An Analysis of Compliance With Warfarin Education Guidelines for Patients 65 and Older Diagnosed With Atrial Fibrillation
Merchant M. University of the Incarnate Word
Purpose: To determine the compliance with National Patient Safety Goals 2012 and ascertain whether the education was provided by a registered nurse or a pharmacist and to find out the compliance to teaching guidelines.
Significance: Atrial fibrillation (AF), a common condition causing stroke due to clots formed in the heart, is treated with warfarin, a potent anticoagulant that has serious bleeding complications and requires careful compliance with the medication regimen and dose adjustment (Alexis et al, 2006). Approximately, 29.5401 per 1 million people die of AF every year (World Health Organization, 2011). Recent data on AF in San Antonio suggest a striking number of 22 000 residents with irregular heartbeats (BHS, fall 2012). The National Patient Safety goals by Joint Commission (2012) (NPSF, 2007) clearly defines the need for warfarin education in patients newly started on warfarin therapy and delineates the aspects of education that needs to be focused with these patients for safety and prevention of readmission. Adequate education is linked to better INR control in elderly.
Design: A descriptive retrospective design to determine whether patients 65 years or older with a new-onset AF, from November 2011 to October 2012 admitted in a nonprofit faith-based hospital.
Methods: A retrospective electronic record review was used for data collection. A random sample of 25 patients 65 years or older who attended the emergency room of a hospital in downtown location was drawn from a computerized list of all those who attended from November 2011 to October 2012. A total list of 156 patients admitted in the study period was used of which every fifth patient was randomly selected to get a total of 25 samples. The majority of the sample was female (16, 64%), with a mean age of 75.8. Most of the samples were Hispanic (21, 84%).
Outcomes: The data included demographic variables such as gender, age, ethnicity, and data related to warfarin education provider and compliance. Results of the study suggested that only 9 patients (36%) were prescribed warfarin for anticoagulation, whereas only 3 (12%) of the patients received education from an RN. Evidence supported that only 1 patient (4%) received guideline-based education. Eight of those who were not or dered warfarin had a documented contraindication for same, and they were started on either aspirin, Plavix, or Pradaxa as anticoagulant.
Conclusion: Findings did support that there is under prescription of warfarin for patients 65 years or older, and there is lack of formal education activity related to warfarin by a trained staff based on the NPSG 2012 guidelines.
Implications: The prescription of warfarin is central to stroke prevention and warfarin related education based on NPSG 2012 guideline is the need of the hour.
An Interprofessional Approach to Medical Error Disclosure: A One-Day Event Curriculum
Houser A, Escamilla K, Jungnitsch S, Christensen C, Rohan A. University of Texas, Austin
Purpose: The purpose of this project is to create and present a proposal for a training module on error disclosure targeting multiple health professionals that work together as a collaborative team. A primary objective was to design a program that is affordable, engaging, applicable to many clinical settings, and logistically easy to coordinate.
Significance: Error disclosure is an integral part of the medical profession. It allows for transparency, improved patient care, and the facilitation of trust and collegiality. The Interprofessional Error Disclosure curriculum is unique in that it addresses the current lack of interprofessional education on error disclosure and emphasizes that recognition of and intervening with errors are the responsibility of the entire patient care team.
Background: Teamwork and support systems are critical in facilitating error disclosure, and approaching this from an interprofessional perspective will not only emphasize this, but it will also encourage a professional culture based on values and ethics. A curriculum is greatly needed in the medical community as the majority of students do not receive error disclosure training, and those who do are likely to only be medical students.
Method: A predetermined facilitator will lead this single 3- to 5-hour training session. Different healthcare professionals will attend (eg, nurses, pharmacists, physicians, social workers). The session will begin with a guided discussion on error disclosure myths, the current culture change regarding them, and the 4 R’s of apologizing. Then, a video of patients affected by medical errors will be viewed to increase empathy for patient experiences of medical mistakes. Participants will then be separated into smaller groups each consisting of different professionals. They will engage in an icebreaker detailing their respective daily responsibilities to help educate one another. A case scenario in which a medical error was made will be assigned to each group, and they will be responsible for discussing the errors involved, brainstorming solutions and corrective actions, and simulating the 4 R’s of apologizing through role-plays. The groups will present and discuss their cases to the rest of the participants, and the program will end after a debriefing by the facilitator.
Outcomes: Outcomes will be assessed by using pretest and posttest assessing skills, awareness, comfort, and confidence following the training. In addition, each small group will have the opportunity to create a “cheat sheet” that will facilitate the error disclosure process in the future.
Conclusions: Training on error disclosure, especially one that targets interprofessional collaboration, is a necessity and is currently lacking in the health profession. Not only does such training improve collegiality, but it can also improve patient and professional satisfaction. The design of Interprofessional Error Disclosure illustrates that interdisciplinary error disclosure training can be affordable, efficient, helpful, and fun.
Implications: All spheres of influence of the clinical nurse specialist may benefit from interprofessional education for collaborative medical error disclosure: hospital systems can be strengthened through networking among the disciplines; RN to RN relationships may be reinforced, and direct care to the patient may be enhanced.
Are Evidence-Based Cardiovascular Disease(CVD) Risk Assessment Models Being Used in Family Practice Clinics on Ethnically Diverse Heart Healthy Women Ages 18 through 45 Years?
McCullough C, Fraser S. University of the Incarnate Word
Purpose: The purpose of this study is to ascertain if evidence-based CVD risk assessment models are being used in family practice clinics on ethnically diverse heart-healthy women aged 18 through 45 years. Research questions: Are heart healthy women between 18 and 45 years of age being screened in primary care clinics for cardiovascular disease (CVD) risk using an evidence-based model? If they are, which one is being used? Are women in the high-risk category offered any education and/or referrals?
Significance: The no. 1 killer of women is heart disease. In the United States, nearly half a million women will die of CVD at a cost of 444.2 billion a year. More women below the age of 45 years are developing CVD, and 9000 will have an myocardial infarction within a year. Evidence-based cardiovascular risk classification remains the cornerstone of prevention and can improve the prediction of risk and guide intervention. However, it is not well known and embraced in clinical practice. As patient advocates, educators, counselors, providers, and caregivers, nurses are central to identifying each patient’s various disease processes, risk factors, and barriers to care to attune prevention and care for each woman. Part of Healthy People 2020 objectives and goals are designed to improve cardiovascular health and quality of life through prevention, detection, and treatment.
Design: This descriptive, retrospective design was used to determine if evidence-based CVD risk models are utilized in a family practice setting.
Methods: A purposive retrospective electronic chart review was conducted on 90 women who seek medical care in a medically underserved primary healthcare clinic. Women ranged in age from 18 to 45 years, with a mean age of 32 years. Thirty-two percent were Hispanic, 21% were African American, 26% were white, and 21% were Asian. The patient’s age, ethnicity, body mass index, smoking status, systolic blood pressure, total cholesterol, high-density lipoprotein, high sensitivity C-reactive protein, parental history of a myocardial infarction before the age of 60 years, and waist circumference measures were gathered using a data collection sheet designed by the researchers. Descriptive statistics were used for data analysis.
Outcomes: Sixty-five percent had a body mass index over 25 kg/m2, indicating overweight and/or obesity. High systolic blood pressure was found in 51%. No lipid panels were drawn on 58% of the subjects, and 12% of those who had them drawn were abnormal. Record review showed no evidence of cardiac risk assessment, education, referrals, or treatment for these risk factors.
Conclusions: Assessment of the data indicated that 61% of these subjects are at risk for CVD. Duplication of this research needs to be conducted on other demographically and geographically different family practice clinics and on the barriers to implementing this type of evidence-based CVD risk assessment.
Implications: According to the American Heart Association, long-term risk for CVD can be reduced by performing evidence-based CVD risk assessment and appropriate interventions periodically in early and mid adulthood. Therefore, it is important to implement early adulthood evidence-based CVD risk models.
Bedside Report: A Process Change
Clevenger D. University of Arkansas
Purpose: Does the use of a standardized bedside report versus taped report help increase patient satisfaction and decrease nursing overtime usage?
Significance: An evidence-based practice (EBP) project developed by a clinical nurse specialist (CNS) student influencing change within a facility will be discussed. Lack of proper communication during change of shift was identified as a needed area for improvement by the CNS student. Approval for a pilot EBP project was granted by university professors, hospital EBP committee, and finally the hospital administration. Previously, on the medical-surgical nursing units, all oncoming nurses listened to a taped report for 30 minutes. The taped report was frequently interrupted by off-going staff giving “verbal updates” leading to overtime usage and disruption of the report. Additionally, taped report did not allow patient inclusion in the plan of care, which may decrease patient satisfaction scores.
Design: A before-after experimental design was used. The independent variable was the method of communication, taped or verbal at bedside. The first dependent variable is patient satisfaction as shown by the SHEP (Survey of Healthcare Experiences of Patients) data already being collected. The second dependent variable was the amount of overtime hours used during change of shift overlap.
Methods: Two nursing units were included in the study: 2A medical surgical and 2B medical surgical/telemetry. Patient satisfaction data were collected via the SHEP survey sent to patients after discharge from the 2A/2B inpatient units. Survey results and overtime usage during shift overlap was compared before initiation of bedside report and after initiation of bedside report.
Outcomes: Patient satisfaction scores were measured by 3 SHEP survey questions. In all but one of the SHEP questions, our inpatient units showed improvement. The results of our second dependent variable, RN overtime usage also shows a significant improvement. On our 2A medical surgical unit, we had a total of 28.5 hours of overtime for the month of January prior to the initiation of bedside report. The total for the month of April was 4.15 for the same unit, after the initiation of bedside report. On the 2B medical surgical/telemetry unit, the total RN overtime usage for January was 4.5 hours, which decreased to 2.25 hours in April.
Conclusions: Both units are completing face-to-face report with some struggles noted in compliance in the actual bedside rounding. Our facility has since begun to “unofficially” monitor our compliance rates with bedside rounding during report. Data are currently still being collected regarding RN overtime usage during shift overlap and patient satisfaction scores. Further results will be available upon presentation of poster.
Implications: Bedside reporting has the ability to have a significant influence on the satisfaction of patients during their hospital stay. Additionally, nurses may also have an increase in their satisfaction as well through better communication, transferring of trust, and building of relationships. There is an array of positive reasons to perform bedside reporting; the challenge lies with breaking the barriers of the frontline staff and actually getting them to the bedside.
Capturing Clinical Nurse Specialist Outcomes: A Clinical Nurse Specialist Student-Led Project at a Magnet Community Hospital
Mankoff A, Ansryan L. California State University, Long Beach
Purpose: To develop a streamlined clinical nurse specialist (CNS) reporting tool that demonstrates value and cost savings attributed to CNS led projects and innovations within an organization.
Significance: Due to the unique collaborative nature of CNS practice, it is often difficult to quantify how the CNSs work is tied to organizational outcomes, as well as cost savings for an institution. This is important in a new CNS role. No tool existed in a Magnet-designated community hospital to demonstrate how the current work of the CNS group was impacting patient outcomes, aligning with forces of Magnetism, and meeting organizational goals.
Background: Based on the CNS’s function in the 3 spheres of influence: patient, staff, and organization, there are numerous unmeasured indirect savings provided by the CNS that can be quantified. These include impacts on staff retention, organization and program accreditation, Magnet designation, safe practice, and error elimination. The need for a stream lined tool to provide concrete evidence to assist an organization in understanding these savings and benefits provided by the CNS is essential.
Methods: A“one-stop” tracking tool was created as part of a CNS student 4-month clinical experience guided by an onsite preceptor. Discussions with an 8-member CNS group and representatives from quality improvement were held to gain insight about the content and format of the tool. Review of the literature and current CNS practice were also discussed to identify key content. The 23-column Excel spreadsheet documents projects in relation to scope, organizational values, time allotted, priority level, and literature-based savings/costs and can be organized by CNS or the group as a whole. The tool can be filtered by all fields, and tables/graphs can be extrapolated quickly to report project status and outcomes. The CNS group pilot tested the new tool by entering current 2012 projects and summarized and presented this to the vice president of nursing and patient safety manager for feedback.
Outcomes: Results were summarized for the CNS group identifying the number and type of projects being led/conducted by CNS’s, as well as their impact on patient outcomes, cost savings and how projects fit within organizational strategic goals and forces of Magnetism. To date, the tool has been used by 8 CNSs tracking over 30 projects related to quality improvement, staff development, and harm reduction. The value of the CNS role was demonstrated in areas of accreditation, fall reduction, and staff development thus far.
Conclusions: Having a single tracking tool to document and monitor progress, outcomes, and evaluate the work of a CNS/CNS group is imperative to quantify the value of the CNS role. Having 1 place to document project progress and outcomes eliminates duplication of efforts and ease of outcome dissemination.
Implications: As a new CNS, it is imperative to have a systematic method to help communicate the value of the contributions of the CNS role and the value that projects yield for the organization. This tool provides the novice CNS with a structure to monitor and measure outcomes.
Clinical Nurse Specialist Student Use of the Promoting Action on Research Implementation in Health Services (PARIHS) Framework: Application in the Clinical Environment
Klaess C. East Carolina University
Purpose: The purpose of this abstract is to identify the components of the Promoting Action on Research Implementation in Health Services (PARIHS) framework, note the similarities with the clinical nurse specialist (CNS) spheres of influence, and provide an example of application in the practice setting.
Significance: One of the hallmarks of the clinical nurse specialist role is the integration of evidence-based practice into the 3 spheres of influence. Due to the complexities of the healthcare environment as well as the challenges of implementing interdisciplinary practice changes, a framework is useful tool for the CNS as well as the student.
Background: The PARIHS framework centers on the relationship of evidence, context, and facilitation in change processes and provides a means of assessing these processes to ensure successful change (Rycroft-Malone, 2004). In the PARIHS framework, evidence encompasses research, clinical experience, patient experience, and local data/information. Contextual factors include culture, transformational leaders, and evaluation. The facilitator must adapt the facilitation process to the situation and understand the multiple roles of the facilitator in change.
Description of Methods: For the clinical experience, this student paired with an experienced CNS to assess current practice in a defined clinical area.
Evidence: Literature review of best practice in the defined clinical area, assessment of the inpatient and outpatient settings integral to patient management, direct time with the interdisciplinary team, interviews and assessment of patient/family experiences, and retrospective chart review of 97 electronic records. Context: Culture—the mission of the academic, tertiary care center is to advocate and practice evidence-based medicine to improve community health; Leadership—embraces the core value of caring for patients, their loved ones and each other; Evaluation—the institution values teamwork, excellence, multidisciplinary environment, and translating discoveries into practice; Facilitation—determination of skills and areas of focus for practice change.
Outcomes: The semester-long clinical experience involved review of recent literature on aggressive management of hyperglycemia in new-onset diabetes after kidney transplant, assessment of current practice and patient outcomes, and development of institution-specific recommendations for implementation of new evidence-based patient management strategies. A thorough analysis was obtained by utilizing the PARIHS framework. The preliminary results have been shared with physician champions, and discussions started on how to utilize the data to impact future practice.
Conclusions: The PARIHS framework provided a blueprint for assessment of a clinical area, guided assessment and evaluation of clinical problem, and encompassed areas to consider for implementation of change.
Implications: This model has implications for utilization in the educational environment as well as CNS practice. The PARIHS framework prepares CNSs to advance organizations toward the high end of evidence, context, and facilitation and assimilates how CNSs advance nursing practice via the 3 spheres of influence (Hopp, 2010).
Clinical Nurse Specialist Graduate Students Implement Health Coaching Program to Lower Economic Population
Allison A, Frank K. Indiana University
Significance: To allow 2 clinical nurse specialist (CNS) graduate students the opportunity to engage in community health services, mentor undergraduate nursing students, and implement a health coaching program to a lower economic neighborhood.
Design: Two CNS graduate students participated in an initiative called “Reducing the Risk” to serve as resources for both at-risk adults attending a community high school’s wellness center and undergraduate nursing students completing clinical hours for their community health course. The only prior nursing experience by the CNS graduate students involved hospitalized patients in the clinical setting. The purpose of this project was not only to aid in the improvement of health behavior in this population, but also for the CNS graduate students to gain insight and experience in community health nursing.
Methods: The 2 CNS graduate students formed connections with the community members attending the wellness center to determine their health needs and knowledge deficit. The interest and lack of awareness about hypertension lead to a 3 series program on (1) general information about blood pressure, (2) how nutrition affects blood pressure, and (3) other amendable risk factors of hypertension, including weight management and smoking cessation. The CNS graduate students interacted with community members on a weekly basis, gaining awareness of their health needs and actively working on their communication skill set with this new outpatient population.
Outcomes: At the end of the semester, the 2 CNS graduate students were able to identify personal improvements in the way they interacted with community members. The undergraduate nursing students verbalized the ways the graduate students mentored them throughout the semester, identifying them as role models, able to mimic communication skills with their patients. The community members expressed further interests in programs presented by the graduate students. They were also able to teach back some of the information gathered in the hypertension program.
Conclusions: Instituting a program involving both undergraduate and graduate nursing students can benefit the experience of the nursing students and the community the students are addressing.
Implications: The connections that the graduate students attained with the community members attending the wellness center give way to more individualized programming to be implemented for the following semester. The goal for next semester is to continue with the learning experiences the graduate students have gained, be mentors to the new undergraduate nursing students, and expand the programming provided to include a full research project. By gaining institutional review board approval, obtaining quantitative and qualitative data, and disseminating the new knowledge achieved, the CNS graduate students will fully experience this process.
Clinical Nurse Specialist: Leading Innovations for Health Care Change: Developing and Implementing an Evidence-Based Nurse-Driven Mobility Protocol
Hendrickson A. SUNY Upstate Medical University
Purpose: The purpose of this project is to maintain and improve the functional status of hospitalized older adult patients and to decrease length of stay.
Significance: The American older adult population is projected to double by 2050. Older adults average 4 comorbidities, leading to higher risk for hospitalization. Immobility during hospitalization results in negative outcomes such as functional decline, pressure ulcers, and falls that lead to increased length of stay and healthcare costs. The clinical nurse specialist (CNS) can facilitate innovative healthcare change by developing and implementing an evidence-based nurse-driven mobility protocol for medical units.
Background: Older adults are cared for in all adult units at a large upstate New York hospital, yet no standardized mobility protocol exists outside intensive care unit and surgical units. This leads to inconsistent care and negative outcomes for patients on medical units and for those transferred from higher levels of care. The CNS student approached key stakeholders, including nursing staff on the pilot unit about developing a nurse-driven mobility protocol for a medical unit based on current evidence-based practice.
Approach: A literature review was performed, using immobility and functional decline in hospitalized older adults as search parameters. Several evidence-based databases were investigated to obtain current best evidence. Nurses from local hospitals were interviewed about current protocols. The design was evaluated by shared governance. Volunteers were utilized to encourage patient ambulation through socialization techniques. Effectiveness will be evaluated by comparing patients’ functional status at admission and discharge and lengths of stay before and after the project.
Outcomes: The mobility protocol is currently piloting on a medical/geriatric unit. Preliminary data results collected for 2 months (N = 87) showed either improvement (39.1%) in at least 1 ADL at discharge, or maintenance of functional level from admission through discharge (61.1%). Approximately 4% were ineligible for the protocol. Complete data results will be available by conference.
Conclusions: An evidence-based nurse-driven mobility protocol provides a consistent framework to maintain and improve patients’ functional status and lower length of stay.
Implications for Practice: Using a standardized mobility protocol provides improved, consistent care to patients from all medical units. The use of volunteers to motivate patients is instrumental in achieving positive outcomes. The CNS, as a leader in innovation for healthcare change, facilitates improved care and positive outcomes through the development and implementation of an evidence-based nurse-driven mobility protocol.
Designing a Novel Nursing Intervention for Lower Extremity Radiculopathy Secondary to Failed Back Surgery Syndrome (FBSS)
Anel B, Boyce M, Fite L, Simo A, Zanville N. Indiana University
Purpose: To describe a nonpharmacologic nursing intervention designed to relieve lower extremity nerve pain in an adult patient with a diagnosis of failed back surgery syndrome (FBSS).
Significance: For millions with FBSS, postsurgical nerve and muscle pain radiating to the buttocks, hips, and legs is a significant concern. Current approaches to manage pain symptoms (eg, steroid injections, additional surgery, spinal cord stimulators) can be effective, but risk, high cost, and invasiveness associated with the interventions all point to the need for safe, minimally invasive, adjunctive pain management interventions in this population.
Background: The heated ginger compress uses multiple, distinct mechanisms of pain relief, including therapeutic heat and aromatherapy. Evidence that compounds found in ginger such as gingerols, shogaols, paradols, and zingerone may mediate inflammatory neuropathic and nociceptive pain through alteration of COX-1 and COX-2, interleukins (IL-1 and IL-12), and tumor necrosis factor α activity have been shown in vitro models of pain.
Description: Three ounces of ginger root is minced and placed in cheesecloth and bound with a rubber band. Place in 1 gallon of 127°C water for 2½ hours. Immerse 2 hand towels in the ginger-infused water, then wring them out and place on the low back, alternating as the towels cool, for a total of 30 minutes.
Outcome: The development of a nonpharmacological nursing intervention designed to relieve lower-extremity nerve pain in an adult patient with a diagnosis of FBSS.
Conclusions: This novel intervention offers a possible adjunctive intervention for nerve pain secondary to FBSS. If determined to be effective, it provides a new, low-cost, easy-to-use intervention for pain relief.
Implications: Research is needed to determine feasibility and efficacy of the intervention. Clinically, this intervention provides a low-risk alternative for patients seeking additional relief of pain associated with FBSS.
Developing a Method for Quickly Identifying Patients With Cancer With Febrile Neutropenia for Expedient Admission to Oncology Services at OU Medical Center
Nooner A. University of Oklahoma Health Sciences Center
Significance: Early identification of neutropenic fever in patients receiving treatment for cancer can reduce morbidity and mortality for this vulnerable population. The emergency department (ED) and direct admission to the oncology medical floor are the primary entry points to the hospital for this population. Neutropenia may mask stable sepsis and patients can rapidly deteriorate without proper screening and treatment.
Background: Neutropenia is a reduction in circulating neutrophils, the body’s first line of defense against invasion by pathogens. Chemotherapy and radiation treatments commonly induce neutropenia. Without adequate numbers of circulating neutrophils, patients may not exhibit the classic signs of infection such as erythema, purulence, or edema. Fever may be the only sign of a life-threatening infection.
Design: An adult interdisciplinary team was tasked with developing an algorithm to identify patients at risk for neutropenic fever. The team combined various neutropenic fever indicators from research and guidelines from National Comprehensive Cancer Network to develop the Very Immunocompromised Patient (VIP) algorithm and clinical pathway.
Methods: Guidelines from the National Comprehensive Cancer Network and several research articles on detection and treatment of neutropenic fever were used to create the VIP algorithm and clinical pathway. Patients will trigger the algorithm when they present with fever or shaking chills, and they have received chemotherapy and/or radiation treatment for cancer in the past 45 days. Once identified, patients will be placed on the clinical pathway with the expectation that they will have blood cultures drawn and antibiotic therapy started within the first hour of arriving to the hospital. The adult neutropenic fever order sets have been approved for use. The adult neutropenic fever algorithm and clinical pathway are in the process of being submitted to all service lines for endorsement of institution-wide implementation.
Conclusion: Upon endorsement of the VIP algorithm, the tool will be implemented in the ED and inpatient units to determine the effectiveness. Records of all ED and direct floor admissions of adult patients with any neutropenic DRG combined with any oncology DRG are being reviewed for administration time of first dose of antibiotic. The time of arrival to the hospital and time to administration of first dose of antibiotic are being tracked to determine the impact of the algorithm on patient care.
Implications: The use of a neutropenic fever algorithm can assist healthcare providers to recognize and treat neutropenic fever earlier to reduce the morbidity and mortality associated with infection in the immunocompromised patient.
The Development of an Electronic Headache Pain Diary for Children Who Experience Headache as a Symptom of Concussion
Pasek T, Sumrok V, Kontos A, Locasto L. Robert Morris University. Reichard J. Consultant, Bethel Park, PA
Purpose: The specific aims of this study are to (1) improve the assessment and documentation of headache pain for children with concussion and (2) collaborate with children, clinicians, and a software engineer to design a prospective, real time, age-appropriate, and appealing prototype electronic pain diary for children to use to record headache pain following concussion.
Significance: Concussion is the primary diagnosis for thousands of children who are discharged from the emergency department each year following traumatic brain injury (Langlois, Marr, Mitchko, and Johnson, 2005; Thomas, Collins, Saladino, Frank, Raab, and Zuckerbraun, 2011; Langlois, Rutland-Brown, and Wald, 2006; Lau, Collins, and Lovell, 2011). Of all the signs and symptoms of concussion, headache is the most common and frequently reported symptom (Cahill, Nickles, Fonder, 2012; Halstead et al, 2010; Blinman, Houseknecht, Snyder, Wiebe, and Nance, 2009). Headache pain following concussion can be life altering for children and their families, affecting school attendance and participation in activities for months (Blume et al, 2012; Aromaa, Sillanpaa, Rautava, and Helenius, 2000; Powers, Patton, Hommel, and Hershey, 2003). Typically, children report concussion-related headache pain to clinicians using recall, but there are limitations to this in comparison to prospective diary measures (Lundquist, Rugland, Clench-Aas, Bartonova, and Hofoss, 2010; Lewandowski, Palermo, Kirchner, and Drotar, 2009; Larsson and Stinson, 2011; Larsson and Fichtel, 2012; van den Brink, Bandell-Hoekstra, and Abu-Saad, 2001). Children and adolescents evaluated headache severity and duration more negatively using recall than with prospective diary measures (van den Brink et al, 2001). Furthermore, a diary may be important for validating symptoms among family, friends, and teachers who may doubt injury severity (Sadeh, 2005; Gurr and Coetzer, 2005; Kirkwood, Yeates, Taylor, Randolph, McCrea, and Anderson, 2008; Horner, 2000). Self-report through the use of electronic pain diaries is considered increasingly popular, establishing validity and confidence in data for children 8 years or older (Palermo, Valenzuela, and Stork, 2004; Stinson, 2009; Connelly and Bickel, 2011). The value of electronic pain diaries and real-ime data collection over paper diaries includes more accurate pain intensity rating and richer data (Lundquist et al, 2010; Lewandowski et al, 2009; Larsson and Stinson, 2011; Larsson and Fichtel, 2012; van den Brink et al, 2001; Palermo et al, 2004; Stinson, 2009; Connelly et al, 2011).
Design: The design is mixed methods.
Methods: Robert Morris University institutional review board (IRB) granted approval (IRB #120803). The University of Pittsburgh IRB approval is pending (#PRO12090200). Thirty children with concussion will be interviewed. A prototype electronic headache pain diary will be developed from interviews. Ten clinicians will be surveyed to determine the feasibility and utility of the electronic headache pain diary for assessment and documentation
Findings: Data collection will occur from December 2012 through February 2013.
Conclusions: An electronic pain diary designed by children for the assessment and documentation of concussion headache may be feasible and useful.
Implications: Future research may include application development.
Evaluation of Post–Cardiac Arrest Therapeutic Hypothermia
Deal K, Balzer-Costin A, Young S. University of Maryland
Purpose: The purpose of this initiative was to evaluate variation in practices and to identify best practice method for therapeutic hypothermia (TH) following cardiac arrest in a large academic medical center.
Significance: In 2010, the American Heart Association placed a stronger emphasis on TH after arrest in unconscious patients (Patel and Kumar, 2011). A recent meta-analysis demonstrated that TH improves neurologic and survival outcomes in patients who experienced cardiac arrest (Adler, 2011). For every 7 patients treated with TH, one life is saved. Investigators have reported that 74% of 2248 physicians surveyed have never used TH (Boehm, 2010).
Background: Within the medical center, there was not a standardized best practice method for TH. Three different devices, Gaymar cooling blanket, Arctic Sun, and Icy Catheter, are used throughout the hospital. The lack of standardization reduces efficient resource utilization and can pose a risk to patient safety.
Description: Cardiac arrest data from 2011 were obtained through chart audits and from the cardiopulmonary resuscitation database. Data collection included the number of patients who received TH, the method used in each case, patient outcome, and the number of adverse reactions associated with each case. Adverse reactions were defined as skin break down, temperature overshooting, dysrhythmias, and coagulopathies. Additionally, a survey was distributed to nurses to identify barriers to use of TH.
Outcome: In 2011, there were more than 900 cardiac arrests recorded. According to the cardiopulmonary resuscitation database, 26 patients received TH. However, a chart audit revealed that TH was documented in only 11 patients. Of these 11, 2 were cooled using the Icy Catheter. The remaining 9 were cooled with the Gaymar cooling blanket. There were 2 incidences of coagulopathies. Temperature overshooting occurred in 1 patient with the cooling blanket. Ten of the 11 patients died, and the 1 survivor was subsequently discharged. Staff survey results revealed that of the 88 respondents, more than 20% lacked knowledge about TH process and more than 40% were not familiar with documentation requirements for TH.
Conclusion: There are significant barriers to the implementation and documentation of TH. The number of patients receiving TH and the incidence of complications were too small to justify a recommendation for best practice. The discrepancy between the cardiopulmonary database results and the chart audit highlights that documentation for TH needs improvement. The analysis of survey results suggests that nurses do not have the necessary knowledge regarding TH and the documentation system.
Implications: A prototype for a new documentation tool was developed and is currently awaiting cardiopulmonary resuscitation committee approval. Based on survey results, a TH educational program was created for staff nurses. This program focused on the indications, benefits, adverse effects, and proper procedure for each TH method used throughout the medical center. A dual approach improving both the knowledge of TH implementation and documentation of TH has great potential to reduce obstacles identified by staff nurses, eliminate discrepancies in the cardiopulmonary arrest database and chart audits, increase appropriate use of TH, and ultimately improve patient outcome post–cardiac arrest.
Feasibility of the Implementation of a Sleep Protocol in the Intensive Care Unit (ICU)
Reyes-Guzmán I. University of Puerto Rico
Purpose: The purpose of this clinical project was to provide education and to implement a sleep protocol in a medical-surgical intensive care unit (ICU).
Significance: Sleep is considered essential for the recovery of illness. Patients in ICU are often sleep deprived. Poor quality of sleep is one of the most experienced stressors during their ICU stay. The ICU environment is one of the multifactorial causes for sleep interruption in ICU. Noise, light, and interventions of the staff are key elements of the ICU disruptions.
Description: The project included a selection of 3 registered nurses working night shifts as sleep promoters, development of promotional education materials, educating nursing staff about concepts of sleep in the ICU and sleep protocol, and implementation and evaluation of the sleep protocol. The intervention in the sleep protocol included controlling different factors that affect sleep (eg, pain management, anxiety), environmental modifications (eg, lights, noise), quiet time (from 7 to 9 PM and 1 to 5 AM), and clustered interventions.
Outcomes: Nursing staff found the protocol useful and feasible for implementation. The educational training developed awareness of the importance of promoting sleep in the ICU after the project’s implementation. A total of 5 patients were evaluated, and each reported that their sleep experience was excellent and with few interruptions. They expressed satisfaction with their sleep experience.
Conclusion: The nursing staff is key in implementing interventions needed to improve sleep in the ICU; the protocol interventions may contribute to improve sleep experience in ICU patients.
Implications: The implementation of this protocol in nursing practice will help the nursing staff create consciousness of the importance of sleep for ICU patients, as well as the physiological implications when sleep is interrupted, and how clinical interventions facilitate the creation of an environment that promotes sleep and contributes to patient outcomes.
From Womb to Newborn Intensive Care Unit: Taking an Alternate Journey to Realistic Learning
Wood C. Creighton University
Significance: Education is a very important piece of healthcare. However, we have a tendency to inundate our newly graduated nurses with massive amounts of information. Simulation has been used to help solidify information, but can be costly and time consuming. If we think outside the box with our delivery of education, we can induce an emotional connection with the information that will translate into care at the bedside. Through this cost-effective simulation, students can become engaged in learning by creating personally meaningful knowledge of a concept.
Background: Nurse residencies have been around in some fashion for a while. Our neonatal intensive care unit (NICU) has recently transitioned from a traditional 8- to 12-week orientation process to a 2-year residency program. Information is presented using the format from the Association of Women’s Health, Obstetric and Neonatal Nurses, currently in the form of didactic lectures. Although comprehensive information is presented, recall of the information and the full understanding of the impact on practice are not being realized.
Design: As a means of creating an emotional connection with the information provided, we began to explore alternative methods for information dissemination. We selected a course, early development of the neonate, which was originally offered via lecture, and created a video of the journey form womb to NICU from the perspective of the baby. The video was filmed using the camera as the actual baby. Residents wear specially designed glasses to blur vision. The room is set to a very cold temperature and kept completely dark to emphasize the actions on the video. Water is lightly sprayed on the participant using water bottles with plastic fans connected to simulate the temperature change at the “birth.” It is a complete sensory stimulation of the journey an infant takes from the womb to the NICU.
Methods: The students watch the video and, then, were debriefed on their experience. They were then asked to answer a questionnaire to evaluate the emotional connectedness to the information provided.
Conclusion: Of the 25 residents who have experienced the simulation, all 25 have reported a profound difference in the emotional connection with the information. The most significant difference came from coaches’ feedback reporting a significant difference in the handling of the babies while the residents are on duty.
Implications: The use of sensory simulation can emotionally connect the new nurse resident with the information presented, making a lasting impression on the care they provide to our most fragile patients.
Glycemic Control Outcomes Between African American Adults With Type Two Diabetes Who Do or Do Not Self Monitor Their Blood Glucose
Nyankey D, Padmanabhan M. University of the Incarnate Word
Purpose: To determine whether there is a difference in glycemic control between African American adults with type 2 diabetes who self-monitor their blood glucose level and those who do not, at a Community Health Center in East San Antonio.
Significance: Healthy People 2020 has goals to reduce disparities and improve glycemic control in ethnic minorities. Uncontrolled diabetes leads to comorbidities such as heart disease or strokes, resulting in huge costs.
Design: A descriptive, retrospective design was used to ascertain glycemic control outcomes among African Americans who do or do not self-monitor their blood glucose. Studies show that African Americans are affected more by diabetes than other minority groups. Self blood glucose testing is useful in managing treatment plans and preventing diabetes complications. Nurses and their clients can use the test to check medication compliance or adjust other self-care activities. The Centers for Disease Control and Prevention recommends self glucose testing for those with uncontrolled diabetes as is the case with many African Americans. Glycosylated hemoglobin (HbA1c) test is used to estimate the average blood glucose level over the past 2 to 3 months and monitors glycemic control.
Methods: A convenience sample of 30 subjects was retrieved from electronic records of participants who attended the health center in the last 3 months. All were African Americans with a mean age of 52 years. Two-thirds of the sample were female (20, 66.7%), and only 9 (30%) reported glucose self-monitoring. Fifty-seven percent had HbA1c levels greater than 7, signifying poor glycemic control, and 90% (27) had a body mass index greater than 25 kg/m2 indicating overweight, with 67% of those in the obese and morbidly obese category. Descriptive statistics and independent-samples t test were used for data analysis.
Outcomes: An independent-samples t test was conducted to compare the HbA1c values for the group that monitored their own glucose and those who did not. There was no significant difference in scores for those who self-monitored (mean, 9.411 [SD, 3.35]) and those who did not (mean, 10.005 [SD, 4.98]); P = .75 (2-tailed).
Conclusions: This study suggests that African American adults with diabetes need more education on self–glucose monitoring including the correct technique and its role in glycemic control. Limitations of the study include the small sample and an unequal group size.
Implications: Providers can utilize the findings to help African Americans in diabetes self-care management. Further research is needed using a larger sample.
Identifying A Delirium Assessment Tool Which Registered Nurses Can Easily Apply
Allison A, Culver D, Frank K, Love S, Newkirk E. Indiana University
Purpose: The purpose of this project is to identify a valid, reliable instrument that registered nurses (RNs) can easily use to accurately assess delirium.
Background: Delirium is often underdiagnosed and underrecognized by healthcare providers, leading to higher rates of morbidity, mortality, and longer hospitalization stays. Registered nurses are poised to notice a change in the patient’s mental status or behavior, enabling rapid intervention to prevent further decline in the patient population affected by delirium. However, most barriers related to delirium assessment are associated with nursing knowledge deficit and the lack of an assessment tool. With a better understanding of delirium, RNs then need a reliable, valid, quick, and easy-to-understand assessment tool specific to delirium.
Methods: A small sample of RNs was surveyed to determine their perceptions and barriers on assessing patients for delirium, which verified the need for a consistent assessment tool. Utilizing the Agency for Healthcare Research and Quality guidelines for screening delirium in older adults, a search for a valid, reliable tool that RNs would agree to use was completed. The Nu-DESC was identified as a delirium screening instrument that can be easily integrated into routine care and clinical practice. It is easy to use, time-efficient, and accurate with established validity and reliability; this tool leads to prompt delirium recognition and treatment. The Nu-DESC will be implemented on an adult medical/surgical unit by educating RNs on the administration and documentation of the tool, which will be completed on each patient at admission, each shift, and with any change in cognitive status. Efficient resources will be provided to ensure successful implementation of this tool.
Outcomes: Presurveys and postsurveys will be completed by the RNs to assess for delirium knowledge and their perceptions of the Nu-DESC. Chart audits will be completed to ensure 100% compliance in screening patients.
Conclusions: Implementing the Nu-DESC as a screening tool for delirium will allow RNs to (1) be able to differentiate between confusion and delirium, (2) more frequently assess patients for delirium, and (3) be empowered to deliver interventions for prevention and management of delirium. Increasing the communication between RNs, interdisciplinary team members, and patients’ family members will ensure more timely diagnosis and treatment of delirium.
Implications: The lack of research studies on implementing a delirium screening tool exhibits the importance of this project, which could lead to improving nursing assessment for delirium, resulting in more accurate, timely identification of delirium, and implementation of appropriate management and treatment interventions.
Identifying the Relationship between BMI and Daily Exercise
Boman P, Kurji N. University of the Incarnate Word
Purpose: To determine the correlation between the number of days that an individual exercises and the body mass index (BMI) in a selected group of individuals who belong to a wellness center.
Significance: Recent obesity research points to a growing obesity rate in the United States. Obesity contributes to the development of heart disease and diabetes, the first and sixth leading causes of death, respectively. Many studies have found correlations between a sedentary lifestyle, unhealthy eating habits, and increased in BMI. A number of strategies appear to reduce the prevalence of overweight and obesity, such as encouraging gyms and grocery stores to open in a community, improving community safety and exercise infrastructure, and zoning residential and business buildings with in walking distance. Many believe that they merely need to choose the right diet (Atkins, Celebrity, etc) to lose weight, but the studies are showing that although having some form of weight control program is important, the type of diet chosen makes very little difference compared with he impact of regular exercise. With no signs of a reversal in the growth rate of obesity, rates seem poised to continue growing well into the future.
Design: A retrospective descriptive correlational design was used to correlate the number of days individuals spent exercising and their BMI.
Methods: A retrospective electronic record review was used for data collection. A random sample of 50 adults who attended a wellness center was drawn from a computerized list of all those who attended for the last 60 days. The majority of the sample was male (31, 62%) with a mean age of 44. Most of the sample were married (29, 58%), Hispanic (19, 38%), or white (21, 42%), and 74% had a BMI in the overweight-to-obese range (25–39.6 kg/m2). The data included demographic variables such as gender, age, marital status, religion, BMI, ethnicity, number of days spent excising, height, and weight. Descriptive statistics were used to describe the sample, and Pearson coefficient was used to determine the relationship between number of days of exercise and BMI.
Outcomes: The relationship between number of days of exercise and BMI was investigated. There was a medium negative correlation between the 2 variables, r = −0.337, P < .05 with more days of exercise associated with lower BMI.
Conclusion: Increased exercise as measured by days attending a wellness center is correlated to a decrease in BMI. This difference is statistically significant (P = .017).
Implications: Participation in regular exercise will lower the BMI. It will also benefit the individual by reducing cardiovascular risk and incidence of diabetes, thereby improving quality of life.
Implementing an Innovative Clinical Role to Improve Neonatal Outcomes While Supporting Family-Focused Care
Williamson K. East Carolina University
Purpose: The purpose of this project was to establish an innovative role designed to provide transitional care at the mother’s bedside in labor and delivery for eligible newborns. Without funding to hire additional nurses into this position, a core group of nurses from all maternal-child health (MCH) units volunteered. The Neonatal Assessment Nurse (NAN) shifts the long-standing practice of transferring the infant to where the work is accomplished back to keeping the maternal-newborn dyad together.
Significance: Introduction of the NAN, as a dedicated clinical assignment, positively facilitates fetal to neonatal transition by decreasing separation, increasing percentage of skin-to-skin experiences, improving nurses’ perspective of neonatal care, decreasing neonatal intensive care unit admissions, and improving maternal satisfaction.
Background: A nurse-driven taskforce in collaboration with the MCH clinical nurse specialist discovered that inconsistent care practices impacted the quality of neonatal care and maternal satisfaction. Knowing the stabilization and bonding benefits of minimizing the separation of the mother-newborn dyad at delivery, the taskforce, chaired by a clinical nurse specialist student, integrated the role of a NAN into the care delivery process.
Description: Strategies for NAN success included detailed role description, patient care priorities, and a decisive evaluation plan for those infants requiring nonintensive, yet supportive care and monitoring. A comprehensive process of didactic education and clinical orientation was individualized based on the nurse’s expertise along the spectrum of neonatal care. Simulation scenarios served as teaching adjuncts and reinforced evidence-based practices.
Outcome: Medical record reviews will monitor neonatal outcomes. In addition to didactic class evaluations, the NAN nurses will complete a self-assessment questionnaire that addresses the effectiveness of the orientation curriculum with their confidence and NAN skill level. The Caring Behaviors Inventory by Wu, Larrabee, and Putman (2006) was used before/after NAN to gain clinical nurses’ perspective about care delivered to neonates less than 4 hours of age. This tool was chosen because it aligned with the hospital’s choice of Watson Caring Theory as the framework that currently guides nursing practice.
Conclusions: The enthusiasm of the NAN-identified nurses and creative staffing models developed by the MCH units’ charge nurses ensure daily shift coverage. By its design, we expect to have (1) client improvements in neonatal thermoregulation, physiologic adaptation, and establishment of breast-feeding; (2) advanced neonatal nursing knowledge and skills demonstrated after completion of the NAN orientation curriculum; and (3) nurses’ attitudes reflect an improved system care delivery process that better supports their ability to provide neonatal transition care at the mother’s bedside.
Implications: The NAN role in labor and delivery presents an extended benefit of having a dedicated nurse to provide neonatal care in situations when transition time requires additional poststabilization assessments and/or extended pulse oximeter monitoring. With no literature available on this topic, publication of the positive results of this innovative change will help others adopt similar roles specific to their settings.
Improving Discharge Teaching for Patients With Diabetes After Open Heart Surgery: A Clinical Nurse Specialist-Led Innovation
Hartmann M. SUNY Upstate Medical University
Purpose: To develop discharge teaching for patients with diabetes after open heart surgery to improve patient outcomes.
Significance: Patients with diabetes represent 25% to 30% of patients who undergo cardiac surgery. Hyperglycemia in the perioperative and postoperative periods is associated with increased complications, especially sternal wound infections. Adequate glycemic control can prevent this negative health outcome and reduce readmission rates, additional surgical procedures, and pain and suffering for the patient. Diabetes self-management must continue after discharge.
Background: While glycemic control in the intensive care unit is well understood, the transition to outpatient management of diabetes requires a different knowledge base. Patients with diabetes undergoing cardiac surgery may have their home regimen changed at discharge requiring them to learn about new medications or insulin. Some patients had no prior education; others may be newly diagnosed. The literature reveals that while nurses have expertise as cardiac surgical nurses, they frequently lack updated knowledge about diabetes management, which has radically changed over the years. They feel inept and lack the confidence to teach patients the skills they need to self- manage their diabetes. The hospital stay, with its critical nature, motivates patients to take a more active role in their own healthcare and provides an excellent opportunity to provide life-altering education for improved diabetes self-management.
Methods: In this clinical nurse specialist–led innovation, a literature review examined evidence-based databases to discover how to improve discharge teaching about diabetes. Clinical guidelines from the American Diabetes Association and the American Association of Diabetes Educators were also accessed. A short survey was administered to the nurses on the cardiothoracic unit, which revealed impediments to discharge teaching about diabetes, including the lack of readily available teaching materials, insufficient knowledge about diabetes, and confusion about what to teach patients. Knowledge about diabetes, assessed through a pretest administered to nurses, was less than optimal regarding oral medications, home glucometer use, diet, and insulin administration. A plan was made for a series of in-services and posters to address the educational needs of the nurses. An assessment tool was developed to help determine what teaching needed to be done with each patient. Educational material already on the hospital Web site was outlined, described, and made more readily accessible.
Conclusions: Diabetes is a complex disease, which is managed differently in the inpatient and outpatient settings. Patient education about diabetes self-management requires nurses to be able to understand how the disease is managed on an outpatient basis, as well as being able to manage hyperglycemia in the intensive care unit. Ongoing diabetes education for nurses is vital.
Implications: The clinical nurse specialist possesses competencies as an expert clinician and educator and is in a unique position to facilitate improved patient outcomes by supporting nurses as they educate patients and assist with transition to diabetes self-management. Education for all inpatients with diabetes is a necessary approach that would improve patient outcomes and reap financial benefits in terms of decreased readmissions, lengths of stay, and complications.
Increasing and Improving Communication Through Interdisciplinary Rounds
Lange M. SUNY Upstate Medical University Hospital
Purpose: The purpose of this project is to improve communication through Interdisciplinary Team Rounds (IDR) and develop an integrated patient plan of care that improves patient outcomes.
Significance: Effective communication is key to successful teamwork and to generating an efficient patient plan of care. A standardized plan of care involves input from many disciplines. The clinical nurse specialist (CNS), with expert consultation competencies, facilitates the process of integrating these different disciplines into 1 team. Improving communication among the team members and developing an integrated plan of care will decrease length of stay, reduce errors, identify problems early, and improve patient outcomes.
Background: Interdisciplinary Team Rounds existed in a community hospital. When the clinical nurse specialist (CNS) student joined the team, the IDR was ineffective. There was inconsistency in rounding, attendance of team members varied on a daily basis, and charting was not uniform from one unit to the next. There also was no clear leader of the team. The dialogue during IDR was in nursing report style versus sharing of unmet goals.
Method: The CNS student joined the team and has assisted in leading the team. As a leader and advocate for healthcare change, the CNS student performed a literature search using Cochrane, CINAHL, and PubMed. Joint Commission standards were also reviewed for IDR expectations. Next a survey given to nurses, managers, respiratory therapists, nutritionist, case managers, and social workers found that staff did not know what IDR was or who was supposed to lead the team. Survey findings also found that staff did not know how to complete a plan of care appropriately. The CNS student’s plans included IDR education at staff meetings and on a 1:1 basis. A tool has been created to guide the team members in planning goals for patients during IDR. Also a second survey will be completed to see if understanding of IDR among staff has improved.
Outcomes: A new integrated plan of care is pending and will be complete by conference time.
Conclusions: An integrated plan of care and consistent IDR will improve communication among team members and improve overall patient outcomes.
Implications: As an expert clinical leader, the CNS is able to lead groups and facilitate discussions. By uniting a team of different disciplines, the CNS can lead them through discussions that will address patient problems, implement efficient plans of care, and evaluate patient goals. The CNS is a leader for healthcare change and through education and leadership can improve communication among the Interdisciplinary team.
Intensive Insulin Therapy and Its Impact on Critical Care Mortality: A Systematic Review of the Literature
Doherty M, Higgins R. University of Massachusetts, Boston
Background: Critically ill patients are at high risk for stress-induced hyperglycemia. Evidence has linked hyperglycemia with poor outcomes and a higher risk for morbidity and mortality. Intensive insulin therapy (IIT), or tight glycemic control, may have a beneficial effect on decreasing mortality in critically ill patients. In 2001, a landmark, randomized controlled trial studied the use of IIT in surgical patients and reported a significant decrease in mortality. As a result, IIT was adopted in intensive care units throughout the world. Although the results of the landmark trial have not been reproducible in recent studies, hospitals still follow its guidelines. The purpose of this systematic review is to address a knowledge gap in practice and evaluate current evidence in literature to determine if IIT versus conventional insulin therapy (CIT) has a positive effect on critical care mortality.
Methods: A systematic review of the literature was done to compare IIT versus CIT and mortality in critically ill patients. Studies for review were obtained using searches of electronic databases (4) and by hand searches of bibliographies of primary evidence studies. Keywords used in searches were “intensive insulin therapy,” “critical care,” and “mortality.” Studies selected were based on inclusion and exclusion criteria and independently reviewed by 2 readers.
Results: Ten studies were selected for review and compared with the 2001 landmark study for IIT. Overall consensus showed no statistically significant difference between IIT and CIT and its impact on critical care mortality. However, studies showed hypoglycemia was statistically higher in IIT (P < .001).
Recommendations: Intensive insulin therapy is not associated with a significant decrease in critical care mortality over CIT, but it is associated with an increased risk for hypoglycemia. Given these results, IIT should not be recommended for use in practice over CIT. Future studies should examine algorithms and protocols for insulin therapy and address standardizing the practice. This knowledge gap in practice highlights educational opportunities for the direct patient care provider both at the bedside and at the prescribing level.
Nurse Initiated Hourly Rounding: An Intervention Worthwhile
Mast H. University of Texas, Austin
Purpose: The objectives of this study are to discuss the evidence-based benefits of a nurse initiated hourly rounding program and advocate for nurse education and nurse leadership in development and implementation of a national nurse-initiated hourly rounding protocol for use across all hospital systems.
Significance: Clinical nurse specialists as leaders, educators, and consultants to bedside nurses across the nation have a role in advocating and developing protocols and policy that benefit patient safety, save money, and avoid adverse outcomes due to hospitalization, especially with clear evidence at hand.
Background: The poster will provide a summary of the strength of the evidence to support hourly rounding, including cost savings, and describe the elements of the best hourly rounding initiatives identified in the literature.
Methods: The study was a literature review to determine whether nurse-initiated hourly rounding is associated with increased patient/staff satisfaction, decreased use of patient call lights, and increased patient safety.
Outcomes: Current evidence suggests that successfully implemented hourly rounding protocols can potentially reduce the rate of falls by greater than 50% across various wards and decrease the use of call lights by as much as 40% to 50% and the development of pressure ulcers by approximately 14%. In as many as 88% of research studies, researchers discovered improvement in patient satisfaction (Meade et al, 2006). Additionally, although staff satisfaction was not directly measured in most studies, nursing staff who worked on experimental units often verbally reported increased satisfaction, due to quieter units and additional time to care for their patients and perform other tasks (Meade et al, 2006).
Conclusions: Hourly rounding is a care model that effectively decreases patient’s call-light use, increases patient satisfaction, and increases patient safety. A beneficial recommendation to practice involves the development and implementation of a national nurse-initiated hourly rounding protocol for use across all hospital systems (Deitrick et al, 2011). This hourly rounding process would also need to include internal checks and balances system, as well as protocol measurement tools (Meade et al, 2006).
Implications: Hourly rounding has continuously demonstrated improved patient safety, a decrease in fall incidences, a decrease in call-bell use, and improved patient satisfaction, resulting in improved outcomes for patients, staff, and organizations. Clinical nurse specialists should use their 3 spheres of influence to aid in the development of a national protocol for use within all hospital systems and organizations. Protecting patients and promoting patient safety are key to delivering state-of-the-art evidence-based practice.
Policy Fellowship: A Unique Path to Learning Core Competencies
Bell K. University of Texas, Austin
Objective: After seeing this poster, learners will understand the components of the Archer Fellowship in Public Policy and how clinical nurse specialist students can gain knowledge from real-life application of leadership and advocacy.
Significance: Clinical nurse specialists (CNSs) are called to be leaders in advocacy and participate in public affairs that influence patient, nurse, and system outcomes.
Design: The University of Texas System Archer Graduate Program in Public Policy is designed to immerse graduate students interested in public affairs in the policy-making process at the national level. Students participate in a 12-week program that consists of academic, scholarship, and internship didactics.
Description: This year, I was awarded Archer Fellowship as a CNS graduate student and was the first nurse to be awarded this honor. As a fellow, I studied, worked, and lived in Washington, DC. The coursework was led by leaders in public affairs from various government and nongovernment agencies, which provided an integrative, interactive, and applicable learning environment. The full-time internship was supported by the Oncology Nursing Society, where I worked alongside the director of policy as an advocate for oncology nursing issues.
Outcomes: The experience was life altering. As a CNS graduate student, I influenced issues that affected patient/family outcomes, the nursing profession, and the healthcare delivery system. Several important policies included access to cancer screening, equal access to chemotherapy medications, risk evaluation mitigation strategies, nursing workforce shortages, nursing education, healthcare reform, nursing research funding, and safe practice guidelines. As an intern at Oncology Nursing Society, I performed the role of expert clinician when I spoke about oncology patient outcomes. I worked as a consultant when I collaborated with others on tobacco cessation strategies. I was an educator to lawmakers who needed clarification on oncology or nursing issues. I was a researcher as I gathered data to support evidence-based healthcare policy.
Conclusions: Graduate students can learn current issues facing the CNS spheres of practice and how they can effectively engage in the policy–making process to improve system-wide outcomes. By engaging directly with legislators, the CNS student can gain insight into professionalism, politics, and the law-making process.
Implications: Internships in public policy are unique learning experiences that develop core competencies in leadership, collaboration, research, coaching, and advocacy. An internship of this nature will allow the student to apply the CNS essential characteristics of clinical expert, consultation, ethics, and professional citizenship. Graduate CNS students should be encouraged to seek opportunities for internships in policy and advocacy.
The Role of the Clinical Nurse Specialist Student in Improving the Care of the Neuroscience Patient
McCormick M. York College of Pennsylvania
Purpose: The purpose of this clinical project is to identify the impact a neuroscience education class has on enhancing neuroscience knowledge and improving clinical practice.
Significance: Neuroscience patients are a unique population that requires skilled staff who are trained to identify early and subtle neurological changes that may occur. Consistent and accurate documentation in addition to compliance with the Stroke Performance Measures are imperative to provide effective and quality care to this population.
Background: The neuroscience education class was designed and implemented to provide the nursing staff on the dedicated neuroscience/stroke unit’s specific and detailed information regarding care of the neuroscience patient along with the significance and importance of the Stroke Performance Measures. Evaluations are used to receive feedback on the usefulness of the material presented, but the actual knowledge gained or implications for practice changes have never been measured.
Description: The stroke coordinator, staff development instructor, and a graduate student in a clinical nurse specialist (CNS) program collaborated to design the neuroscience education class. The class consists of lectures on neuroanatomy and physiology, stroke, patients with behavioral problems, seizures, and interdisciplinary care of the stroke patient. A 10-question pretest has been created by the CNS student to administer prior to the start of the class to assess the baseline neuroscience knowledge of the class participants. The participants will be instructed to complete the pretest and ensured the results will be kept confidential. Two weeks following the education class, the participants will be given a posttest to assess their knowledge after attending the class. The CNS student will also audit the documentation of those who attended the class to check for consistency and compliance with the required documentation.
Outcome: The neuroscience education class is scheduled for December 2012. The results of this clinical project will be available for discussion and evaluation in January 2013 and for presentation at the NACNS Conference in March 2013.
Conclusion: Planning the neuroscience education class has given the CNS student the opportunity to collaborate with other disciplines. Throughout the planning of this clinical project, the CNS student has gained an appreciation for the importance of the CNS role in planning, implementing, and evaluating education programs to improve outcomes.
Implications: Education programs are frequently offered to the nursing staff, but the knowledge gained and translation into practice are often not measured. Measuring the knowledge and practice changes following attendance at the education program will illustrate the effectiveness of the information presented and how the nursing staff translates the information into practice. The CNS student will also have the opportunity to evaluate the effectiveness of the education class based on the results of this clinical project and can make suggestions for changes and modifications for future programs.
Using the Palliative Performance Scale Version 2 (PPSv2) in Obtaining Palliative Care Consults
Fedel P. University of Wisconsin Milwaukee
Significance: Patients with chronic illness report moderate to low levels of quality of life. Relief from suffering may be found in services provided by palliative care; however, their services are often underutilized, in part, because of difficulties in prognostication. The Palliative Performance Scale Version 2 (PPSv2) is a prognostication tool that can help overcome this barrier. The PPSv2 is a functional assessment tool. Research has shown patients with the lowest scores to have increased mortality as compared with patients who scored higher on the scale. Nurses are the caregivers most present at the bedside and are in the best position to assist in prognostication and advocate for the patient and their end-of-life needs. The project aim was to increase nurses’ knowledge of palliative care and to increase comfort in identifying need for palliative care and requesting palliative care consults for patients with chronic conditions.
Design: The research design was a pretest/posttest with a nursing education intervention. A convenience sample of staff nurses was used on one 26-bed medical unit located in a Midwest tertiary hospital. Institutional review board exempt status was obtained in July 2012. Pretest and posttest survey was administered through SurveyMonkey. The educational intervention was presented at a unit staff meeting in August 2012. A 1-month posteducational mentoring period of unit staff followed the educational intervention prior to completion of the postsurvey.
Methods: For both the pretest and posttest survey, participants rated their comfort level in identifying patients needing palliative care and in asking physicians for a palliative care consult using a 1- to 5-point Likert scale. Three true/false questions on when palliative care should be initiated were adopted from the palliative care quiz for nursing to assess knowledge level. The educational intervention content included palliative care philosophy, palliative services, significance of timing of palliative care consults, and how to use the PPSv2 assessment tool. A 1-month postintervention coaching and mentoring period followed the educational intervention. Mentoring was provided by the clinical nurse specialist student during daily rounds.
Outcomes: A paired-samples t test was conducted to evaluate the impact of the intervention on nurses’ scores on the pretest/posttest. There was a statistically significant improvement on the 5 comfort and 3 knowledge survey questions (P = .040 and .027, respectively). Nurses also reported a significant increase in comfort level of identifying patients in need of palliative care (P = .005). Cronbach’s α for the pretest and posttest survey tool was .803.
Conclusion: Education combined with coaching and mentoring of staff nurses by the clinical nurse specialist student had a positive influence on nurses feeling more comfortable in identifying patients who are in need of a palliative care consult.
Implications: Use of an assessment tool that overcomes barriers to prognostication may result in increased palliative care consults. Nurses who are more comfortable in using the prognostication tool to identify patients in need of palliative care are in a better position to advocate for the patient’s end-of-life needs and request a consult.
Why Not a Formula? A Clinical Nurse Specialist Change
Waldau H. SUNY Upstate Medical University
Purpose: To provide consistent patient teaching by all nurses from labor and delivery, intensive care nursery, and mother-baby units about the benefits of breast-feeding and the risks of formula in order to decrease formula supplementation rates.
Significance: Formula supplementation leads to a greater number of ear, gastrointestinal or respiratory infections, diabetes, childhood cancers, intestinal diseases, hospitalizations, and rising obesity rates. Formula decreases protective bacteria allowing foreign protein into the gap junction in babies younger than 6 months, making the infant vulnerable.
Background: Baby-Friendly, as defined by the World Health Organization/United Nations Children’s Fund, serves to promote, protect, and support breast-feeding in the hospital or birth setting. To comply with Baby-Friendly standards, 1 institution chose to concentrate on 1 step of the standard, decreasing formula supplementation rate to fewer than 20%. This institution felt it was important to educate all staff in regard to compliance with standards and regulations to increase the health of the newborns by decreasing the rate of supplementation.
Method: A literature review, using several databases, was conducted using the key words breast-feeding, infant gut composition, supplementation, infant microbiota, breast milk, gut flora, intestines, newborn, nursing, and formal education. Inclusion criteria include exclusively, totally, or fully breast-fed infants; infants 3 months or younger; uncomplicated, singleton, and term pregnancy (≥37 weeks); greater than 2500 g; and 5-minute Apgar score greater than 7. Exclusion criteria include intent to formula feed, a medical condition or treatment that contraindicated breast-feeding, and admission to intensive care. The clinical nurse specialist student developed a breast-feeding teaching in-service fair using 10 stations to educate providers to teach patients in a consistent manner. Every employee, including physicians and nurses from all units in maternal-child nursing and the out patient clinics, was educated regarding breast-feeding according to Baby-Friendly standards. All were evaluated and expected to successfully complete the competency by either demonstration or question/answer. The stations included (1) feeding cues of the newborn: breast-feeding or bottle feeding, (2) positioning and latching, (3) counseling the feeding decision of a mother who has chosen to feed formula, (4) counseling to maintain exclusive breast-feeding, (5) skin to skin, (6) preparing formula, (7) rooming In/discharge support, (8) teaching and assisting hand expression and finger feeding with a dropper, (9) pump setup/supplemental nursing system, (10) breast milk and baby labeling and identification.
Conclusions: Educating providers to teach about prenatal breast-feeding that is consistent with what hospital nurses will be teaching will afford the best newborn outcomes. The in-service fair prepared nurses and providers (N = 290) to comply with Baby-Friendly standards. Initial data analysis demonstrated a 9% decrease in supplementation rates. Further analysis will be completed before conference.
Implications in Nursing: The clinical nurse specialist can lead change by helping providers to educate mothers starting during the prenatal stage about breast-feeding to improve the health outcomes of their newborns.