiate a staged orientation � Orientation: Develop and initiate a staged orientation programs that customizes the learning process in order to meet nurse’s individual needs and reinforce standard work.
� Competency: Develop and initiate an annual competency program to standardize and maintain nurse’s skills while reinforcing standard work.
� Support and Accountability: CNL rounds on all patients to monitor all performance measures and evaluate patient’s needs while offering nursing support and accountability.
� Multidisciplinary teams: CNL initiates multidisciplinary patient/family meetings on all patients in ICU that are complicated or have been in ICU for seven days or longer. patient/family meetings on all patients in ICU that are complicated or have been in ICU for seven days or longer.
� Evidence –Based Practice: Develop system redesign teams for protocol changes to empower nurses to utilize evidence based practice with the goal of improving patient outcomes such as: hyperglycemia, hypoglycemia and sepsis.
Empowering nurses
Comprehensive education program
Staged orientation program
Standard Work vs. Autonomy
�Empower the nurses to use EBP creating Autonomy
�Implementing the change creating standard work
Improving Outcomes� Improved outcomes with sustainability only happens
when the nurses are empowered to make changes
� Administration focuses on a topic and the outcome � Administration focuses on a topic and the outcome improves until the focus changes and the outcome declines
� How do we achieve improved outcomes with sustainability?
CNL Interventions in the ICU� Improved Patient Care
and Outcomes
� 5 Million Lives Campaign
� Improved Staff Competency and Morale
� Staged Orientation� Central Line Bundle
� VAP
� RRT
Staged Orientation
� Critical Care Course Development
� 36/40 work week
� Shared Governance
� CCRN study group
� Improved patient safety
(visibility with rounding)
ICU Recognition
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SAVAHCS ICU Central Line Related Blood Stream
Infection Rates
Update : off the path� VAP: One VAP in November 2011
� Central line infection: Three new central line infections: One in October, November, and December ( the ICU made a change to swab caps) An aggressive ( the ICU made a change to swab caps) An aggressive education program on how to use swab caps was initiated \
� Results: we have gone three months with no hospital acquired infections.
� Back on Path
RRT decreased Codes outside of
ICU by 54%
Pain
Template
Developed
Meets requirement of VHA directive, of VHA directive, Joint Commission
And needs of nurses
Empowering the nurses to achieve excellence
Interdisciplinary patient and family meetings
CNL rounding on all ICU patients: supporting the staff and patientssupporting the staff and patients
Initiating standard work for nurses
Aim: Improve Patient Outcomes
Results in the ICU� RN Vacancy Rate
� 26% in 2008
� Vacancy decreased to zero and maintained
• Hypoglycemic Protocol
zero and maintained through 2010
� Currently 2 vacant positions
� Interdisciplinary Family Meetings resulting in decreased length of stay
Outcome Data� Fy10 to Fy11, ICU went 77 weeks no central line
infections� Fy10 to Fy11. ICU went 88 weeks no VAPs� No ICU MRSA transmissions for two years, Fy10 and
Fy11� Sepsis mortality rate decreased from 48”% to 16% in � Sepsis mortality rate decreased from 48”% to 16% in
Fy10� Prior to implementation of the insulin protocols,
incidents of events with blood sugars less than 45mg/dL in 2009 averaged 2.25%. Our Fy10 rate decreased to 0.8% and we have earned recognition by IHI (Institute for Healthcare Improvement) and IPEC (Inpatient Evaluation Center) as best practice.
Aim
The aim of the CNL is to improve patient outcomes and empower the nurses. Evidence based heath care must be embedded into the nursing culture to maintain the be embedded into the nursing culture to maintain the quality of care patients deserve and expect. It is the combination of Standard Work, Culture of Caring, Evidence Based Care, and Skilled nursing care that improved patient outcomes at SAVAHCS. The CNL responsibility is to inspire the nurses to achieve excellence.
Empower the Nurses by
implementing Pilot Studies
� Nurses identify a problem
� Empower the nurses to develop a PICOT question
� Empower nurses to complete an EBP literature search
� Empower the nurses to implement a Pilot Study following the Iowa Model for change
� Empower the nurses to make a change according to the evidence
The SAVAHCS was honored with the Robert W. Carey Performance Excellence Award for 2011. There was only
SAVAHCS winners of the 2011 Carey
Performance Excellence Award
Performance Excellence Award for 2011. There was only seven awards given across the nation. This prestigious award recognized SAVAHCS as a leader in sustaining high levels of performance an service to our veterans.
Example of a Pilot study
�Pressure ulcer prevention bundle
By Glenda RiggsBy Glenda Riggs
Pressure UlcersPressure ulcer (PU)
�A localized area of damage to the skin and underlining tissue caused by pressure, shear, friction, or a combination of these factorscombination of these factors
Hospital Acquired Pressure Ulcer (HAPU)
�A pressure ulcer developed during a stay in the hospital
Problem� Pressure ulcers are a global concern
� Pressure ulcers complicate the hospitalization resulting in higher morbidity, mortality and increase resulting in higher morbidity, mortality and increase cost for the patients
� Critically ill patients are at higher risk for PUs and prevention can be very challenging
� Two and half million Pressure ulcers (PU) are treated
annually in acute care facilities across the United States.
The cost of a single full thickness PU is approximately
$70,000 resulting is a cumulative cost in the range of up
to $11 billion (Slowikowski & Funk, 2010)to $11 billion (Slowikowski & Funk, 2010)
Problem� The Southern AZ VA Health Care System (SAVAHCS)
is a 285-bed hospital with a 19 bed Intensive Care Unit (ICU)
� Hospital acquired pressure ulcers (HAPU) are � Hospital acquired pressure ulcers (HAPU) are considered preventable, and have become a liability for hospitals and caregivers (Peterson, Schwab, Van Oostrom, Gravenstein, & Caruso, 2010).
Organizational Culture and Readiness for System-Wide
Integration of Evidence Based Practice (EBP)
� Southern Arizona VA Health Care System (SAVAHCS) is dedicated to EBP
� SAVAHCS’s EBP committee implements all practice changes
� Iowa Model of Evidence-Based Practice to Promote Quality Care is used for guidance at SAVAHCSCare is used for guidance at SAVAHCS
� EBP is encourage and is embedded into the culture at SAVAHCS
� SAVAHCS is committed to improving quality of care by using EBP
Proposed PICOT Question� In the ICU with acute and chronic critically ill patients
at risk for pressure ulcers (P), how does the initiation of an aggressive pressure ulcer prevention action plan bundle consisting of seven interventions (I), compared to the current standards: regular mattress surface, to the current standards: regular mattress surface, HOB greater than 45 degrees, dressings only over pressure points after diagnosis of PU stage one or greater, cushions on O2 tubing when red or painful, skin protectant after dermatitis, and every two hour turns at 20 to 40 degrees (C), decrease the rate of HAPUs in the SAVAHCS ICU (O), within a three month pilot study (T)?
Review of Evidence and Synthesis of
Literature
�The literature supported the design of the pressure ulcer prevention bundle presented in the proposed PICOT question. PICOT question.
�Cumulative Index to Nursing and Allied Health Literature (CINAHL):
� Major heading: pressure ulcer
� Subheading: prevention and control
PUP Bundle Interventions1. Risk assessment using the Braden Scale
2. Repositioning
3. Nutrition assessment
4. Skin assessment every shift
5. Skin intervention with appropriate Medline skin
product
6. Allevyn dressing
7. Cushion to protect ear from o2 tubing
Pilot study� The survey team will implement a pressure ulcer
prevention bundle consisting of seven evidence-based intervention
� Measure the effectiveness of the prevention bundle. � Measure the effectiveness of the prevention bundle.
� Measure the impact of educational interventions on the knowledge base of the nursing staff
� Initiate further research as indicated using the Iowa Model for change
Solution� Education for all nursing staff on pressure ulcer
prevention (PUP) and treatment
� Implement a PUP bundle in the SAVAHCS intensive care unit (ICU)care unit (ICU)
� The bundle will be initiated when the Braden Scale (pressure ulcer risk assessment) scores mild risk or higher
� Survey team will monitor the pilot study by rounding daily on every patient in the ICU
Goal: Elimination of
Pressure
EBP literature search on
pressure ulcer prevention
(PUP)
Nursing education on pressure ulcer
Evaluation of Pilot study
and initiation Pressure Ulcers in
SAVAHCS ICU
education on pressure ulcer
prevention and treatment
Initiation of a PUP Pilot
Study
Pilot study and initiation
of further research
Solution and Expected Outcomes
�The objective of the proposed evidence based study is for SAVAHCS nursing staff to initiate a HAPU prevention bundle consisting of evidence-based interventions with a goal of eliminating HAPU at interventions with a goal of eliminating HAPU at SAVAHCS ICU.
BY:
� Increase the knowledge base of the nursing staff for PUP and treatment
� Implementing an evidence based PUP bundle consisting of seven intervention
Solution and Expected OutcomesThe following outline covers the proposed solutions and
expected outcomes of the project:
�A risk assessment using the Braden Scale is imperative �A risk assessment using the Braden Scale is imperative in preventing PUs
� The Braden Scale offers the best
sensitivity/specificity balance and the highest
prediction rate (Gray-Siracusa & Schrier, 2011).
continued�Reposition the patient every two hours using pillows
�Nurses will be educated on turns using the 30-degree tilt side-lying position with pillows to support the back, knees, and ankles (Gray-Siracusa & Schrier, 2011). 2011).
Continued Reposition �A dynamic surface compared to a static surface is
preferred. The air chambers alternate relieving the pressure points resulting in decreased PUs (Gray-Siracusa & Schrier, 2011). Siracusa & Schrier, 2011).
�The head of bed will be kept less than 30 degrees and the heels floated with Gaymar boots. A Gaymar seat air mattress will be initiated when out of bed in chair with every one-hour repositioning.
Solution and Expected Outcomes�A nutrition consult will be implemented for all
patients at risk. The consult will meet the individual needs of the patient’s nutritional needs.
� A detailed skin assessment needs to be performed on admission and every shift in
order to document any existing PUs and to determine the needs of the patients.
Solution and Expected Outcomes�Proper skin care using Medline skin care products:
Remedy Antimicrobial Cleanser, Remedy Skin Repair Cream, Remedy Inzo Barrier Cream, and Remedy Dimethicone Skin Protectant Dimethicone Skin Protectant
Solution and Expected Outcomes�An Allevyn dressing will be applied on the sacrum,
elbows, and heels for prevention and treatment of PUs.
�A protective cushion will be applied to the oxygen tubing to protect ear from the friction of the tubing.
Evaluation Plan� The National Database of Nursing Quality Indicators
(NDNQI) defines the HAPU rate as the number of patients who develop a PU after their admission to the hospital divided by the total number of patients in the hospital divided by the total number of patients in the population studied times 100 (Gray-Siracusa & Schrier, 2011).
� A quasi-experimental design will be used to assess the difference in HAPU rates before and after initiation of the PUPB using one-way analysis of variance.
Data CollectionEvaluate Process and Outcomes:
�The team will assess and record the process during scheduled rounds.
�A weekly prevalence study will be completed using �A weekly prevalence study will be completed using structured guidelines for data collection.
� A Medline pre-test will be given to the nurses before the pilot study. A post- test will be given after the pilot study is completed. The results will be compared to measure the impact of the educational interventions.
SummaryThe overall internal and external validity of the
literature review was high. The different studies focused on many of the same interventions. All the studies supported each other findings and come to the same conclusions further supporting their validity. The literature review revealed many different risk factors and therefore needs multiple interventions to achieve and therefore needs multiple interventions to achieve success in preventing HAPUs in the critical ill. HAPUs are considered preventable, and have become a liability for hospitals and caregivers (Peterson, Schwab, Van Oostrom, Gravenstein, & Caruso, 2010). Prevention must be a priority.
� Research
� Chalken, N. (2011). Reduction of hospital acquired pressure ulcers in the intensive care unit. Journal of Wound, Ostomy and Continence Nurses Society, 38(35).
� Eigsti, J. E. (2011). Beds, baths, and bottoms: A quality improvement initiative to standardize use of beds, bathing techniques, and skin care in general critical-care unit. Dimensions of Critical Care Nursing, 30(3), care unit. Dimensions of Critical Care Nursing, 30(3), 169-176. doi:10.1097/DCC.0b013e31820d25b1
� Gray-Siracusa, K., & Schrier, L. (2011). Use of an intervention bundle to eliminate pressure ulcers in critical care. Journal of Nursing Care Quality, 26(3), 216-225. doi:10.1097/NCQ.ob013e3182oe1be
� Jackson, M., McKenney, T., Drumm, J., Merrick, B., LeMaster, T., & VanGilder, C. (2011). Pressure ulcer prevention in high-risk postoperative cardiovascular patients. Critical Care Nurse, 31(4), 44-53. doi:10.4037/ccn2011830
� Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing healthcare (2nd ed.). Philadelphia, PA: Wolters Kluwer / Lippincot Williams& Wilkins .Williams& Wilkins .
� Nanjo, Y., Nakagami, G., Kaitani, T., Naito, A., Takehara, K., Lijuan, J.,...Sanada, H. (2011). Relationship between morphological characteristics and etiology of pressure ulcers in intensive care unit patients. Journal of Wound, Ostomy and Continence Nurses Society, 38(4), 404-412.
� Peterson, M. J., Schwab, W., Van Oostrom, J. H., Gravenstein, N., & Caruso, L. J. (2010). Effects of turning on skin-bed interface pressures in healthy adults. Journal of Advanced Nursing, 66(7), 1556-1564. doi:10.1111/j-1365-2648.201005292.x
� Racco, M., & Phillips, B. (2010). Developing a protocol for intensive care patients at high risk for pressure ulcers. Critical Care Nursing, 30(3), 77-80. ulcers. Critical Care Nursing, 30(3), 77-80. doi:10.4037/ccn2010501
� Shahin, E. S., Dassen, T., & Halfens, R. J. (2009). Incidence, prevention and treatment of pressure ulcers in intensive care patients: A longitudinal study . International Journal of Nursing Studies, 46, 413-421. doi:10.1016/j-ijnurstu.2008.02.011
� Slowikowski, G. C., & Funk, M. (2010). Factors associated with pressure ulcers in patient in a surgical intensive care unit. Journal of Wound, Ostomy and Continence Nurses Society, 37(6), 619-626.
� Strand, T., & Lindgren, M. (2010). Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: A description cross-sectional study. Intensive and Critical Care Nursing, 26, sectional study. Intensive and Critical Care Nursing, 26, 335-342. doi:10.1016/j.iccn.2010.08.006
� Uzun, O., Aylaz, R., & Karadag, E. (2009). Reducing pressure ulcers in intensive care units at a Turkish medical center. Journal of Wound, Ostomy and Continence Nurses Society, 36(4), 404-411.