the impact of focused nursing education on picc occlusion rates
TRANSCRIPT
Evaluation of a Nursing Educational Intervention
on the Proper Technique for Incentive Spirometry
in Post-operative and Trauma Critical Care Patients
Sara Couch, RN,BSN,CCRN - EBPI fellowLaura Dibsie, RN, MSN,CCRN - EBPI mentor
UCSD Medical Center
Recognition
• Financial and Logistical Support:– Juana Burkhart, RN, BSN, CCRN - SICU manager– Mary Hackim, RN, MS – Director, EDR– UCSD Department of Nursing
• Team members– Sue Wynn, Informatics Nurse– Caroline Brown, RN, PhD. - Facilitator– Helen Ogg, SICU Clinical Nurse Educator– Mary Wickline, Librarian– Julie Emerick, RT– All SICU staff for their patience and participation!!
The Catalyst
• Need to understand and improve nursing role in care and outcome of SCI patients.
• RNs had inconsistent understanding and practice related to pulmonary management of SCI patients
• Desire to complete CNIII promotional process.
Significance
• SCI patients are often associated with a sudden and tragic lifestyle change, this can be further complicated by pulmonary issues during recovery.
• Responding to staff and patient concerns related to patient plan of care and desire to improve patient outcome.
PICO question
• Population – UCSD, SICU RNs and RTs • Intervention – Implementation of an education
program about incentive spirometry• Comparison – Knowledge and documentation of IS
practice with non-ventilated trauma and post-surgical patients.
• Outcome – Improved scores in post-education knowledge assessment and improved documentation
The Evidence
• No “Gold Standard” for acute pulmonary care of SCI patients.
• Limited literature available.• In the literature, inspiratory muscle training
(IMT) is consistently associated with improved patient outcome.
• Incentive spirometry is an effective IMT therapy.
Applying: Project Design
• IRB application submitted June 2007• Revisions and approval July 2007• 5 week study design including:
– Pre-test and chart audit– Live education to staff– Post-test and chart audit– Data analysis
Methods: Procedure
• Human subject approval #071124X• Recruitment
– IRB approved email and staff meeting announcements, including informed consent info
– Verbal consent at time of education
• Data collection – EMTEK query – Pre-tests available – 14 days– Education – 10 sessions/8 days (3 week span) with post test completion– EMTEK query
Methods: Instruments
• Knowledge Test – IRB approved– Brief– Multiple choice– Focused on EBP found in literature review– Same instrument used pre- and post-test
• Chart query– 3-week time frame; pre- and post-education– All non-ventilated SICU patients
Sample and Setting
• Convenience sample of SICU RNs and RTs– Day and night shift; career, per diem, or temporary/contract– Varied experience– Either gender– Pre-test n = 46– Post-test n = 40 (5 RTs)
• Education sessions primarily in Surgical/Trauma ICU of academic medical center in large metropolitan area
Findings Pre/Post
• Nurses’ knowledge improved with education• Knowledge of most effective treatment time
more than doubled (almost 100%)• Pre-test: About half the nurses understood
differences in terminology between IS breath (Vital Capacity) and resting breath (Tidal Volume)
• Post-test this improved to more than three-quarters
AGE GENDER HEIGHT
0 10 20 30 40 50 60 70 80 90 100
POST
PRE
% CORRECT ANSWERS
Greatest Improvement
24%
88%
What 3 factors determine pts goal volume?
3-5 Seconds
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
POST
PRE
% CORRECT ANSWERS
Most correct answers
48%
98%
How long should pt hold breath?
Most Commonly MissedPre & Post
Vital Capacity Tidal Volume
0%10%20%30%40%50%60%70%80%90%
100%
PRE POST PRE POST
correct incorrect
Incentive spirometry measures what?
48%
78%
50%
20%
Documentation Pre-
• Pre-education documentation was inconsistent• Two options: “Done” or “Active”• Comments not detailed
– attempted– UTA– CDB– 10 x 1000
Documentation Post-
• Definitely more detailed• Patient’s effort now documented• Computer charting that prompts intervention• Includes target volume (to trigger RN)
New Charting
Similarities / Unchanged
• Some patients, including those on room air, have no documentation for IS therapy
• No standard for frequency of charting IS treatment
Advancing and Adopting
• Laminate target volume insert information and post in supply area
• Follow up on obtaining insert info in several languages for patient and family
• Fellow follow-up with staff and SCI patients• Summarize key findings on ‘Hot Topics’
Bulletin Board• Incorporate findings into standards of care
Lessons Learned
• Clinical Project/Information– Not the anticipated focus from initial application, but greater
appreciation and understanding IMT using IS.
• EBPI Experience– Where we started vs. where we ended up– Empowered to ask questions and challenge current practice– Tools to research and investigate the answers – More critical of practice and literature – Appreciate constant presence of opportunities for
improvement
Select References:
Royster, R.A., Barboi, C., & Peruzzi, W.T. (2004). Critical care in the acute cervical spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 9(3), 11 – 32.
Agency for Healthcare Research & Quality. (2001). Treatment of pulmonary disease following cervical spinal cord injury. Summary, evidence report/technology assessment: number 27 (AHRQ Publication No. 01-E013). Retrieved February 13, 2007 from http://www.ahrq.gov/clinic/epcsums/spinalsum/htm
AARC Clinical Practice Guideline: Incentive Spirometry. Retrieved April 5, 2007 from http://www.rcjournal.com/cpgs/ispircpg.html
For additional information please contact:
Sara Couch – [email protected] Dibsie – [email protected]