New Knowledge, Innovations, and Improvements - NK01
NK1 That nurses at all levels evaluate and use published research findings in their practice
"The registered nurse integrates research findings into practice" - ANA Nursing Scope and Standards of Practice , 2004
"I just did what I thought made sense - now I see how using research and evidence in the literature, we might have done things differently and better!"
2010, Nurses on 5South
"What research exists on how to prevent and reduce our falls?"
Ongoing, Director of Patient Care Services, Penrose Hospital
"I have searched and searched and the only good research article I can find is from 1998. Can I use this article to help me implement some new practices?"
2011, Outpatient Clinic Case Manager RN
Our commitment to provide quality care and to implement evidence based practice (EBP) is inherent in our Professional Practice Model. Florence Nightingale, one of our selected theorists, provided the expectation for nurses to continually seek, evaluate, and use research findings in practice.
Our CNO, nursing directors, and the co-chairs of our EBP/Research Nursing Council, are certified and/or master's prepared. These nursing leaders set the stage as they review current research for credibility and application within our nursing services. The Nurse Scientist and Magnet Coordinator consistently forward peer reviewed articles for nurses at all levels to review, evaluate, and consider for implementation. Summaries from the AHRQ Research Activities are forwarded to appropriate disciplines/managers regularly. The Director positions of: Effectiveness, Infection Control, Patient Safety, and Risk Management all require a nurse with an advanced degree; they also require a candidate who leads performance improvement and evidence based practice initiatives which are inclusive of applicable research findings.
We maintain two primary structures that support access to published research and evidenced based practices. These structures are our medical library (complete with an MLS trained librarian) and access to current peer reviewed publications (both online and print formats). In addition, we have continuing access to professional nursing journals through the Mosby Suite. Our associates are able to connect to electronic resources through the Webb Library at Penrose Hospital is available on the hospitals' associate web portal, "My Virtual Workplace." Access to the Webb Library is available to any associate, physician, or community member who wishes to peruse peer-reviewed publications.
Evidence Based Processes/Research Nursing Council:
The EBP/Research Nursing Council, in conjunction with our Clinical Nurse Specialists both provide leadership in evaluating and actualizing research findings. When we were looking for a solid methodology for implementing Evidence Based Practices, The EBP/Research Nursing Council considered and evaluated several models. In making the determination, the Ronald Reagan University Nursing Department Evaluation Criteria and Scoring for Models of EBP Changes was used. Based on this scoring, the Rosswurm and Larrabee Conceptual Model for Translating Evidence into Clinical Practice was selected for use in our organization. This model is actively used as nurses implement and evaluate projects to disseminate in regional evidence based practice conferences. Nursing units that established hourly rounding and bedside shift change, report some successes with this EB practice. In support of this conclusion, Carolyn Cusick, BSN, RN, Manager Oncology states, "We are using both bedside shift report and hourly rounding. Patients state that they don't need to use the call light very often because staff is checking on them frequently." ( NK1-1 , NK1-2 )
Several other hospitals within the Centura system have since adopted the Iowa model. In order to evaluate the process' results and to review lessons, Centura's Nurse Scientists will gather at a symposium in March of 2013 to discuss the system.
Each unit has an assigned EBP Council member to contact for consultation, questions, and education. ( NK1-3 ) These council members made rounds on units, they encourage nurses to reflect on their practice, they ask clinical questions of their colleagues, and they demonstrate access to professional literature. The recent addition of a Nurse Scientist position will provide additional support for accessing and evaluating research findings for application in practice. This new role will assist nursing teams or individuals through the entire research process; including instruction on how to: formulate a question, perform the literature review, prepare the IRB submission, perform the research, and prepare for presentations (be it through poster, presentation, or journal articles). Additionally, nurses can call an EBP Council member to receive assistance with literature searches for EBP questions.
In the process of evaluating nursing practice or reading professional journals, nurses of all levels request recent research to support best practices. To support nursing staff in the evaluation of articles for quality, our internal nursing newsletter, TLC featured a guide for deciding what constitutes a "good" article. ( NK1-4 )
Previous CNO (Kate McCord, MSN, RN, NEA-BC):
Prior to her resignation in 2012, the previous Chief Nursing Officer requested a literature review for her evaluation of capnography. She used the literature for discussions in the interdisciplinary Pain Committee. As Centura Health evaluated policies related to monitoring and patient safety related to use of analgesics, the research supported policy revisions and led to her request for capnography equipment in 2012. ( NK1-5 )
Directors (Rose Ann Moore, MSN, RN, NE-BC):
Individual nurses enrolled in graduate school are evaluating research and planning their own research studies within PSFHS. Rose Ann Moore, MSN, RN, NE-BC, Director of Patient Care Services, Penrose evaluated research on treatment of aggressive behaviors on inpatient medical and surgical units. Moore states,
"Conducting a literature search of current practices was a very tedious process. Discouraged with my first search, which yielded many articles pertaining to emergency departments; I took my mentors' advice and conducted a second search with new search terms pertinent to the inpatient setting. After reviews of over 60 abstracts and articles, I laid the foundation of my practicum with 19 current articles that addressed successes and failures of care with behavioral health patients in hospital settings. I created an annotated bibliography after reading an article from the University of Phoenix's library, Center for Writing Excellence."
The trends noted in the care of patients with high-risk for agitation, aggression, and violence include the identification of triggers and root causes for behavior emergencies. Improving knowledge in the care of patients with dementia, delusion, substance withdrawal, and psychiatric diagnoses was a priority. Age groups at high-risk for these behaviors include young adults and the elderly. The literature supports that those greater than 65 years have a 50% higher risk for a behavior emergency, due to a variety many factors. These include: depression, experiencing declining health, the lack of a support system, chronic pain, fear of illness, and loneliness. (Linck, 2004)
Some of the newest evidence and best practices place an emphasis on clinical algorithms. These algorithms are a set of instructions that assess the patient for: danger to self and others, whether or not a hold is necessary, needing assistance in determining medical care needs, whether an inpatient admission is warranted, and if a psychiatric evaluation would be useful. (White, 2010) A psychiatric evaluation supported by standing orders is helpful to clinicians when making objective decisions related to placement and clinical interventions (White, 2010).
Theresa Lutze RN, Clinical Manager PH 8 requested evidence about manual versus automated BP measurements. The unit was debating whether or not they should return to manual readings for more accuracy. Before the literature search was completed, Rochelle Salmore MSN, RN, NE-BC attended the Centura EBP Conference where she met a presenter and her mentor. Salmore discussed the benefits versus hardships of having RN's in their residency complete an EBP project with the presenter. They provided copies of EBP projects that these new graduates had completed at Poudre Valley Hospital. One study was on just this topic, so the RN was contacted for her reference list and findings. This was given to Lutze. ( NK1-6 )
Audrey Simpson RN, Clinical Manager evaluated the literature and research focused on hypertension in African Americans. Following this, she prepared brochures and a class that was presented at her church to this population. ( NK1-7 )
Wound Care Clinical Nurses (Rochelle Salmore, MSN, RN, NE-BC):
Rochelle Salmore RN, Clinical Manager referred wound care nurses to the Wound Ostomy Continence Nursing (WOCN) web site for information on managing leaking Gastrostomy Tubes. WOCN's recent white papers were purchased and distributed to the Wound Nurses for reference. The titles of these papers included: "Guidelines for Management of Lower Extremity Venous Disease," "Guidelines for Management of Lower Extremity Arterial Disease," "Management of the Patient with a Fecal Ostomy: Best Practice for Clinicians," "Incontinence Associated Dermatitis: Best Practice for Clinicians," and the most recent digital textbook on wound care. All wound nursing staff have access to these sources from their computer desktops. ( NK1-8 )
Ethics Committee Member (Debra Nussdorfer, MSN, RN, NE-BC):
In the context of reviewing the policy on the declaration of death and recent experience as an Ethics Consultant, Nussdorfer requested assistance with a literature review. She provided the following recommendation, which was accepted by the Ethics Committee and included in the policy revisions. The medical librarian assisted in completing a literature review. The first selection provides expert recommendations based upon relevant literature by experts from Wake Forest University School of Medicine and is accepted by the American Academy of Pediatrics and Child Neurology Society. She recommended inclusion in a revised policy, which was completed in 2012: B-09-c. ( NK1-9 )
Penrose Cancer Center Clinical Nurses:
The PSF Cancer Hospital's clinical nursing staff and physicians use the NCCN (National Comprehensive Cancer Network) treatment guidelines in all planning and follow-up. The "treatment summaries" that our Survivorship Navigators give to patients at the end of their care are based on ASCO (American Society of Clinical Oncologist) guidelines and recommendations. The NCCN and ASCO guidelines are all evidenced based. The care plans that the Survivorship Navigator presents/reviews with the patients and their caregivers are also based on ACS, ASCO, and NCCN guidelines. ( NK1-10 )
Direct Care Nurses:
Nursing Practice Council Our quality improvement data identified the need to reduce falls and improve patient satisfaction. The professional journals were writing of the benefits of hourly rounding and bedside report. The council requested research and other literature to evaluate and consider prior to implementing practice changes.(NK1-11 )
Journal Club To encourage the use of EBP in daily clinical nursing, Peggy Plylar, MS, RN, CRRN, CNS Joint and Spine Coordinator started a journal club through Wikipedia to promote easy access by all shifts. Liz Smith RN states "We had the opportunity to discuss the advantages/challenges of bedside shift report. The article prompted discussion and provided current information on how to implement this practice. I liked the support to examine evidence based literature." ( NK1-12 )
Newborn Pain In early 2011, staff in the Mother-Baby Unit realized that much attention was paid to adult pain, but little was given to newborn pain management during circumcision and other painful procedures. Rosi Behrman performed a literature search then presented her findings to the Charge Nurses and then to the Unit Practice Council, where it was decided that a competency check list should be developed based on evidence-based findings.
The UPC also decided to work on better charting through using the NIPS Intervention. Staff members were reminded about charting at a staff meeting, and the Assistant Clinical Manager sent an email to all staff reminding them to document newborn pain interventions just as they would for an adult. Education was developed for the staff and presented at staff meetings. This was followed by a competency check off ( NK1-13 ) performed by nursery staff or LouAnn Cox, Assistant Clinical Manager. All new staff members are required to complete this as part of their orientation, and it is now part of the annual skills review. ( NK1-14 ) ( NK1-15 )
Developing a Pre-Op Hysterectomy Class:
The nursing staff on 5 North was frustrated because they felt pain relief for the post op hysterectomy patients was inadequate. The patients' expectations were to have no pain. The patients were slow to resume daily activities and did not want to switch to oral pain medication, all resulting in increased lengths of stay. After discussing the problems at staff meetings and through the Unit Practice Council, they realized these patients were receiving very little information preoperatively about their surgeries. The physicians only provided a few technical details about the actual surgery and instructions about being NPO preoperatively. The pre op clinic focused mainly on completing the admission paperwork and arrival instructions.
Penny Bernard, BSN, RNC, Charge Nurse chose to develop a pre op hysterectomy teaching class as her MSN Population Focused Practice Practicum. It also served as a perfect QI project. After performing a literature search, she enlisted the following various clinicians in order to get their opinion on information the patients would need: case managers, VP nursing, several staff nurses, and her mentor for the class, a masters prepared RN with research experience.
Using the structure of a FOCUS PDCA, the group decided to develop a power point presentation for the class along with a written booklet the patients could take home at the end of the class. Ann Kjosa, MBA/MHN, RN, FACHE, VP Nursing worked with Bernard to show her how to develop the presentation. After the members of the committee had revised the written material several times it was reviewed by the physician champion. ( NK1-16 , NK 1-17 )
The presentation is scripted, that is, the slides have the information to discuss so all speakers will give the same information. Three staff nurses have trained with Bernard to present the class: Fern Cunio, Carmen Logger, Carol McKinney. Physicians are excited and are asking for additional classes to be offered each month.
Bernard learned that coordinating with so many people to develop "just the right" product is very time consuming, and communication to and among the group is critical. The first two classes have been completed with 10 pre op patients. The evaluations and verbal comments were very positive. There was much participant discussion during and after the class with questions and mutual sharing of concerns. ( NK1-18 , NK1-19 )
New research is omnipresent in all of our nursing units. It is provided through several key elements of our staff (CNO, Nurse Scientist, Medical Librarian, etc.) as well as through the efforts of our managers, charge nurses, and direct care nurses. This research is accessed for a number of reasons ranging from an individual advancing their education to a systematic improvement in a unit's procedures. Nurses at all levels evaluate and use published research finding in their practice.
New Knowledge, Innovations, and Improvements - NK02
NK 2 Consistent membership and involvement by at least one (1) nurse in the governing body responsible for the protection of human subjects in research, and that a nurse votes on nursing-related protocols.
Institutional Review Board - Membership, Voting Structure, and Process:
The administration of PSFHS oversees our Institutional Review Board (IRB). This board is responsible for the protection of human subjects in research. It approves research requests and it provides oversight to ensure that approved methodologies are being followed. Membership and participation is specified in our IRB Standard Operating Procedures, which were originally established by the Hospital and its Governing Board. At any given time at PSFHS, we have at least one nurse who actively participates on our IRB and they all vote on nursing related protocols. Currently, we have one nurse with regular voting rights and one who is the IRB alternate member. ( NK2-1 )
The IRB is designed to provide a fair voice for all members of our community. The policy reinforces this design by stating:
"The IRB shall have members with varying backgrounds to promote complete and adequate review of research commonly conducted at or affiliated with Penrose-St. Francis. The IRB shall be sufficiently qualified through the experience and expertise of its members, and the diversity of the members' backgrounds including consideration of the racial and cultural backgrounds of members and sensitivity to such issues as community attitudes, to promote respect for its advice and counsel in safeguarding the rights and welfare of human subjects" Page 1, IRB Policies. In addition, the voting process is defined. ( NK2-2 See Highligted Portions of Attachment)
The nursing seat on the IRB is filled by the Chief Nursing Officer. The CNO appoints nursing members to the IRB who have an interest in research, and are qualified by their educational background with a minimum of master's level preparation. The following is a list of our recent IRB participants who are nurses (this also demonstrates consistent nurse membership):
- Susan Baker, PhD, RN represented nursing as a voting member of the IRB from 2009-2010.
- Judy DeGroot, MSN, AOCN, Lead Nurse Navigator was the 2011 nursing representative on the IRB.
- Peggy Plylar, MS, RN, CRRN, CNS, Joint and Spine Coordinator, is the member for 2012- 2013.
- Helen Graham, PhD, RN, Manager Cardiac Rehab and Diagnostics, is the current alternate voting member of the IRB.
- Nurses on the IRB vote on all nursing research studies. ( NK2-3 )
Nurse Responsibility for Protection of Human Subjects in Research:
The Nursing Leadership Council and the Evidence Based Practice/Research Nursing Council approve all nursing research projects prior to submission to the IRB. The IRB nursing representative is also a member of the Nursing EBP/Research Council and communicates between these two bodies regarding nursing research. This peer review process promotes robust nursing research proposals aligned with organizational priorities and ensures the protection of human subjects. Final approval for all nursing research requires the signature from the Chief Nursing Officer and the Chair of the Nursing EBP/Research Council. ( NK2-4 Peer Review, NK2-5 Letter of support)
The attached flowchart provides a visual view of the research process and is in alignment with the nursing research policy. ( NK2-6 )
The Primary Investigator is responsible the protection of human subjects in research. Proof of completion of the National Institutes of Health training on Good Clinical Practices is required for submission to the IRB. ( NK2-7 , NK2-8 , NK2-9 )
PSFHS nurses have a long history of consistent and active membership in the IRB, our governing body for the protection of human subjects. They advance the cause of the profession through their commitment to the development of scientific understanding through the evaluation of sound methods and wise experiments.
- Susan Baker, PhD, RN represented nursing as a voting member of the IRB from 2009-2010.
- Judy DeGroot, MSN, AOCN, Lead Nurse Navigator was the 2011 nursing representative on the IRB.
- Peggy Plylar, MS, RN, CRRN, CNS, Joint and Spine Coordinator, is the member for 2012- 2013.
- Helen Graham, PhD, RN, Manager Cardiac Rehab and Diagnostics, is the current alternate voting member of the IRB.
- Nurses on the IRB vote on all nursing research studies. ( NK2-3 )
New Knowledge, Innovations, and Improvements - NK03
NK3 That direct-care nurses support the human rights of participants in research protocols.
The history of 20th century medicine is littered with abuses of human research subjects. As a faith based organization whose focus is on the sanctity of human life, we take great care to ensure that such abuses do not occur here. The ANA Code of Ethics for Nurses provides the structure that directs our nurses to support the human rights of participants in research protocols. The text states that, "the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." (ANA Code of Ethics for Nurses, 2001)
We are regulated at the Federal level by the Department of Health and Human Services Policy for Protection of Human Research Subjects as well as the Food and Drug Administration (FDA). The PSFHS Institutional Review Board (IRB) serves an important role in the protection of the rights of human research subjects through project review, approval, and continued monitoring processes. The IRB Standard Operating Procedures describe in detail the FDA required steps for assuring protection of human subjects. This seventy eight page document is available onsite.
Nursing Guidelines Policy R-01-g "Nursing Research Studies," provides guidance and specific direction for review and approval of nursing research studies. The directives in this policy state that, "Research studies conducted by Penrose St. Francis nursing associates and/or students is conducted in a safe, efficient, and prescribed manner that protects the safety of the participant and is consistent with all federal, state, and local regulations."
PSFHS Nursing's Professional Practice Model (PPM) depicts the patient in the center encircled by our values, vision, and our nursing standards of practice. Practicing with a relationship based care philosophy strengthens our nursing practice as we advocate for our patients, provide information, and support their decision making.
The EBP/Research Nursing Council structure advocates for the protection of human rights through the organization and process for peer review. This council is made up of a Nurse Scientist, advanced practice nurses, direct care nurses and a senior nurse leader. Two Ph.D prepared RN's with emphasis in nursing research are members of the Nursing EBP/Research Council; they are available for consultation to all nursing associates. In addition to the CNO, this council approves all nursing research prior to submission to the IRB. Following this approval, researchers are referred to the IRB for final review and approval. ( NK3-1 )
PSFHS nurses conduct nursing research, review research projects, enroll participants, and assist with data collection. While all nurses are required to support the human rights of participants, their role dictates the type of training and supervision required during their participation in the development and accomplishment of research. Projects are officially approved by the Institutional Review Board.
Institutional Review Board (IRB):
IRB Standard Operating Procedures, available on IRBNet.org, include all of the FDA guidelines for safely performing research involving human subjects as well as membership requirements. All researchers in the PSF system must submit their research via IRBNet.org; as a result, they all have access to these guidelines.
All research conducted within Penrose St. Francis Health Services must receive final approval from the Institutional Review Board. Interdisciplinary Policy, I-07-f - IRB, Institutional Review Board Policy, states:
"The IRB is formally designated to review and monitor biomedical research involving human subjects. In accordance with federal laws and regulations, an IRB has the authority to approve, require modifications in (to secure approval), or disapprove research. This group review serves an important role in the protection of the rights and welfare of human research subjects . The board operates on the three basic Belmont Principles of: 1) Respect for Persons which involves the voluntary consent to participate in research, the informed consent to participate in research, the protection of privacy and confidentiality, and the right to withdraw from research participation without penalty; 2) Beneficence, which is the obligation to secure the well-being of the research subject; and 3) Justice, that the potential risks of research should be born equally by the members of our society that are likely to benefit from it.The research cannot systematically select specific classes or types of individuals simply because of their ease of availability or their compromised position. Informed consent will be sought from each prospective subject or the subject's legally authorized representative, in accordance with, and to the extent required by §46.116 or for all subjects entering a clinical investigation that commences on or after July 27, 1981. Informed consent will be appropriately documented, in accordance with, and to the extent required by §46.117." HIPAA - refer to HIPAA Interdisciplinary Practice "Use of disclosure of Protected Health Information (PHI) for Research No. 21." [Emphasis added]
This internal guidance clearly demonstrates our organization's desire to protect the human rights of participants. We are committed to ensuring that the dignity of life is preserved in any and all patient interactions with medical staff at PSFHS. Furthermore, direct-care nurses (along with all medical personnel) who participate in research projects which include human subjects are held accountable for the strict adherence to the above policies.
University Access for Nursing Research:
Nursing students and faculty from the University of Colorado, Colorado Springs' (UCCS) Beth-El College of Nursing and Health Sciences perform research at PSFHS. Faculty and students must obtain project approval from the UCCS IRB before applying for approval to conduct research within PSFHS. Deborah Kenny, PhD, RN, FAAN, Associate Professor, and Associate Dean for Research at UCCS, is a member of the University IRB and sits on PSFHS' Nursing EBP/Research Council. The Nursing EBP/Research Council and PSFHS Nurse Scientist collaborate with Kenny, who also happens to be the chair of the UCCS IRB, to ensure that researchers meet the requirements of both IRB Committees. Other universities including online schools must follow the same requirements to perform research at our hospital. ( NK3-2 )
Penrose Cancer Center:
The Penrose Cancer Hospital is known nationally for its cancer care and research contributions. Clinical research nursing staff completes the Protection of Human Subject's training during orientation and again every two years. They are also required to attend training at the Colorado Cancer Research Program - which is done twice a year and all staff attend. This training is centered on consent processes, serious adverse event reporting, protocol overview, and patient recruitment. At least two of the three research nurses attend a Research Cooperative group meeting annually. At these meetings, the discussion is the consent, the protocol, adverse events, reporting requirements, and monitoring patients during the study.
While the research nurse is responsible for the Serious Adverse Event reporting, they also work closely with the physician to determine the appropriate grading of the event(s). This demonstrates concern for the rights and safety of the subjects while on a clinical trial. ( NK3-3 )
Nursing adherence to Patients Rights is required by law, policy, and nursing practice standards. Our Policy on Patient Rights states that patients have the right to:
"Consent to or refuse to participate in teaching programs, research, experimental programs, and/or clinical trials. The facility will protect patients and respect their rights during research, investigation, and clinical trials involving human subjects by:
a. Giving information to facilitate patients'' ability to make a fully informed decision
b. Describing expected benefits
c. Describing alternatives that might also help them
d. Explaining procedures to be followed
e. Explaining that they may refuse to participate, and that their refusal will not compromise their access to the facility's services." ( OO27-4 )
The above is further evidence of our commitment to the preservation of patient/human rights within the healthcare setting. We support the right of patients to either participate or to refuse participation in research protocols. Patients are provided with all the relevant information so that they can make their decision based upon informed consent. We believe that this standard is absolutely critical in protecting human rights.
Orientation and education to support the human rights of research participants begins at Hospital Orientation, where it is clearly articulated that our mission, vision, values and focus on relationship based care. The Patients Rights are reviewed in detail during orientation and monitored through our nurses in the Patient Representative Department. All nurses are oriented to the 24/7 availability of an Ethics Consultant and referred to the Nursing Code of Ethics for Nursing.
Recognizing that all nurses involved in research are responsible for the protection of human subjects, education on related topics is presented via the nursing newsletter, TLC to broaden awareness. ( NK3-4 -TLC)
Specific nurse roles require different levels of orientation and education. The following is a breakdown of certain examples:
• Clinical Research Nurses complete orientation upon hire and training on Protection of Human Subjects every two years. They are required to attend training at the Colorado Cancer Research Program twice a year. This training is centered on the consent process, serious adverse event reporting, protocol overview and patient recruitment. Two of the three research nurses attend a cooperative group meeting annually where the discussion is on consents, protocols, adverse events, reporting requirements and monitoring patients while on a study. ( NK3-5 )
• Primary Investigators are required to complete the National Institutes of Health (NIH) Office of Extramural Research NIH Web-based training course, "Protecting Human Research Participants." Debra Nussdorfer RN, Primary Investigator for the Green Zone submitted the training certificate with the Research Proposal in 2011. ( NK3-6 )
• The Chair of the Nursing EBP/Research Council informs council members of related issues either in the meetings or through emails. ( NK 3-7 )
• During the ASCENT program, historical examples of violations of human rights of subjects (Tuskagee incident, NAZI medical practices, Willowbrook State Schools, MKULTRA) provided the background for education on the need for an informed consent process in research. ( NK3-8 )
Clinical Trials conducted at and through PSFHS Cancer Center supports the human rights of participants in research protocols through the informed consent process. Each study has an IRB approved consent process with documentation.
The Nurse Navigators are aware of clinical trials at Penrose, and they are always on alert for a potential trial candidate. The navigators discuss the potential options with patients in general terms (trial title and scheme) and they coordinate clinical trial nurse involvement when appropriate. If one of their patients is on a trial, the clinical trial nurse and navigators coordinate/share the patient calendar to insure that tests are scheduled appropriately and adverse events/side effects are documented and discussed with the trial nurse.
Once patients are referred for consideration for a clinical trial, the Cancer Hospital Research Nurses explain the study and the consent process and review the patient's medical record to determine eligibility. Once a patient is registered and/or randomized, these nurses implement the trial protocol including ordering medications and coordinating treatment as appropriate.
For patients in clinical trial studies, the Cancer Research Nurses' role is to ensure that the patients are treated according to the protocol specifications, which includes the protection of human rights. These nurses collaborate with other healthcare providers to consistently obtain informed consent and adhere to protocol specifications. They do not administer any of the treatments themselves, but complete nursing assessments, evaluate responses to treatment, and support symptom management in alignment with the approved research proposal. Christine Smith, BSN, RN, OCN, Clinical Research Nurse shares the following exemplar of protecting patients rights as a research subject:
"I am the clinical research coordinator for a patient I will call Bob. In 2012 he was referred to Clinical Trials. Following the research protocol, we assessed for eligibility and consented him. Another nurse provided chemotherapy education and we began to coordinate his treatment. The physician completed assessments, imaging completed tests, pharmacy was informed of his chemotherapy regimen and the Infusion Center was notified of his clinical trial medication regimen on each treatment day. I meet with the patient, family and physician to monitor his treatment, responses and side effects. I attend all his physician appointments which provide excellent opportunities to coordinate and evaluate his care." ( NK3-9 )
Nurse and Patient Participation in Research Studies:
In the study entitled, "Dissemination and Implementation of Evidence-Based Methods to Measure and Improve Pain Outcomes," study nurses asked patients directly about their experiences. On the selected day, trained nurses identified patients experiencing pain in multiple hospital units. Patients were asked to verbally consent to participate by answering several brief questions. These questions were structured to gauge pain experience and to collect demographic and clinical data (age in years, gender, race/ethnicity, insurance, reason for hospitalization [categorized], type of pain [categorized], and use of pain medicine). Prior to interviewing the patients, nurses completed the National Institutes of Health (NIH) Office of Extramural Research Web-based training course, "Protecting Human Research Participants" as well as Pain Study Training. ( NK3-10 )
Charge Forward: Building Nursing Unit Leaders a PSFHS nursing research study with nursing managers required formalized support of human rights. The following statements were included in the research proposal:
Human Rights Completion of the survey assumes consent. Names or units will not be included in the surveys. The responses will be kept in a locked office and password protected spreadsheet. Consent is assumed with the completion and return of the questionnaire. There will be no perceived risk to the safety of subjects.
Charge Forward was completed in September 2010 and involved 17 nurse manager participants.
Deb Avery, BSA, RN is the Primary Investigator (PI) for the study, "Do Medically Supervised Exercise Programs Decrease Hospital Readmissions and Increase Quality of Life for Subjects Recently Hospitalized and Diagnosed with Congestive Heart Failure?" As the PI, she discusses the study with each potential candidate and answers any questions they have. When they indicate understanding and agree to participate, she presents the Informed Consent for them to read. The consent must be signed before they participate in the program. If they elect not to be part of the study, t hey may still attend the gym programs but there will be no data collected for the study. ( NK3-11 )
Nurses in the Infusion Center and on PH 11 Oncology regularly treat patients who may be participating in Clinical Trials. Clinical Research Nurses coordinate care related to Clinical Trial protocol, including ensuring diagnostic and monitoring tests are completed as well as to confirm that documentation meets Clinical Trial requirements. In addition, reporting of adverse events and side effects requires collaboration between the Research, Oncology and Infusion Nurses. Jill Dodge, RN, Clinical Manager Infusion Center states that her staff is aware when patients are part of clinical drug trials:
"We do give chemo to patients that are on clinical trials. They make up a small part of our chemo population. We are always informed when patients are on a study, since often times the drugs are supplied by the study. We also often have to draw special lab work. They do have signed consents that are faxed to us by the MD office with the pt's orders. If the patient is on study and has adverse reaction to the chemo, then the MD and the research nurse that are notified. The Cancer Center Research Nurse sends physician orders for each infusion treatment session" (NK3-12 )
PSFHS is committed to the humane treatment of healthcare subjects and our nurses support their human rights. Our structures and processes are designed to ensure only research projects proceed that are ethically sound, meet Good Clinical Practice Guidelines and are approved by the Nursing EBP/Research Council and PSFHS IRB. In the implementation and development of these projects, our regulations guarantee that patients give informed consent to research and direct-care nurses. Ongoing education promotes awareness of the requirement to protect human subjects in research protocols.
New Knowledge, Innovations, and Improvements - NK04
NK 4 Describe and demonstrate the structure (s) and process (es) used by the organization to develop, expand, and/or advance nursing research.
Nursing research is essential to achieving our nursing vision of becoming “the recognized leader in relationship based care dedicated to excellence in nursing practice balanced with concern for the well being of our caregivers.” In addition, the ANA Nursing Administration: Scope and Standards of Practice (2009) holds us accountable for creating a supportive environment with sufficient resources for nursing research, scholarly inquiry, and the generation of knowledge. Guided by one of our selected nursing theorists, Florence Nightingale, we strive to model her practice of systematic study, research, and the use of statistics. We have identified several structures and processes within PSFHS that develop, expand and/or advance nursing research.
Structures to Develop, Expand, and/or Advance Nursing Research:
Professional Practice Model (PPM) Embraces Research and New Knowledge Our nursing vision directs PSFHS nursing to utilize the best available evidence to guide practice decisions. Two featured elements of our PPM (Standards of Professional Practice and Quality of Care) require nursing to identify clinical problems related to nursing practice and to incorporate research findings.
Shared Decision Making — Nursing Evidence Based Practice/Research Council The Nursing Evidence Based Practice/Research Council includes nurses from many settings and levels. Co-Chaired by a direct care nurse and a nurse practitioner/educator, the council’s functions include:
- Encouraging and supporting the implementation of evidence based practices
- Analyzing research for scientific merit and applicability to practice
- Building the professional image and accountability of nursing
- Adding to nursing knowledge through classes, research, and publishing information
- Determining the quality and feasibility of nursing research proposals before IRB presentations
- Enhancing collaboration and professionalism
- Providing direction throughout the nursing research process
- Encouraging and assisting in the preparation of material for publication
- Communicating with Centura and CHI EBP Councils
Shared Decision Making — Professional Development Council The Nursing Professional Development Council promotes nursing participation in research, special projects, and quality improvement activities through the Clinical Advancement Program (CAP). The decision to include all three areas is one strategy to recognize levels of nursing expertise and to demonstrate PSFHS’ commitment to systematic processes that improve quality of care. Building competencies in systematic processes and literature reviews is necessary for implementing quality improvement and special projects. In addition, these strategies expand the skills necessary for nursing research within PSFHS. The analysis of the first two years of CAP identified frequent participation in special projects (EBP) and quality improvement. Gina Wamble, BSN, RN-BC, participated in data collection for a research study and submitted her portfolio for CAP awards. (NK4-1)
Nurse Scientist Position In 2012, PSFHS designed a new position for nursing, Nurse Scientist, which Rochelle Salmore, MSN, RN fills part-time. As she made the transition to this role, from her previous position of Wound Clinic Manager, she had five research studies either in process or on the path to the IRB. As a mentor and coach, she assists nurses with individual projects of special interest or school research related projects. Because of the 1:1 attention, these nurses are greatly appreciative as demonstrated by the following: “Thank you so much for your help. This online class is driving me nuts and the professor is not much help at all. I do appreciate you being here!” Kelly Ledbetter, RN 11/29/12. “You have really made this much clearer and helped me focus.” Louise Wilson, RN 12/13/12.
The position description for the Nurse Scientist includes:
- Fostering the development of a practice environment conducive to the conduct of research and evidence based practices.
- Supports the institution’s efforts to improve quality care, linking research to improved patient outcomes.
- Facilitates changes in practice based on research and quality improvement findings
- Promotes, supports, and facilitates individuals engaging in research activities to advance research in practice: evidence based practice, the conduct of research, research utilization, and dissemination of research results.
- Provides a broad range of consultation including but not limited to the following:
- Research questions
- Project development
- Abstract presentations
- Poster presentations
- Podium presentations
Processes to Develop, Expand, and/or Advance Nursing Research:
Nursing EBP/Research Council Comprised initially of a few interested nurses, increased employment of clinical nurse specialists, and a growing interest from direct care nurses has expanded the council to represent and lead from multiple levels and settings. Deborah Kenny PhD, RN, FAAN, Associate Dean for Research, Beth-El College of Nursing is a member of the EBP/Research Council and is available for questions regarding research. Her expertise and passion for nursing research encourages our own professional and organizational growth. Debora S. Richardson DNP, RN, AOCNS is a newly hired CNS whose past experience in research will enrich the Council and provide additional resources for education and mentoring members.
Council members provide support, encouragement, coaching, and peer review to nurses planning presentations, considering research, developing poster or podium presentations and writing abstracts. Peer Review of posters and proposals utilizes experts to assist novice researchers/presenters to learn a professional way to prepare an abstract or presentation. This process also assures the final product is accurate and professional. (NK4-4)
Education/Awareness Processes to develop and expand our nursing research program include educational and awareness tactics.
Recognizing the need for education for council members and other professional nurses, Kenny designed and presented experiential education on implementation of EBP and Nursing Research. Three workshops held in 2011 provided education and hands on learning as participants began literature searches and reviews, formulated research questions and drafted research proposals. (NK4-5)
The table below identifies the topics and current status of research questions that were developed during Kenny’s classes:
Status – One year later
Chronic Back Pain Management
Pilot project active. Proposal to IRB drafted.
GI Lab Patient Recovery Process
Extensive literature search, but due to PSFHS interpretation of anesthesia guidelines, must maintain current practice.
Post Partum Depression
Unit Practice Council on Mom Baby unit initiated post partum screening and education. (EBP)
In addition to the educational opportunities offered by external experts, we have offered internal education on nursing research through displays, nursing newsletter, contests and classes.
Fall Education Booths, 2010
Hall of Evidence, Nurses Week 2010-2012 (NK4-6)
2011 Nurses Week (NK4-7)
Skin Education and Research in 2012
Sacred Cow Contest (NK4-8)
Participation in conferences promotes interest in research and evidence-based practice as well as by providing educational and networking opportunities. Nurses have attended regional and national conferences as participants and as presenters. The 5thAnnual Centura EBP, Research, and Innovation Conference was held November 9, 2012 at the University of Denver. Co-sponsored by PSFHS, one hundred fifty associates representing Centura Health facilities, local hospitals and academic partners from Regis University and University of Colorado attended. Centura Heath associates Debra Nussdorfer, MSN, CNS, NE-BC, (PSFHS) and Kathleen Bradley, DNP, RN, NEA-BC presented “EBP-Getting Started” while two Centura Health Nurse Scientists presented “EBP-Advanced.” Our goal was to advance research by providing education at varying levels to meet participant’s needs. Eleven concurrent sessions with 23 podiums along with 16 posters were presented during the daylong conference. 6.4 contact hours were offered to those who attended. Other PSFHS presenters included: Elly Peters, MSN, RN, OCN; Judy Day BSN, RN; Katrina Roy, BSN, RN; Daniele Lakin RN, CCRN and Dawn Ingram BSN, RN. In addition six nurses from different settings and levels attended the conference. (NK4-9)
The PSF Nursing Annual Report recognizes nurses who participate in nursing research, again, promoting awareness and interest in research. (NK4-10)
Resources The Penrose St Francis Nursing Intranet provides tools and references for staff nurses to explore evidence based practice and research. In addition, the Webb Library and medical librarian are excellent resources for developing and expanding nursing research. (NK4-11)
To promote nursing research and EBP, Salmore asked her manager to request budgetary support for nursing research be officially placed in next year’s budget. (NK4-12)
During nursing orientation all nursing associates are given instructions on how to access the library and access full text journal articles online. After the medical librarian retired in June, 2011 we were without a librarian for 7 months. As Nurse Scientist, Salmore was invited to participate in the interviews of the new applicants. This involved screening the original resumes, phone interviews of 3 finalists and in person interview with the final choice. Other nurses were invited to the final interview. (NK4-13)
Policies and Procedures Prior to the EBP/Research Council formation, nurses from PSFHS and local universities contacted the IRB directly. The IRB nurse member informed the EBP/Research Council of studies approved that involved nursing. Following the submission of a poorly designed study in 2009 from an outside nursing student researcher, the IRB asked that all nursing studies first be peer reviewed by the EBP/Research Council. Subsequently, a nursing research policy was developed along with a peer review checklist. After approval by the EBP Council reviewers, a recommendation is sent to the Nursing Leadership Council including CNO who gives final approval.
Access to Experts Access to internal and external experts through formal and informal consultation supports the growing nursing research program at PSFHS. A new position, the Director of Nursing Research, was recently added at Catholic Health Iniatives (CHI). This role is to design and implement nursing research projects across CHI. A recent meeting with PSFHS nurses, the UCCS Associate Dean of Research, and the CHI Director of Nursing Research identified new opportunities to coordinate research projects and share knowledge with CHI Nurse Researchers across the United States. Ideas for expanding research relationships with universities were explored. The synergies of these experts provided other strategies for advancing nursing research at PSFHS. (NK4-14)
Centura Health Nurse Scientists/Researchers Experts and mentors are accessible through Centura Health with three RN’s with earned PhDs in Nurse Scientist positions. In addition, nurses within Centura Health have performed research within our setting providing a model and positive experience for our PSFHS nurses. Jane Braaten, PhD, RN presented her study, Cognitive Work Analysis to Uncover Constraints in Rapid Response Team Activation, to the Nurse Practice Council and asked for nurses to participate (NK4-15). The Nursing Councils and the Code Blue/RRT Committee will receive a presentation of the findings.
Clinical Nurse Specialists and Infection Preventionists Joan Strauch, RN, ICP provided expertise in the design and implementation of the Green Zone Research Study. Strauch contacted CDC to consult with their experts and verify that what we were proposing was with infection control requirements.
Peggy Plylar, MS, RN,CNS, CRRN, Joint and Spine Coordinator began as Primary Investigator for a Research Study: Pre-Operative Interventions for Patients with Chronic Pain Having Lumbar Spine Surgery. The research team included Kim Booton, RN, Program Coordinator, PSF Spine Center of Excellence, Kathy Guy, MSN, RN, NE-BC, Director Professional Practice, Alison Goldberg, RN, Orthopedic Staff Nurse, Jane-Allin Cloutte, BSN, RN, and Salmore. The study eventually became too complex and was broken down into smaller valuable QI projects which are currently in progress. This process provided significant professional development as nurse differentiated research, EBP implementation and QI as well as learning the process to write a research proposal. (NK4-16)
Participate in State and National Research Committed to advancing nursing research, PSFHS has accepted several opportunities to participate in nursing research at the state and national level. In 2010 and 2011, PSFHS nurses participated in national/state research including the Hill Rom International Pressure Ulcer study, National Pain Indicator Development, and Shared Decision Making.
In 2013 PSFHS will participate in a NINR R-01 multi-site study that will look at Latino patients with life threatening illness (e.g., end stage liver, kidney, heart failure, COPD, etc.). It is a randomized control trial, approved by COMIRB, to improve quality of life for Latinos with advanced disease. The goal of this research is to improve pain and symptom management, quality of life, advance directive decision making, improve hospice and community resource access, and less aggressive care at the end of life.
Advancing Research through Leadership in Evidence Based Practice Implementation:
Advancing nursing research may start with nurses assuming leadership roles in implementing evidence based practices. Two nurses are currently beginning major projects:
Bladder Training – Louise Wilson, BSN, RN, PH8 Rehab, is a strong believer in bladder training, having seen major successes in her previous position at a rehab facility. Working with the Nurse Scientist, a plan was developed where she would recruit two newer nurses who have expressed interest in bladder training. They will be her program assistants who will work with one or two patients over the course of their stay to complete the training. Wilson will also prepare a story board listing the evidence for performing bladder training and the methods to employ. Adhering to better elimination plans has the added benefit to help reduce falls. Getting patients to the bathroom on a schedule may prevent the “urgent” need to jump out of bed, losing balance or becoming lightheaded and falling. (NK4-17, NK4-18)
Nutritional Supplements – Lenora Kraft, BSN, RN knew trauma surgeons inconsistently ordered nutritional supplements. Kraft originally wanted to begin a research project about this, but in working with the Nurse Scientist, she realized that there is sufficient evidence. She developed a plan to improve the practice on PH9. Lenora is currently gathering chart data to compare outcomes of trauma patients who did and did not receive supplements. Once the data is complete, she will prepare a story board for the staff. Because nurses can request nutritional supplements without a physician order, staff needs to become aware of the need for early nutrition and act on their knowledge. (NK4-19)
Advancing Nursing Research through Replication Studies Rochelle Salmore, RN completed original research which was published in 2002. This article, “Development of a new pain scale: Colorado behavioral numerical pain scale for sedated adult patients undergoing gastrointestinal procedures” was published in Gastroenterology Nursing, 257-262. Since publication, she has received requests for use of the pain scale. Recently she received requests from researchers in California and Chile to replicate her study. A software development company, requested permission to use the scale in their endoscopy software (NK4-20) Approving the requests to replicate her study is one way to support the advancement of nursing research.
Penrose Cancer Center (PCC) Nurses at Penrose-St. Francis Health Services have been active participants in nursing research for many years. Our Cancer Center participates extensively in Clinical Trial chemotherapy research, and currently three nurses are employed as Research Nurses. The Research Nurse serves as the liaison between the physician investigator, the research base, and the patient or participant. The Research Nurse provides clinical and data management support to identify, enroll and manage patients on national research studies involving prevention, cancer control, and treatment of cancer in conjunction with the Colorado Cancer Research Program. (NK4-21) In addition, nine Nurse Navigators work with patients participating in clinical trials and other cancer center research studies.
The PCC has been involved in cancer prevention, cancer control, and treatment clinical trials for more than 30 years. There are currently over 70 studies available for various malignancies. Local patients gain access to the latest treatments being tested, while researchers can quickly expand their pool of patients – with a goal of developing more effective prevention and treatment strategies. Since 1992, the PCC has been part of the Colorado Cancer Research Program (CCRP). The CCRP is designated as a Community Clinical Oncology Program by the National Cancer Institute (NCI). In addition to the affiliation with the CCRP, the PCC joined the Radiation Therapy Oncology Group (RTOG) in 2007. The PCC is also working with Accuracy on CyberKnife studies and have been affiliated with the CHI Institute for Research and Innovation (CIRI) and the CIRI Oncology Research Alliance for clinical trials since 2008.
The Penrose Cancer Center was selected as one of 16 facilities in the country to participate in the National Cancer Institute’s Community Cancer Centers Program (NCCCP). The NCCCP is a three-year pilot program that is testing how a national network of community cancer centers can both expand cancer research and deliver the latest, most advanced cancer care to many more people, right in their hometowns. In January, 2012, NCCCP began a joint project with the American Cancer Society Patient Report Outcomes, now referred to as the Patient Reported Outcomes Symptom & Side Effects Study.
The C-STEPS Research Program is coordinated by Elly Peters, MS, RN, OCN, Survivorship Nurse Navigator. Penrose Cancer Center is partnering with the University of Colorado’s Cancer Center to participate in a study called C-STEPS. C-STEPS stands for “Cancer Survivorship Telephone Education and Personal Support Program.” This is a research study that involves telephone education and personal support. The study will consist of up to six confidential telephone counseling sessions. The goals of the program are:
1. To help cancer survivors maximize their health
2. Focus on ways to cope with life challenges after treatment while maintaining a healthy lifestyle
3. To develop a cancer survivor telephone counseling program based on prior research and disseminate it within community based cancer center
Participants learn ways to manage stress, improve diet, get physically active, and work with their physician to create a medical follow-up plan that is just right for them. Recruitment started in September 2011 with a goal of recruiting 80 participants from Penrose Cancer Center. As of February 2013, thirty seven participants have been recruited and 16 have completed the project. (NK4-22)
PH 7 Surgical (Orthopedic) Nurse Participation in Research Nurses participate in research on the orthopedic unit by collecting post operative data for the “Clinical Evaluation of the OrthoPAT® and Tranexamic Acid in Reducing the Transfusion and Utilization Rates Associated with Anterior Approach Total Hip Arthroplasty.” The objective of this study is to demonstrate that the use of the OrthoPAT® or tranexamic acid and significantly reduces the rate of autologous or allogeneic red blood cell transfusions in patients receiving an anterior approach Total Hip Arthroplasty. While there is some risk for autologous transfusion, the OrthoPAT is also labor intensive for the nursing staff to assemble and operate in order to re-transfuse the patient’s own blood. If tranexamic acid can reduce the need for transfusions, nursing time can be saved. Nursing staff is collecting the post operative data that includes vital signs, and post operative transfusion volumes, whether autologous or allogenic. (NK4-23)
Values Analysis Nurse A recent addition to the EBP Council, the Values Analysis Nurse, is excited to be part of the Council. She states that “I use evidence based information every day when I research new products.” Value analysis uses evidence-based clinical research data to help ensure that products and technologies achieve measurable improvements to our patient outcomes. Value analysis provides the data to guide strategic investments and support both stewardship and offering our providers and communities the most effective tools and technology. Her research brings a different perspective to the Council where we all learn from each other. She instructed the Council on the use of Hayes Research, the company that conducts research for product evaluation for clinical outcomes. (NK 4-24)
The structures and processes at PSFHS to develop, expand and advance nursing research continue to mature. We are confident that the recent addition of a nurse scientist will result in additional research studies initiated and investigated by primary care nurses. Clinical Nurse Specialists and nurses in formal education programs have been the primary investigators with the role of direct care nurses expanding from data collection to developing questions and proposals. Primary Investigators have been slowly expanding from Helen Graham, PhD, RN, Rochelle Salmore, MSN, RN, NE-BC, Deb Nussdorfer, CNS, RN, NE-BC, Debbie Avery, BSA, RN, CEN, Peggy Plylar, MS, RN, CRRN, CNS, Colleen Eismann, BSN, RN, staff nurse, ICU, Janet Laird, BSN, CCRN, staff nurse, PACU, Diana Patterson, BNS, MA, RN, Education Resources, and Lori Dagostino, BSN, RN, OCN, Navigator, Cancer Hospital.
The Sacred Cow Contest in 2012 was received with interest and excitement as nurses read the results stated “I have a question too. When is the next contest?” Our Cancer Hospital Research Nurses have experience in the research process and maintain current NIH training. As they join the EBP/Research Council we know their expertise with research will be an added resource for other nurses.
New Knowledge, Innovations, and Improvements - NK04EO
NK 4 EO Nursing research studies from the past 2 years, ongoing or completed, generated from the structure (s) and process (es) in NK4. Provide a table including: Study title, study status, Principal investigator name (s), Principal investigator credentials, role (s) of nurses in the study, Study scope (internal to a single organization, multiple organizations with a system, independent organizations collaboratively), Study type (replication--yes or no; qualitative, quantitative, or both. Select one (1) completed research study and respond to the four (4) criteria listed in the EO guidelines provided in this chapter.
Table Including: Study title, Study Status, Investigators, Nurses' roles, Scope, and Type: NK4EO-1
Title - Making a Difference with the Green Box (to improve contact with patients in isolation):
( NK4EO-2 )
Principal Investigator (PI) Debra Nussdorfer MSN, PMHCNS-BC, NE-BC, Magnet Coordinator
Penrose St. Francis Health Services, Nursing Administration
In collaboration with PSFHS Infection Control, PH 4 Medical, Respiratory Therapy, and Environmental Services
Study Dates: November 2011 - November 2012
Purpose and Background:
The Centers for Disease Control and Prevention recommend the use of Standard and Contact Precautions for multidrug-resistant organisms (MDRO) to reduce transmission of these organisms. Patients infected or colonized with these organisms are placed in contact isolation. Contact precautions require all persons coming in contact with the patient to gown and glove prior to entering the patient room. The process of gowning and gloving takes time, adds a barrier between staff and patients and adds costs to healthcare. Studies have assessed the unintended impact of isolation on patient mental health, physician's ability to perform examinations, patient satisfaction, patient safety and time spent in direct patient care. One question is what innovative strategies exist to limit transmission of organism and reduce patient isolation?
The PI is a Psychiatric Clinical Nurse Specialist and has an interest in promoting holistic care including focus on mental health issues in patients treated in the acute care setting. The Infection Prevention nurses mentioned the following study to the PI. At the 2011 APIC Conference, a study conducted between January 2009 and December 2010 reported:
A 504-bed Midwestern health system saved up to 2,700 hours and $110,000 a year by creating a "Red Box" safe zone, a three-foot square of red duct tape extending from the threshold of the door, to facilitate communication with patients on isolation or "Contact Precautions". Conducted by the infection prevention team at the Trinity Medical Center in the Quad Cities on the Iowa/Illinois border, the study revealed that by utilizing this safe zone, their hospitals were able to save time, money in unused gowns and gloves, and that the quality and frequency of communication between healthcare professionals (HCP) and isolated patients increased. (Franck, Behan, Herath, Mueller & Marhoefer, 2011)
At Penrose Hospital, the physical layout makes it is impossible to see and make direct eye contact with patients from the door, requiring the nurses to enter the room several steps to see and talk directly with the patient. When patients are on contact precautions, prior to entering the room people required to don personal protective equipment (PPE). This process sometimes results in delays or the need to don PPE, see the patient, remove PPE to leave and obtain items and then repeat the process. The quality improvement study discussed at APIC presented an idea for PSFHS to consider for our organization. The PI decided to complete a literature review and explore the potential for a research project.
The PI took the following steps:
1. Completed a literature review (Included in the Research Proposal)
2. Contacted Trinity Medical Center and spoke with nurses who created the "Red Box"
3. Sought expert consultation from the EBP/Research Council
4. Explored idea with Infection Preventionists (IP)
a. IP nurses contacted the Centers for Disease Control and Prevention ( NK4EO-3 )
5. Obtained consultation from Deb Kenny, PhD, RN, UCCS
6. Drafted the research proposal
7. Met with PH 4 Unit Practice Council members and Clinical Manager for approval to do research on the unit
8. Obtained Peer Review from nurse peers on the EBP/Research Council ( NK4EO-4 )
9. Obtained approval from the Infection Control Committee ( NK4EO-5 )
10. Obtain Nursing Letter of Support ( NK4EO-6 )
11. Submitted proposal to the IRB for approval ( NK4EO-7 )
12. Implemented research proposal
PH 4 Medical was selected and agreed to participate in the research study. The unit nursing staff was informed by their clinical manager and the primary investigator of a research study focusing on nursing workflow including contact with patients. The nursing staff was informed that workflow reports/tracker data were not specific to individual staff, but inclusive of all nursing staff on the unit. A seven day period was identified for pre-intervention data collection. Using a tracker, nursing time in minutes spent inside a patient room and frequency of nurse/CNA patient contact was collected on all patients in contact isolation. The same amount and frequency data were collected on an equal number of patients who did not have contact isolation and were in a room next door or across the hall from the patients in isolation. ( NK4EO-8 )
In collaboration with infection prevention and environmental services, the nursing associates implemented an adapted "Green Box" intervention as discussed at APIC 2011. The name "Red Box" was changed to Green Box since the study hospital used the term Red Box for a different process. The adaptation was the size of the marked Green Box and was determined based on room shape and size. The PI and Infection Prevention Nurse marked the areas in each single patient room to define the Green Box. The nursing staff used green frog tape to make the Green Box visible. The size allowed face to face contact between nursing and patient but did not allow touch contact. Nursing staff was educated on the opportunity to enter the Green Box area without PPE with patients in contact isolation. The PI and IP observed for compliance through daily rounds and reminders to the nursing staff during the first two weeks of implementation. ( NK4EO-9 )
A seven day period between 4-6 weeks post intervention was identified for data collection. The data collection process followed the same steps as pre-intervention data collection.
Debra Nussdorfer, MSN, RN, CNS, NE-BC
Rochelle Salmore, MSN, RN, NE-BC
Joan Strauch, RN, CIC
Wendy Lowery, BSN, RN-BC
Aimee Doman, RN-BC
Brenda Molencamp, MSN, RN, NE-BC
Deb Kenny, PhD, RN, UCCS
Nursing Leadership Management Council
Infection Control Committee
Deb Kenny, PhD, RN, FAAN, University of Colorado assisted with data analysis. Using SPSS an analysis of covariance (ANCOVA) was run using pre-test post-test means.
• More contact with non-isolation patients pre intervention than post intervention. Statistically non significant. Given this group did not receive an intervention, the possible reasons for the difference are unclear.
o Pre-intervention 9.74 min/hour
o Post-intervention 5.64 min/hour (However, the non isolation patients did not receive an intervention.)
• There was a 1.07 minute/hour increase in contact time with isolation patients post intervention. However, this difference is not statistically significant.
o Pre-intervention 7.79 min/hour or 187 min/24 hrs
o Post-intervention 8.86 min/hour or 213 min/24 hrs
Final Report ( NK4EO-10 )
Implications and Recommendations:
The increase in nursing direct contact with patients in isolation using the Green Box, while not statistically significant, may provide clinical significance. The data collection occurred primarily during the twelve hour day shift and an additional 12 minutes of direct contact with patients may provide time for additional assessment and intervention that may positively benefit isolation patients' physical, cognitive and emotional health.
Nursing staff feedback was positive with eagerness to continue the intervention. Many patient room set ups do not allow for visualization or direct contact with isolation patients without complete personal protective equipment (PPE). The Green Box allowed for this contact while maintaining infection control. It can also be theorized that cost savings resulting from a decreased use of PPE may exist.
Further studies with larger samples may provide additional data for analysis. In addition, monitoring patient safety quality indicators including falls pre and post Green Zone would provide an opportunity to consider effectiveness of Green Zone on patient safety. Finally satisfaction for patients in isolation pre and post Green Zone may yield additional evaluative data for changes in nursing practice.
The findings from this research will be presented at the20th National EBP Conference, University of Iowa, Iowa City, April 19, 2013. ( NK4EO-11 )
Abad C, Fearday A, Safdar N. (2010). Adverse effects of isolation in hospitalized patients: a systematic review. J Hosp Infect., 76(2):97-102
Afif, W., Huor, P., Brassard, P., & Loo, V.G. (2002). Compliance with methicillin-resistant Staphylococcus aureus precautions in a teaching hospital. Am J Infect Control, 30(7), 430-433.
Barratt, R., Shaban, R., & Moyle, W. (2007) Behind barriers: patient's perceptions of source isolation for Methicillin-resistant Staphylococcus aureus (MRSA). Aust J Adv Nurs, 28( 2), 53-59.
Evans HL, Shaffer MM, Hughes MG, Smith RL, Chong TW. (2003). Contact isolation in surgical patients: a barrier to care? Surgery, 134(2), 180-188.
Franck, J.N., Behan, A.Z., Herath,P.S., Mueller, A.C., & Marhoefer, K.A. The red box strategy: an innovative method to improve isolation precaution compliance and reduce costs. Am J Infect Control, 39(5), E208.
Gammon, J. (1999). The psychological consequences of source isolation: a review of the literature. Journal of Clinical Nursing Practice, 8(1), 13-21.
Khan FA, Khakoo RA, Hobbs GR. (2006). Impact of contact isolation on health care workers at a tertiary care center. Am J Infect Control, 34, 408-413.
Kirkland, K.B., & Weinstein, J.M. (1999). Adverse effects of contact isolation. Lancet 354(9185): 1177-1178.
Morgan,D.J., Diekema, D.J., Sepkowitz, K., & Perencevich, E.N. (2009). Adverse outcomes associated with contact precautions: a review of the literature. Am J Infect Control 37(2), 85-93.
Rees, J., Daies, H.R., Birchall, C and Price, J. (2000). Psychological effects of source isolation nursing (2): Patient satisfaction. Nursing Standard, 14 (29), 32-26.
Saint,S., Higgins, L.A., Nallamothu, B.K., & Chenoweth, C. (2003) Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control, 31(6), 354-356.
Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L. and the Healthare Infection Control Practices Advisory Committee. (2007). Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, June 2007.
Stelfox ,H.T., Bates, D.W.,& Redelmeier, D.A. (2003). Safety of patients isolated for infection control. JAMA 290(14), 1899-1905.
Yin,S. (2011). Duct Tape Cuts Time and Costs Related to Contact Precautions. Retrieved August 25, 2011, from.http://www.medscape.com/viewarticle/745502
New Knowledge, Innovations, and Improvements - NK05
NK5 How the organization disseminates knowledge generated through nursing research to internal and external audiences.
The PSFHS Professional Practice Model includes the expectation that nurses adhere to professional standards of nursing practice. ANA Standards of Professional Performance: Standard VII holds professional nurses accountable to systematically enhance the quality and effectiveness of nursing practice. Dissemination of knowledge generated through nursing research improves our nursing practice and clinical outcomes as well as contributes to the advancement of the profession. PSFHS nurses recognize their professional responsibility to systematically improve nursing practice.
Nursing Evidence Based Practice/Research Council provides leadership, coaching and mentoring to nurses to disseminate knowledge generated through participation in nursing research and implementation of evidence based practices. Peer review is required for abstract submission, posters and research studies. Mentors from the EBP/Research Council are available for staff nurses to assist in developing their presentations or QI, EBP or research studies. The newly added Nurse Scientist and CHI Director of Nursing Research are additional resources to assist with dissemination of research knowledge.
The Nursing Intranet displays the publications, posters and presentations by nursing staff.
Local, Regional and National Conferences Presenting professional posters and podium lectures is one strategy to disseminate knowledge to internal and external audiences. The Chief Nursing Officer encourages conference presentations by using budgeted monies to pay for conference registration and travel for all nurses presenting. Presentations to external audiences are peer reviewed by the Council and approved by the Nursing Leadership Council. ( NK5-1 , NK5-2 , NK5-3 )
PSFHS Nurses Publish ( NK5-7 ) The attached table provides an overview of articles published by our nurses. The topics of these articles range from evidence based practices, nurse perspectives, interviews, research, as well as book chapters.
Several other nurses throughout the organization have disseminated their knowledge through publishing. Lori Dagostino has been asked to write an article for the NCOON (National Coalition of Oncology Nurse Navigators) newsletter on malignant hematology navigation. Peggy Thomas and Elly Peters have been asked to co-author a chapter in a navigation book on outreach navigation and survivorship navigation. ( NK5-8 )
Pam Assid MSN, CNS, CEN, CPEN, NEA-BC Clinical Manager SFMC Emergency Department disseminates knowledge through publishing. Her most recent publication (2010) was in Nursing Management and it was titled, "How to build an ED Charge Nurse Training Program." She continues to publish on line as well as in print. ( NK5-9 )
Judy DeGroot, RN, MSN, AOCN, was interviewed by ONS Connect, the Newsletter for American Oncology Society about Gay, Lesbian, Bisexual and Transgender issues. She wrote a small article in the Feb 2011 TLC and presented in Nursing Grand Rounds ( NK5-10 )
Poster Presentations within PSFHS Nurses present evidence based practice implementation and research at professional conferences. Poster presentations are also disseminated to internal audiences via displays on units or in our Hall of Evidence. During Nurses Week 2010, we created "The Hall of Evidence" and displayed research and evidence based practice implementation posters for all associates and visitors to view. In 2011 and 2012, we have displayed posters on the home units for dialogue and inspiration. In 2013, we will host "The Hall of Evidence" again in both main hospital buildings.
Nursing Intranet Site The Nursing Intranet Site is another means to disseminate knowledge generated through nursing research and EBP implementation. ( NK5-11 ) Nursing staff have easy access through the Nursing Intranet to:
• Professional Nursing Posters
• Table of Posters and Podium presentations
• Table of published articles
• Link to the Webb Library and Search Engines ( NK5-12 )
To develop awareness of the Nursing Intranet, the nurse managers and Nursing Practice Council members receive occasional reminders about it with an attached link when updates are posted on the site. In January, the Magnet Coordinator encouraged the Magnet Champions to show five nurses on their units how to access the Nursing Intranet and reach the library search engines. As an incentive, the nurses who explored the Intranet and in return sent an email to the Magnet Coordinator were entered in a drawing for a gift. ( NK5-13 )
Nursing Newsletters - The Learning Connection (TLC), TLC EBP , TLC Pain Train
Nursing research is disseminated through short articles, comments or graphs in internal nursing newsletters. These three nursing newsletters highlight research for nursing use. A partial list of TLC issues that demonstrate dissemination of research to internal audiences:
• TLC 2010 September. Cultural Diversity
• TLC 2010 November. Update on Seasoned Nurse Research
• TLC 2010 December. EBP Conference
• TLC 2011 February. Gender Disparity in Stroke, Nursing Grand Rounds
• TLC 2011 March. Healthy Work Environments, HWE Survey results from 5 N.
• TLC 2011 April. Communication Strategies for Patients with Dementia
• TLC 2011 June. Shared Decision Making Research Update
• TLC 2011 July. Hourly rounding impacts patient outcomes. Patient Navigation
• TLC 2012 August. Night shift, lights, sleep and naps. Myth of Trendelenburg ( NK5-14 )
• TLC 2012 September. Culture of Respect
• TLC EBP - Winter 2012-Dissemination of Results from Pain Research Study ( NK5-15 )
• TLC Pain Train- 2012 July - Geriatric Pain ( NK5-16 )
Educational Presentations Our Pain Resource Nurses receive monthly education from the Pain Nurse who bases his education on identified needs and uses research data within his presentations. ( NK5-17 )
Quarterly education based on Skin Resource Nurses' requests is provided. The Clinical Manager coordinates speakers and ensures education is based on research. ( NK5-18 )
Specialty practitioners within PSFHS nursing services disseminate research generated knowledge through formal and informal teaching, distribution of peer reviewed literature and participation in evidence based practice initiatives. The position description states the Clinical Nurse Specialist (CNS) will "Demonstrate scholarly activities by fostering clinical research and communicating advances in nursing science" The CNS is tasked with facilitating change based on research and quality findings. Olinda Spitzer, MSN, RN, CNS, CCRN completed research on hypothermia protocol on post cardiac arrest patients. She presented her research via poster and then used her knowledge and expertise on a Centura Health Clinical Effectiveness Group charged with implementing this practice across Centura Health. ( NK5-19 , NK5-20 )
Wound Nurses routinely present classes to the Unit Skin Resource Nurses. Using current research and evidence based practice obtained to conferences, webinars or professional literature they disseminate the new knowledge and assist direct care nurses to apply or change practice. ( NK5-21 )
Nurse Scientist The Nurse Scientist routinely forwards research summaries from the monthly AHRQ Research Newsletter and The Advisory Board to the appropriate managers, including non nursing. ( NK5-22 )
The PSF Cancer Hospital clinical nursing staff disseminate knowledge generated through nursing research to internal audiences through staff meetings and externally through participation in professional organization meetings. The Lead Patient Navigator distributes research and journal articles to all navigators and encourages dialogue to implement new practices within the service. ( NK5-23 ) The oncology nursing professional organization hosts monthly educational dinners that are well attended by nurses - the most recent had 24 nurses in attendance. ( NK5-24 ) The National Comprehensive Cancer Network Treatment Guidelines, American Cancer Society and the American Society of Clinical Oncology Guidelines are evidence based foundations for treatment planning and patient education.
The PSF Cancer Hospital clinical nursing staff use new and existing research as well as disseminate new knowledge.
Sharon Halla BSN,RN, OCN, Breast Patient Navigator designed and provided the "Complementary Breast Program", a 16 week intensive program for women in active treatment. This program was based on research she had read and critiqued. Following completion of the program she created a poster and podium presentation for external audiences. ( NK5-25 )
Nurses at PSFHS utilize many methods of disseminating new knowledge generated through research. Under the guidance of our PPM, these nurses exemplify the standards of imagination, excellence and evidence based practice and research. These nurses seek educational opportunities locally and nationally. Presentations and publications across the span of nursing promote the sharing of our knowledge with others every year.
New Knowledge, Innovations, and Improvements - NK06
NK6 The structures and processes used to evaluate existing nursing practice, based on evidence.
Our Professional Practice Model provides a framework for excellence in nursing practice. Three elements of the model - Standards of Professional Practice, Quality of Care, and Guiding Principles - hold us accountable for ongoing evaluation of our practice and for the use of evidence based practices. In addition, the Code of Ethics for Nurses with Interpretative Statements states, "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." (ANA, 2001, p.12) The Nursing: Scope & Standards of Practice, Standard 7 states, "The registered nurse systematically enhances the quality and effectiveness of nursing practice." (ANA, 2004. p. 33)
Nursing Quality and Patient Safety Council is part of the formal shared decision making structure at PSFHS. Co-chaired by two direct care nurses and mentored by nursing leadership, this council identifies priority practices and outcomes for ongoing monitoring. Priorities and outcomes are in alignment with the Nursing Strategic Plan and focus on critical nursing practices. ( NK6-1 )
Nursing Practice Council is comprised of direct care nurses from all settings. It identifies annual goals, including targeting evaluation of patient satisfaction in nurse sensitive areas. Goals in Patient Satisfaction, Relationship Based Care, and Nursing Peer Review provide the framework for this council's agenda and actions. In addition, this council reviews and revises Nursing Guidelines based on evidence reflected in the references included on each guideline. Ensuring guidelines and practice are aligned promotes consistent quality nursing practices. In addition, Unit Practice Councils evaluate practice based on evidence. The support of Advanced Practice Nurses provides guidance and education to direct care nurses as they evaluate their practice. ( NK6-2 )
Nursing Evidence Based Practice and Research Council promotes the effective and efficient use of evidence in nursing practice. Nurses need access to evidence to use as they evaluate their practice and the skills/competence to effectively use new practices. This council promotes education and provides consultation and coaching. The attachment demonstrates the council's review of evidence prior to renewal of a Nitrous Oxide contract. ( NK6-3 )
National Database of Nursing Quality Indicators Nursing-sensitive indicators identify structures of care and care processes, both of which influence care outcomes. Ongoing monitoring of nurse sensitive quality indicators at unit and organizational levels is a process to evaluate nursing practice.
Nursing and Interdisciplinary Performance/Quality Improvement Structures Centura Health Clinical Effectiveness Groups (CEG) identify clinical practices that have new evidence available, areas needing improvement in outcomes, and clinical areas identified in strategic planning for improvements. Nursing is represented in each CEG to evaluate nursing practices using evidence and to take the lead to implement changes as indicated.
PSFHS Interdisciplinary Quality Committees such as Falls, Code Blue/RRT, Infection Control, Surgical Improvement Project Committee, and others. Each committee evaluates nursing and other clinical practices comparing outcomes to national benchmarks and reviewing new evidence in their specific areas. Nursing Units and Clinical Effectiveness nurses audit records and reports so that they can provide process and outcome results to each unit.
Implementing EBP: Delirium - Improving Recognition and Documentation QI Project for Critical Care In March 2012, the intensive care unit (ICU) evidence-based practice (EBP) council identified a need to improve the assessment and documentation of delirium in an ICU patient. The ICU patient was experiencing increased incidences of delirium which extend patient length of stay, increase ventilator days, and could have life-long effects. Staff was inconsistent in assessing and documenting delirium. Many nurses were marking "cannot assess" in the delirium assessment on ventilated patients. The delirium order set that was approved for use in 2011 had never been used, and staff were largely unaware of its existence. ( NK6-4 )
The ICU EBP Council requested a literature search and then assigned articles to the members for review and evaluation. ( NK6-5 ) At the same time, Olinda Spitzer, MSN, CNS, RN, CCRN participated in a Centura Clinical Effectiveness Group to develop standardized delirium assessment and treatment protocol based on evidence. Education was needed for staff to understand the definition of delirium, how to assess delirium in the ventilated patient, and how to properly complete the documentation. Information was presented to the Unit Practice Council, who approved implementation of the new evidence based practice. The new protocol and assessment tool was introduced to ICU staff in 2011. Additional education was provided by Lorna Prang, RN, MS, CNS, Littleton Hospital, Denver and Dr. Russell Lee, medical director of the ICU ( NK6-6 )
Copies of the CAM-ICU assessment tool were provided and a video was shown to staff at the June 2012 staff meeting on how to properly assess delirium in the ICU patient, both vented and non-vented. The Unit newsletters provided introductory information on delirium and interventions to decrease delirium. Charge nurses were asked to remind staff during huddles to complete delirium assessments every shift. RASS training was coordinated and provided by the ICU Education Committee at the August 2012 staff meeting. ( NK6-7 )
The UPC requested a "Delirium Report" to improve monitoring and evaluation of nursing practice and patient outcomes. The initial report from October 2012 was the only report that was available to the committee. Ongoing reports will be reviewed at the UPC to evaluate the practice of delirium assessments. Reports from Roni Ferrenberg, MSN, RN, CCRN, Assistant Clinical Manager, indicate that the education increased awareness has increased, and "Delirium Champions" have been added to maintain awareness and continued education.
Unit Based Performance/Quality Improvement: SFMS Post Partum Mom Baby Unit An infant code occurred in late 2010 that led the Mom Baby Unit to evaluate their practice and design an improvement process. In December, 2010, a multidisciplinary task force discussed the occurrence and practices that could improve the process. Members included: Staff RNs Jenn Steffen, Laurie Chromy, Cami Baird, Kathy Wilson OPS Center, Mimi Stillson NNP, Patrick Fisher RT and Lou Ann Cox, Mother/Baby Educator. ( NK6-8 ) Members were assigned tasks to develop or revise the following items: flow charts, OPS Center notification process, policy, exercise code responses, LEARN modules, equipment readiness, location, and availability. Ongoing Mock Codes will provide process for evaluation of nursing practice. ( NK6-9 , NK6-10 , NK6-11 )
National Database of Nursing Quality Indicators The Skin Resource Nurses from each unit and the Wound Clinic nurses complete a quarterly prevalence study of pressure ulcers (PU) per the National Database of Nursing Quality Indicators (NDNQI) standards. This process of peer review provides opportunities to evaluate immediate nursing practice based on standards which include skin and pressure ulcer assessments and implementation of evidence based pressure ulcer prevention interventions. The PU team evaluates care through reviewing the occurrence reports and performing a chart review to determine whether guidelines were followed. By reviewing this information with nurse colleagues on the unit, practice patterns or gaps may be addressed and monitored through the NDNQI PU Prevalence Study process. ( NK6-12 )
Medical Record Audits: Pain Management Routine audits of evidence based practices (e.g. pain management or time outs prior to procedures) are systematic processes to evaluate nursing practice. Our policy on care of patients in pain is evidence based and it defines the expectations for assessment, interventions, reassessment, and the use of specific monitoring tools.
Record reviews identified inconsistency with nursing practice regarding pain reassessment. Unit level discussions and those in Pain Resource Nurse Meetings had not improved practice. Direct care RN's agreed with standards of care and identified one solution. The documentation process included multiple steps and nurses suggested an alternative. Based on this information, a technology change was implemented so this information was easily available to staff. Education to staff via Meditech was provided to promote ease of assessment and reassessment in the EMR. ( NK6-13 )
New knowledge may be a trigger to evaluate existing nursing practice. Velda Baker, BSN, RN, CGRN, attended a conference and learned that when performing celiac plexus blocks a rescue kit must be available. Neither our gastroenterologists nor nurses at PSFHS had heard of this approach, so Baker asked for help from EBP Resource Nurse in researching. The literature search was provided to nurses and physicians in GI Lab. Our pharmacy was contacted with this information, and a procedure was established to have the rescue kit available during each procedure. ( NK6-14 )
Medical Surgical Intensive Care Unit Performance Improvement Team: CIWA (Clinical Institute Withdrawal Assessment) Team 2010-2011 At PSFHS we have four immediate goals for patient detoxification: (1) to provide a safe withdrawal from the drug(s) of dependence and enable the patient to become "drug-free," (2) to provide a withdrawal that is humane and thus protects the patient's dignity, (3) to prepare the patient for on-going treatment of his or her dependence on alcohol or other drugs, and (4) to decrease complications during hospitalization. The CIWA (Clinical Institute Withdrawal Assessment) is a common measure used in North American hospitals to assess and treat alcohol withdrawal syndrome. The measure was used consistently in the PSFHS behavioral health unit.
In 2010 a group of nurses and physician informally identified an opportunity to evaluate our clinical practice against current evidence. PH 5 Medical and Critical Care are primary treatment units for patients in detoxification. An interdisciplinary team was created to review the literature and current policy. ( NK6-15 )
Rhoda Blair Santos, RN, Chair
Rose Ann Moore, MSN, RN, NE-BC, Dir of Patient Care Services at Penrose Hospital
Lynne Wahl, MSN, CNS, APRN-BC
Melissa Williamson, BSN, RN, Clinical Manager, PH 5
Mackenzie Mudd, MSN, RN, Clinical Coordinator, PH 5
Heidi Freeman BSN, RN-BC
Timothy Wyse, MD
Deborah Fry, RN
Don Walker, BSN, RN, ED
Cheryl Allen, RN
The group initially met in late 2010 and audited records to evaluate practice, reviewed the literature, current policy and order set. Based on evidence the group drafted policy changes and presented to the Interdisciplinary Practice Committee for approval.
In 2011, the following revisions were made to the current policy (IDP A-02-q):
• The goals of treatment: safe withdrawal that protects patient dignity and is humane. Prepare patient of on-going treatment, decrease complications during hospitalization.
• Under symptoms of DTs change hypertension to systolic BP > 135
• All patients are initially screened using questions from SBIRT Colorado (Screening & Brief Intervention & Referral). For those patients who the nurse determines 1) should not be drinking or are drinking more than moderate or low risk; the nurse will add and document the CAGE (adult) or CRAFFT (adolescent) screening tool. Exception: In the Emergency Departments, patients who have a chief complaint involving Alcohol are assessed with the ED Alcohol Withdrawal Assessment Tool.
• If triggered by SBIRT and the patient is an adolescent, the CRAFFT questionnaire is assessed and a copy of the Adult Alcohol Withdrawal Order Set is accessed via Meditech. The Alcohol Withdrawal Order Set contains pre-checked orders for immediate implementation as well as orders for physician review. It includes a Psychiatric Emergency Triage Team (PETT) consultation if appropriate. ( NK6-16 )
The CIWA team designed an educational, engaging skit to train nursing staff on changes in practice and provided multiple opportunities for participation. ( NK6-17 )
Unit Based Evaluation of Practice: Penrose Community Urgent Care (PCUC) In May of 2012, a patient who had had sutures at our urgent care later experienced a partial wound separation and was concerned that the wound may not have been properly cleaned prior to suturing. The Clinical Manager evaluated this complaint; documentation and review of practice with providers did not support this patient concern. However, the complaint did prompt an assessment of departmental practices regarding wound care. The Clinical Manager discovered that Urgent Care Techs and RNs had individual practices regarding wound care and that PSFHS did not have a policy regarding traumatic wound care/suture prep. Using our online access to Mosby, the team found guidelines for traumatic wound care. Many staff members and several physicians challenged the Mosby information. The Clinical Manager explained that we could look at additional evidence. Since then, staff and providers have agreed to follow the Mosby recommendations while they have also been gathering information on alternatives. In January 2013, the team reviewed other protocols from Centura Health hospitals. Several articles were found by staff members and are to be reviewed at the April meeting. ( NK6-18 )
PSFHS nurses have many structures and resources for evaluating existing nursing practice based on evidence. The Shared Decision Making Councils at all levels and performance improvement project teams provide the two formal primary structures. The use of APN's, medical librarians, easy access to online professional literature, and record audits are effective resources that support and promote the use of evidence in evaluating and improving nursing practice. Ongoing outcome monitoring and benchmarking facilitate recognition of practices that need further evaluation. Nurses across PSFHS are increasingly questioning practices and evaluating outcomes to improve overall effectiveness and efficiency of nursing care.
New Knowledge, Innovations, and Improvements - NK07
NK7 The structures and processes used to translate new knowledge into nursing practice.
The nursing strategic plan and organizational goals outline expectations for excellence in practice and clinical outcomes. Nursing leaders actively promote and support translation of new knowledge through our shared decision making processes and interdisciplinary quality committees.
Centura EBP Structures:
The Centura Health EBP Oversight Committee provides the evaluation, selection, prioritization, oversight, and coordination needed to ensure the successful deployment of Centura Health's Evidence-Based Practice Initiatives. The structure for Centura EBP is based on bedside associate participation and locally driven implementation at each entity (site) through the following framework:
Centura EBP Oversight Group
• Prioritize EBP work and support EBP teams for successful deployment
• Comprised of entity representatives from different clinical areas of expertise including our systems of care and supporting service areasCentura-Wide EBP Teams
• Develop solutions or interventions following a systematic process improvement methodology in using current evidence, our clinician's expertise, and patient/community expectations
• Comprised of bedside caregivers and other associates to improve the identified outcomes
• For a list of current and past EBP teams, click on the Current Teams and Past Teams menu tab on the left.
Entity Implementation Teams (EITs)
• Receives new processes in the form of a toolkit and determines the proper means of deployment based on their entity culture, structure, and change needs
• Comprised of Chief Nursing and/or Medical Officer (CMO/CNO) of the entity, in conjunction with the entity Clinical Informaticist (CI) and selected entity leaders
• Ensures implementation and ongoing support of the new processes
• Entity leaders Identified by EIT to work with entity informaticist
Nursing Evidence Based Practice/Research Council The Rosswurm & Larrabee Model for Translation Implementation was selected by the council for use at PSFHS. The council has used this model to frame poster presentations at EBP Conferences. One nurse presented a poster on "Innovative Strategies to Teach EBP" which compared the Rosswurm & Larrabee Model to the standard FOCUS PDCA performance improvement model and the nursing process. ( NK7-1 , NK7-2 ) Centura Health Nurse Scientists will be meeting in March to compare and evaluate current models in use and recommend a standard model across Centura Health. ( NK7-3 )
Nursing EBP/Research Council Newsletter In the fall of 2011, the Nursing EBP/Research Council designed and disseminated the first quarterly EBP Nursing Newsletter to keep staff updated on the current PSFHS EBP projects that are being monitored in the system, associates who have prepared and exhibited posters at conferences and educate about the Levels of Evidence. The winter issue publicized the upcoming Sacred Cow Contest along with education about things to look for when reading an article to assure it is based on sound evidence. Updates on measuring and improving pain outcomes were discussed. Help was offered for conducting literature searches. The next issue detailed the winners' questions with answers for the Sacred Cow Contest. EBP issues are planned quarterly; most TLC issues address at least one evidence-based practice. ( NK7-4 , NK7-5 )
Nursing Practice Council The Nursing Practice Council is responsible for reviewing and revising nursing practice guidelines at least every three years or more often if needed. Recently we have approved the use of Mosby Clinical Skills for practice guidelines unless nursing makes a decision to develop a policy apart from Mosby. Since Mosby Clinical Skills update regularly with new evidence based practices, our policies will be based on new knowledge. (NK7-6 )
Interdisciplinary Policy Committee (IDPC) IDPC policy changes include evidence based practice with references and provide a structure to translate new knowledge into practice. This includes different approaches that are developed for specific problems; including: communication, documentation, education, metrics, supply chain, and surveillance. ( NK7-7 )
Obtaining, Communicating and Translating New Knowledge Nurses have access from any computer at work or home to professional journals through the library and Mosby. The librarian is available to assist with literature searches and obtaining articles as requested. In addition, resource nurses such as CNS's and nurse scientist routinely send relevant current literature to nursing council members for review and consideration for translation into practice. The Nursing Intranet is a structure to provide new information to nurses about upcoming or free on line educational opportunities along with Nursing Department resources and news.
New knowledge gained from evidence based practices is continually integrated into the EMR. Along with weekly updates in the Pulse briefly listing the updates, Meditech Tip Sheets are available to staff nurses on a great variety of topics. Many patients do not know the current dose of their home medication. Documentation of this was difficult, requiring numerous clicks. Nurses' input allowed changes to the process with alerts to allow follow up to gather correct information. Communicating this new documentation knowledge is seen in Meditech Tips. ( NK7-11)
Nursing newsletters also communicate new knowledge and assist in translation into practice. Pharmacy has used this newsletter to communicate specific medication changes. ( NK7-18 )
Expert Resources - Clinical Nurse Specialists/Diabetic Educators/Nurse Practitioners CNS', Diabetic Educators and Nurse Practitioners continually update their new knowledge and practice by attending conferences and reviewing current literature. In addition, these experts provide education to nursing staff to advance their knowledge and participate in evidence based practice groups to translate the knowledge into practice. In 2011 and 2012, these clinical experts provided education in the following practice areas:
• Information added to neurologic assessment section in ICU Training Program.
• Expanded ICU Training Program to include shared decision making principles and expectations.
• Through literature review, provided Lab Analysis class to nurses during Nurses Week, New Graduate ASCENT program.
• Heart Failure lectures in New Graduate ASCENT program
• Hemorrhagic Complex Strokes
• Neuro ICU and Stroke Unit Management
• Changes in the Diabetic Teaching programs
• Updated PSF diabetic protocols
• Diabetes and Wound Healing
• New graduate education (ASCENT) classes on Diabetes Management taught three times/year
Nursing Orientation During Nursing Orientation, nursing staff learn about the Nursing Professional Practice Model which includes the expectation of practices based on evidence and standards, and the professional nurse obligation to demonstrate continuous learning. New nursing associates are provided an overview of EBP and Performance Improvement as well as review of new practices such as CAUTI and CLABSI bundles. In addition the unit preceptors provide specific detailed orientation and competency review of these new practices( NK7-19 ) Additionally, nursing staff participation in a variety of activities that demonstrate their knowledge and skills in using evidence based practices such as
• The Nurse Practice Council reviews and revises nursing practice policies using current evidence and seeking current references.
• Evidence based practice to reduce central line bloodstream infections involved nurses in clinical effectiveness, management, direct care and PICC as well as collaboration with Supply Chain Management
Processes to Translate New Knowledge into Nursing Practice:
Centura Led EBP Process of Implementation Through PSFHS nursing participation in Centura Health EBP, we are able to identify champions, pilot practice changes and promote standardized practices based on EBP. The following attachments describe the process for implementing evidence based procedures in our approaches to Epidural/Intrathecal Analgesia ( NK7-14 , NK7-15 )
In early 2012, Centura Health established a CAUTI Prevention Evidence Based Practice (EBP) Team chaired by a Nurse Scientist. This multidisciplinary team included nurses, educators, a representative from supply chain management, physicians, infection prevention specialists, a wound/continence nurse, informatics experts, and representatives from our quality department, regulatory readiness, and values analysis.
The purpose of the CAUTI Prevention EBP Project was to reduce indwelling urinary catheter associated complications and to meet the National Patient Safety Goal (NPSG) which became effective January 1st, 2012. The NPSG provided a clear framework for this project.
One element of performance to meet these new NPSG standards was to, "Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections by measuring and monitoring catheter associated urinary tract infection prevention processes and outcomes." This was implemented by:
• Selecting measures using evidence-based guidelines or best practices
• Monitoring compliance with evidence-based guidelines or best practices
• Evaluating the effectiveness of prevention efforts
The goals of the CAUTI EBP Project were to:
• Reduce CAUTI rate per 1000 Foley Catheter days
• Meet Surgical Care Improvement Project's (SCIP) goal to remove Foley by Post Op Day 2
• Reduce urinary catheter days
According to the elements of performance to meet the standard, facilities must insert and manage urinary catheters according to established evidence-based guidelines. The following practice tools were made available across Centura Health:
1. The policy and procedure were written to encompass the evidence-based practices that meet the NPSG recommendations
2. The cause and effect diagram is an evidence-based supplement to the practice guideline for staff to reference
3. The algorithm for removal is a template for conversations with physicians and other LIPs to limit the use and duration of catheterization to situations necessary for patient care. The algorithm will be available for review in the GU Assessment Protocol ( NK7-9 , NK7-10 )
4. The insertion checklist is a tool used at time of urinary catheter insertion for practitioners to achieve the specific elements of performance to meet the NPSG standard. The insertion checklist instruction sheet is a document to hang or post near indwelling urinary catheter products to remind staff to use the checklist during the insertion procedure
Several changes were made by team
Supply Chain product changes based on literature review of product effectiveness, identification of current products, and collaboration with vendors
Meditech documentation changes to standardize insertion, care and removal through all modules ( NK7-16 )
Building CPOE and Physician Documentation (PDOC) screens related to indications for insertion, catheter care and assessment for removal of urinary catheter.
Report for Infection Preventionist to automate data collection
Standardize clinical practice related to insertion, maintenance, and removal of catheters
Standardize competency assessment of insertion, maintenance and removal of indwelling urinary catheters( NK7-17 )
Quarterly point prevalence survey for inpatient care areas ( NK7-12 , NK7-13 )
Jennifer Robertson, BSN, RN, Clinical Manager
Olinda Spitzer, MSN, CNS, RN, CCRN, Clinical Nurse Specialist
Stefanie Quirk, MSN, RN, ACNP, CCRN, Educator
Lynne Wahl, MSN, RN, CNS-BC, Clinical Nurse Specialist
Mackenzie Mudd, MSN, RN, Clinical Manager
Sylvia Kurko, BSN, MBA, RN, Education Coordinator
All nursing associates at PSFHS for mandatory training
Michelle Stephens, RN, Values Analysis
Standardizing infection surveillance and evidence based prevention practices should decrease catheter-associated urinary tract infections and maximize reimbursement payments associated with patient care for these conditions. Key to the collection of comparable data was the adoption and use of the same language. The plan developed by the CAUTI EBP Project Team identified definitions, metrics and reporting tools to guide collection of comparable data that met elements of performance to achieve the patient safety goal.
Other Centura EBP Teams in which PSFHS participated:
Centura Health Hypothermia Post Cardiac Arrest (HACA) EBP Team Olinda Spitzer, MSN, RN, CNS, CCRN from Penrose Intensive Care Unit was co chair of this EBP Team. Spitzer was responsible for completing literature review and analysis prior to design and implementation of a new order set. In addition, she used the literature review to provide education to Intensive Care Unit nurses prior to order set implementation.
Delirium EBP Team In 2011, as a member of this EBP Team, Olinda Spitzer, MSN, RN, CNS, CCRN, facilitated the pilot and implementation of practice changes in the Intensive Care Units at PSFHS.
Ventilator Associated Pneumonia Prevention EBP Team Stephanie Quirk, MSN, RN, NP represented PSFHS on this team. The Talking Points from the CMO of Centura outlined the necessity and reasoning for standardization of VAP Prevention. The Implementation toolkit contained communication tools, policy, protocol and order sets, education, supply information and audit tools. Spitzer facilitated the unit implementation. To help with this, EBP articles were reviewed related to the ABCDE bundle that highlights the most important aspects of practice changes regarding the ventilated patients. ( NK7-8 )
New Knowledge Translated into Nursing Practice:
PSFHS Reducing Pressure Ulcers on Ears The Clinical Manager of the Wound Care unit became aware of a trend with ear pressure ulcers caused by oxygen tubing. Although existing foam coverings were on each unit, staff seldom applied the covers because they did not stay in place unless taped, a time consuming process. Even then, the tape could irritate the sensitive tissue behind the ears, causing increased potential for skin damage.
The increased incidence of ear PU was presented to Managers, Skin Resource Nurses, and the PU Peer Review committee to encourage use of the foam covers, but PU continued. One Skin Resource Nurse decided to tape the foam packages to the oxygen tubing package. Although time consuming, this did work, and while she was doing this, all patients had their oxygen tubing covered. A request was made to Supply Chain Management to begin taping covers to tubing, but it was felt that this would be too time intensive and costly.( NK7-20 , NK7-21 )
The hospital vendor was contacted who supplied a different ear foam cover and silicone tubing for our review. The PU Peer Review Committee and managers looked at both. One unit volunteered to trial the silicone tubing. The comments from the nursing staff and quotes from patients were very enthusiastic, so a formal request from the PU Peer Review Committee was submitted to the Products Committee (SMAT). They requested a three month pilot trial where one unit would trial the new foam covers, another the silicone tubing and one would use the current product. The trial went from January 1st to March 31st, 2011. Evaluation forms were provided and comments gathered. Every two weeks, the Clinical Manager checked all patients on oxygen on the three units to evaluate the skin condition of the ears. ( NK7-22 )
Based on the results of the survey and the comments on the evaluation forms, the SMAT Committee approved the switch to the softer silicone tubing. This occurred in July. Education was provided to all staff about the switch. Two concerns were addressed during the training period. The first surrounded the color of the adaptive tubing. The new tubing was light green, and our current high flow oxygen tubing is bright green. The second was due to the softer silicone used in the new tubing, it would be easy to cinch the tubing too tight and cause a pressure ulcer. Photos and cautions were placed in each supply room following the education. Based on the most recent quarterly Pressure Ulcer Incidence survey, it was found that ear pressure ulcers decreased from the last survey from six to three.
Bedside Shift Report - PH 11 Medical/Oncology Unit The Nursing Practice Council and Clinical Managers have collaborated to translate the literature and evidence in support of bedside shift report to standard nursing practice. Reading the literature and determining implementation plans has been much easier than "hard wiring" the practice.
PH 11 nurses used our standard Process Improvement Process (FOCUS PDCA) to drive practice change. Bedside reports were initiated in August 2011, as the unit identified the benefits for patients and staff with this new practice and provided education. Prior to this change, the unit used a written handoff process with minimal verbal interaction. Bedside report required the nurses to verbally interact with one another as well as the patient/family when they were available. The unit selected outcome measures to evaluate the effectiveness of the practice. The graph below depicts a gradual improvement with a significant drop in December. However the unit resumed improved ratings at an even higher top box number after Christmas. ( NK7-23 )
Our organization is very concerned with creating an environment that interprets and incorporates new knowledge into clinical practices. We do this through support from Centura Health as well as through multidisciplinary committees and councils that pursue knowledge and practices that help to improve patient outcomes. As this section demonstrates, our structures and processes which are designed to incorporate EBP improve patient outcomes throughout our facilities.
New Knowledge, Innovations, and Improvements - NK07EO
NK7EO How translation of new knowledge into nursing practices has affected patient outcomes.
Patient outcomes have been positively affected by the incorporation of new knowledge into PSFHS' nursing practices. A recent example that is key to portraying the importance - and process of translating new knowledge into our clinical procedures is the following exemplar which incorporates existing knowledge, accountability strategies, and new knowledge to link the two.
Peer Review Committee to Prevent Pressure Ulcers:
Purpose and background One nosocomial PU can cost up to $40,000 to treat. Prevention is extremely important to reduce infection potential as well as to save patient pain, nursing staff time, and undue hospital expense. Best practices for PU prevention have been well researched and published. Despite this, our facilities have continued to experience nosocomial PU, leading to the conclusion that best practices were not being followed.
Increased emphasis on prevention began in 2007 and in 2008 we began the "Q2 Campaign," which focused on turning patients every 2 hours, increasing fluids/nutrition, and checking for dryness. This campaign included the best practices for pressure ulcer prevention as gathered from WOCN, NPUAP, Catholic Health Initiative Toolkit, and many peer reviewed journals. Despite implementation of these best practices, nosocomial PUs continued to be found. A new method was needed to increase staff accountability.
The goal of this project was to reduce hospital acquired pressure ulcers.
Methods and Strategies A PU Prevention Peer Review Committee was formed which included: Unit Based Skin Experts from five nursing units, two Wound Care nurses, a Risk Manager, the Clinical Manager of Wound Care (who also chaired the committee), and a Nursing Administrative Assistant. Ad Hoc members included representatives from: physical therapy, dietary, and education. The committee reviewed the most serious nosocomial PU that had occurred each month. The Unit Manager and Unit Based Skin Expert (UBSE) from the treating unit were invited to the meeting. Items reviewed included length of time in ED/OR (if appropriate), the skin assessment documentation on admission, length of time between admission and recognition of PU, documentation frequencies of the Pressure Ulcer Prevention bundle (PUP), turning and nutrition status, specialty support surface, and timing of expert consultation by Wound Care nurses. (NK7EO-1, NK7EO-2)
The Unit Manager and Skin Resource Nurse participated in the discussion of documentation, interventions, and ideas for improvement. The Unit Manager and Skin Resource Nurse created an action plan with input from the committee. The Risk Manager provided input from a Safety/Risk perspective. The Clinical Manager of the Wound Clinic felt that staff and wound nurses needed to be involved as they knew the everyday challenges of bedside care. The presenting unit's Clinical Manager and Skin Resource nurse also attend. When pressure ulcers were reported on a patient treated on more than one unit/area, all units involved are invited.
A Resource Manual with pictures of different states of the PU along with common skin ailments such as skin tears, incontinence associated dermatitis was developed. Each PU photo included treatment guidelines and photos of the proper product. These manuals were placed on each unit. (NK7EO-4)
Quarterly classes that coincide with the Pressure Ulcer Incidence Study are scheduled to increase knowledge of various skin topics. Nurse attendance of these classes is good, and the classes receive positive reviews. Topics are selected based on annual class suggestions provided by the Skin Resource Nurses. (NK7EO-5)
These meetings have resulted in a large change for the hospital; the implementation of a new type of oxygen nasal cannula with "softer" silicone ear tubing on all nursing units based on continued presence of ear pressure ulcers. (NK7EO-7, NK7EO-8) Other unit based changes include:
• NICU changing foot pulse oximetry location every two hours and documentation of that change
• obtaining new specialty beds in ICU
• change in C-Collar vendors
• change in NICU feeding tube securing device
• establishment of use of prophylactic coccyx dressing in ICU to prevent PU
• change in procedures for checking patients' skin post op who have had spinal anesthetic
Another outcome was a renewed focus on education. Education occurred to enhance staff nurse awareness of skin care, when to call a wound nurse, as well as proper documentation. (NK7EO-6) (NKEO-9) A patient education brochure patterned after the brochures in the CHI Pressure Ulcer Prevention and the Medline Industry Toolkits was developed. It is included in each Patient Welcome Packet upon admission to the hospital. (NK7EO-11)
Rochelle Salmore, MSN, RN, NE-BC
Dorothy Bennett, RN, Wound Clinic
Connie Hetzel, RN Wound Clinic
Gail Albritton, Skin Resource Nurse, RN, 11th flr
Helen Bagnate, RN, Skin Resource Nurse CCU
Lois Boschee, Skin Resource Nurse, RN, 5 Medical SF
Judy Kelow, RN, 5 Surgical, Skin Resource Nurse
Kathy Creech, Business Support
Nosocomial PU's have decreased since 2008 due to this increased emphasis on prevention and staff awareness. The goal of this project, to reduce hospital acquired pressure ulcers, was met.
The information about the PU Peer Review format was disseminated through poster presentations in 2010 at the Centura EBP conference and CHI's Quality Improvement Conference. It was also presented at the 2011 WOCN National Education event by the Wound Charge Nurse. (NK7EO-10)
Mattress Improvement and Resulting PU Ulcer Decrease:
Background In March, 2011 a staff nurse in the ED, Cassie Tumanis, RN, BSN, PCCH, CEN cared for a quadriplegic patient who stated that he developed decubitus ulcers at his previous visit to the ED because of the hard mattresses on the gurneys. She asked for help in accessing a protective overlay for patients in the ED. (NK7EO-12)
Methods/Approaches The staff nurse communicated this information to her managers and to the CNO. The information was forwarded to the Wound Care Manager.
Participants A meeting with the ED Unit Practice Council members and the Wound Care Manager was held. Together, they identified alternatives and criteria for getting special mattresses for at risk patients and to obtain a mattress overlay for use on specific categories (those from LTC, patients with bad skin, i.e. cachectic, prednisone, and mobility impaired, i.e. paraplegic, quad, MS, and anticipated stay in ED>2hours ).Measurement/Outcomes A sample mattress overlay was obtained from a vendor and delivered to the ED. New mattresses were not on the budget, so it was decided to wait. For high risk patients, a regular patient bed would be obtained and delivered to the ED for the patient to use while waiting.(NK7EO-3)
Significance/Implications New mattresses were delivered to the ED. As the graph below demonstrates, the total number of PUs have reduced drastically since the mattresses were replaced.
New Knowledge, Innovations, and Improvements - NK08
Describe and demonstrate innovations in nursing practice.
Request- There is description and demonstration of innovation; however, it is not in nursing practice. Please describe and provide substantiating evidence to demonstrate innovations in nursing practice.
PSFHS is presenting two nursing practice innovations. The first is on our Cardiovascular Unit and the second is in our Cancer Center.
1. Patient Education Boards for Open Heart Surgery and Thoracotomy-Thoracoscopy Pathway Video Assisted Thoracotomy Surgery (VATS): An Innovative Nursing Plan of Care Tool
The Cardiovascular Unit (CVU) at Penrose Hospital is a 36 bed private room progressive cardiac care unit of the cardiovascular service line. The unit specialties include patients with acute coronary syndromes, angioplasty procedures, ablations, PCI, pacemaker procedures, cardioversions, coronary artery bypass, valve surgery, Trans Aortic Valve Replacement (TAVR), congestive heart failure and other medical and surgical cardiac procedures. Grounded in the Professional Practice Model, the nurses create a quality caring and healing environment where patients and families are the center of caring practice. CVU staff are also engaged and empowered to ensure patient safety by continually monitoring and improving outcomes through process improvement projects, exemplified by the Patient Pathway Boards.
In November 2010, CVU nursing staff and physicians worked collaboratively to develop an Open Heart Pathway board listing each post op day activity expectation. This provided a visual outline that helped the patient plan their day as directed by the daily activity expectation (plan of care). The boards are 24 X 28, and use easy to read large font. The template face can be erased and reused for the next open heart patient. These Open Heart Pathway boards are hung from the bathroom door, visible for the patient and family to monitor progress and know their plan of care for each day. Once the Plan of Care boards were implemented, nurses anecdotally report patients and family are more involved in care planning and goal setting. (NK8-R1)
In January 2012, a Charge Nurse noticed that thoracotomy patients were having difficulty with their recovery process. In her investigation she found that on numerous occasions these patients were more reluctant to get up and walk or even sit in a chair post surgery. The nurses also reasoned that these patients were more at risk for pneumonia due to not using their incentive spirometry. Despite education on the benefits of walking, the patients were resistant to walking even with the appropriate pain medication. Based on the success with the Open Heart Clinical Pathway Boards, the nurses decided to design and implement a board for the thoracotomy patients. The nurses and physicians worked collaboratively to develop a template that would cover each post op day plan of care. This template included the day of surgery and plans of care through post op day #3 or until discharged. (NK8-R2, NK8-R3)
The post op length of stay for these patients was reduced following implementation of the thoracotomy boards in February 2012. The length of stay pre implementation was 4.5 (January 2012) and post implementation length of stay was 3.4 (December 2012). The red trend line on the graph below shows the continuing trend of reduction in post operative length of stay for VATS and Open Lung Procedures.
The cardiovascular ratings from patients as measured through HCAHPS also demonstrate improvement in three categories.
1. Nurses Listen Carefully improved from 3.75 pre-implementation to 3.88 post 2012.
2. Clear Communication by Nurses also improved from 3.78 pre-implementation to 3.83 post implementation.
3. Family Involvement improved from 3.70 pre-implementation to 3.77 post implementation.
The trend lines on each graph demonstrate the continuing to trend to improved patient satisfaction in all three areas post thoracotomy board implementation in first quarter 2012.
The nurses on the cardiovascular unit identified concerns related to patient post thoracotomy participation in treatment. Recalling the effectiveness of the Open Heart Clinical Pathway Boards they had designed and implemented in 2011, they collaborated with physicians and designed a Thoracotomy Board. By installing these boards in patient's rooms, the nurse engaged the patients in care planning and delivery using a visual model for the care planning dialogues. This innovative practice change resulted in reductions in length of stay for this patient population and overall improvement in patient satisfaction on the cardiovascular unit related to nursing practice.
2. Impact of a Nurse Navigator Telephone Intervention in Reducing Unplanned Hospitalizations in Blood Cancer Patients
The Malignant Heme Navigation Program was established at Penrose Cancer Center in May 2011 and supported by Dr. DeCarolis, physician lead. Monthly multidisciplinary conferences were initiated in September 2011 with a target goal to present ten cases at each conference.
In December the Heme Navigator reported the statistics from the first six months of operation. During this period 69 patients received navigation services and were referred from physicians, nurse practitioners, inpatient nurses, outpatient nurses and pathology reports. The Heme team's goal is to receive the referral as close to the diagnosis as possible. During this initial six months of the program patients received comprehensive navigation including transportation, lodging, meals and grant assistance.
The Heme team identified quality improvement measures for Non-Hodgkin's lymphoma based on the American Society of Clinical Oncology, Quality Oncology Practice Initiative, an oncologist-led, practice-based quality improvement program. In addition, the team decided to monitor and analyze data on unplanned hospitalizations and emergency room visits. The first review of unplanned admits identified patients were admitted for the following reasons: febrile neutropenia, sepsis, dehydration, weakness, severe debilitation, abdominal pain, epistaxis, anemia, chest pain, mucositis, and stroke. (NK8-R4)
The multidisciplinary care team recognizes the reduction of unplanned hospitalizations as a quality indicator meaningful to patients with blood cancers, providers, our institution, and the broader health care system. To achieve a reduction in these unplanned events, a targeted nurse navigator telephone based intervention was developed and implemented.
Background: The physical, emotional, and economic consequences of hospitalization among cancer patients are well documented and underscore the need for interventions to reduce unplanned hospitalizations. Compaci and colleagues (2011) demonstrate the effectiveness of telephone support as an intervention to reduce the incidence of hospitalizations among patients with diffuse large B-cell lymphoma receiving chemotherapy. Coriat and colleagues (2012) demonstrate the impact of telephone support in reducing unplanned hospitalizations among patients with solid tumors receiving chemotherapy. As a member of the multidisciplinary care team, the malignant hematology nurse navigator improves patient outcomes through targeted interventions, specifically utilizing proactive telephone assessment to reduce unplanned hospitalizations.
Purpose: To reduce unplanned hospitalizations among blood cancer patients receiving chemotherapy, the navigator collaborated with members of the multidisciplinary team to develop and implement a telephone intervention.
Methods: In Quarter Two 2012, the navigator initiated proactive telephone assessment of ambulatory chemotherapy patients considered high risk for unplanned hospitalizations. The multidisciplinary team defines high risk patients as those who live alone; are uninsured or underinsured; have poorly managed depression or anxiety; are greater than 70 years of age; or have a documented cognitive deficit. The telephone intervention consists of proactive assessment and management of real and potential side effects of therapy. When symptoms cannot be adequately managed through telephone support, the navigator arranges for the patient to be seen in the office by an oncology provider.
Outcomes: Data collected over six consecutive quarters demonstrate that proactive telephone support performed by the navigator reduces unplanned hospitalizations among blood cancer patients. Pre-implementation of telephone support in 4Q2011 and 1Q2012 unplanned hospitalizations were 24-30%. Post intervention unplanned hospitalizations decreased and have been sustained at 7-13%. In Quarter Four 2011, prior to the implementation of the navigator-specific telephone intervention, 30% of patients experienced an unplanned hospitalization compared to 7% in Quarter One 2013. Between Quarter Four 2011 and Quarter One 2013, there has been a 75% reduction in the percentage of navigated patients experiencing unplanned hospitalizations. (NK8-R5)
Implications: Proactive telephone assessment, within the context of a multidisciplinary approach to the care of patients with blood cancers, reduces unplanned hospitalizations. The multidisciplinary approach represents a fully integrated model of care in which physicians, nurse practitioners, nurse navigators, social workers, and other disciplines collaborate to support the many physical and psychosocial needs of our patients to ensure optimal outcomes. This specific telephone intervention improves patient outcomes and aligns with institutional initiatives to reduce costly unplanned events. Patients can benefit from targeted interventions provided by oncology certified nurse navigators specializing in the care of blood cancer patients.
Compaci, G et al. (2011) Effectiveness of telephone support during chemotherapy in patients with diffuse large B cell lymphoma: The Ambulatory Medical Assistance (AMA) experience. International Journal of Nursing Studies, 48(8) p926-32. doi: 10.1016/j.ijnurstu.2011.01.008
Coriat, R et al. (2012) Cost Effectiveness of Integrated Medicine in Patients With Cancer Receiving Anticancer Chemotherapy. Journal of Oncology Practice, 8(4), 205.
New Knowledge, Innovations, and Improvements - NK09
NK 9 The structure (s) and process (es) by which nurses are involved with the evaluation and allocation of technology and information systems to support practice or nurses' participation in architecture and space design to support practice.
Nurses as active users of technology and information systems participate in interdisciplinary teams to evaluate and allocate resources to support practice. PSFHS nurses are also active participants in architecture and space design to support efficient and effective nursing practice. Organization and unit level committees are structured to include nurses at formal leadership and direct care levels to identify opportunities and evaluate options related to practice.
Our Chief Nursing Officer is committed to improving patient outcomes through excellence in nursing practice. Recognizing the value of nursing input and decision making in selecting, adopting, implementing, and evaluating technology, information systems, and space, she and/or other nurses are leaders or integral members in several committees. The CNO and these committees utilize the Shared Decision Making element of our PPM to serve as structures for nurses to be involved in the evaluation and allocation of technology and IT.
The largest technology structure is Meditech, Centura's electronic medical record (EMR), also referred to as the clinical information system (CIS). Most of the monitoring and diagnostic equipment in the system is electronically linked to this system, thus providing immediate access to current patient information. Electronic interface capabilities with Meditech are now requested on any new equipment being considered for purchase.
At the Centura level, we employ a Chief Nurse Information Officer (CNIO) who provides leadership and oversight of the team of clinical informaticists across Centura Health. This team meets regularly sharing expertise and promoting best practices. ( NK9-1 )
Nursing uses IT to communicate, manage knowledge, mitigate error and support decision making. Nurses in various positions provide their expertise and perspective to IT and space design. PSFHS benefits from formal nursing leadership in IT. Jeanne Barnes, RN is the Director of IT and a member of the Nursing Leadership/Management Council. CNO support is evident through her ongoing participation in the Entity Implementation Team that is tasked to streamline documentation and reduce redundancy. The CNO established a full time Nurse Clinical Informaticist. The Entity Implementation Committee, chaired by the Clinical Nurse Informaticist, Ramona Beal,RN, BSN,is a multidisciplinary committee that guides implementation of evidence based practices and integration of IT to support practice The success of this multidisciplinary team is discussed in NK7. (NK9-2 ) Beal is visible on the units through rounding and education which provides opportunities for direct care nurses to identify their needs, preferences and evaluation of IT.
In January 2013, PSFHS implemented a trial position that is half time informaticist and half time direct care. This dual role will support flexibility for project management and education as well as continue our goal to integrate clinical and IT expertise in decision making. ( NK9-3 ) The PSFHS Staff RN Position Description includes the category "INFORMATICS/TECHNOLOGY" thus holding nurses accountable to "Adapt to rapidly changing technology as evidenced by competency in technology and equipment used in the patient care setting." Direct care nurses serve as Meditech SuperUsers on each unit. They provide feedback and recommendations on Meditech that can improve practice.
Evaluation and allocation of technology and information systems The implementation of our clinical information system (CIS) in 2007 was led by a team that included the Chief Nursing Officer. As clinical staff have adjusted to the changes in structure and processes related to CIS use, evidence-based clinical updates and needed documentation efficiency revisions continue. The Clinical Nurse Informatics Team meets weekly to evaluate Meditech, identify needed changes and test functionality before implementation. This process is designed to support safe, effective and efficient nursing practice. .
Several examples of changes that have saved nursing time are provided.
• The length of the nursing assessment documentation was a source of dissatisfaction among nursing staff. The streamlining decreased documentation time and wait time for patients.- Nursing input helped make many Meditech improvements. "The new Initial Assessment screen has 193 fewer queries and 17.5 fewer screens. The entire document now fits on 2.5 screens. (p. 4) The new Triage Assessment has 65 percent fewer queries. (p. 4)" from IT Annual Report Excerpts
• Patient information sheets for various medical conditions are available for printing.
• Access to the Provider (physician) list is on front page of My Virtual Workplace. The list includes photo, privileges and contact numbers. ( NK9-4 )
• While documenting, nurses may view the protocol for the specific event. ( NK9-5 )
• Entering home medications required many clicks. When patients did not know the names or dosages documentation was even more complicated. This was simplified. ( NK9-6 )
Nursing involvement in evaluation and allocation of technology and information systems is best described through several examples.
IV Pump Selection In November, 2011, Joe Luster, RN, ICU discussed shortcomings of our current IV Pumps and volunteered to help select new models. The Centura Value Analysis Team was just beginning a search for vendors for new pumps models. Joe participated in the Centura Pump Selection Committee meetings where various pumps were previewed. By May, models were selected from each contracted vendor. Demonstrations were set up for each Centura site where nurses were asked for their opinions on the models. ( NK9-7 , NK9-8 ) The nurses selected the pump and monies were budgeted for purchase due to multiple recalls, new pumps have not been purchased yet. However, $552,185 is in the budget for this expenditure the coming year.
PCA Pump Purchases Required for Implementation of CPOE In preparation for CPOE, order sets are being reviewed and revised. The Centura Health EBP Council provided content expertise as order sets based on EBP were built, of which the Vent Bundle order set is a good example.
The Centura Health proposed standardized order set did not include an option for use of propofol. In fact the order set prechecked an order for dexmedetomidine. Many PSFHS physicians prefer to use propofol for ventilator sedation. Dexmedetomidine is emerging in the research literature as a good option for ventilator sedation, especially when trying to wean a patient off of the vent, but is much more expensive than propofol which is equally effective.
PSFHS Pharmacy and nursing, with the help of physician champions, worked with the Clinical Content Steering Committee (CCSC) for Centura to approve the addition of propofol as a second option for sedation on the vent bundle order set. Pharmacy adapted the order set to include both options directing providers to select one or the other, took feedback from CCU nursing and then presented the changes to the CCSC. These changes were approved.
PSFHS current equipment is not capable of giving the bolus doses as described in the order; CADD cassettes would be required to do this properly. Nursing and Pharmacy have requested appropriate equipment prior to implementing the order set.
Supply Chain and Value Analysis are comparing prices between renting vs. purchasing the Solis CADD that was selected by nurses at PSFHS. The intent was to request capital to purchase the new equipment which will improve both efficiency and patient safety in addition to allowing us to implement the revised order set. Stephanie Quirk, MSN, NP and Michelle Stephens, RN requested funding and have been notified that this purchase has been approved. ( NK9-9 , NK9-10 )
State of the Art Support Surfaces and Frames Nosocomial pressure ulcers were still being found despite implementation of various prevention strategies. One reason for pressure ulcers was inadequate support surfaces. Many nurses gave anectodal examples of patient complaints about uncomfortable mattresses. In 2010, the existing beds were from the same manufacturer, however there were four different models ranging in age from 3-20 years old. Only one vendor was authorized for mattress replacement, however, this vendor was not the manufacturer. Purchasing requirements stated that we were allowed to use the original manufacturer for refurbishment and replacement of original parts. We were therefore able to work with the manufacturer for replacement and refurbishment of the mattresses.
A survey of materials was completed listing all of the mattresses that needed to be replaced. ( NK9-11 ) It was discovered that ICU had more of the older beds and mattresses than originally thought. Not coincidently the ICU had a higher rate of nosocomial PU than the rest of the hospital. Priority was given to refurbish their mattresses, and replacement of 6 beds was budgeted for 2011 and $300,000 for 2012. The Wound Care and ICU Clinical Managers and the CWOCN nurse met with the vendors to review and determine options needed on the ICU beds. The ICU Manager also presented accessory options to the nursing staff for their input. Fourteen beds were purchased for ICU, and requests for replacement beds continue to be placed in the budget annually. Current funding will complete bed replacement in ICU. ( NK9-12 , NK9-13 )
Forty foam mattresses were ordered to serve as replacements on the general nursing units. Mattress refurbishment was an option offered by the vendor. In house "refurbishment" was completed in 2011. ( NK9-14 )
Training for all staff on the proper operation of current bed features, emphasizing the pressure reduction feature, was provided to all nurses. ( NK9-15 see picture ) This will be an ongoing training/refresher scheduled annually. Although CCU bed operation is provided during skills review, a special training was also set for their staff. ( NK9-16 ,NK9-17 )
Another problem was identified with ancillary department surfaces in that the quality of padding is poor. Multiple vendors presented capabilities of mattresses for imaging equipment. Research continues into contracted vendors and pressure relieving surfaces made to order that will not distort the imaging process. The manager of the Wound Care services met with the Imaging Director to review options.
Advancing Practice, Improving Efficiency and Effectiveness in Penrose Surgery - Robotics in the Operating Room:
The Robotic Team at Penrose is comprised of eight nurses, certified surgical techs, robotic surgeons, vendor representatives, supply chain, finance, revenue integrity, facilities, safety and sterile processing. Administration and senior leaders make final decisions for capital purchases based on expert input from these professionals.
Steve Bollinger, BSN, RN, CNOR is the Assistant Nurse Manager in Surgery and leads the Robotic, Urology and Gynecology Teams. Nursing is responsible for the patient care, logistics including bed, positioning, safety, equipment and instruments in the robotic suite. Partnering with physicians and sterile processing ensures set up is accurate and timely.
Penrose's robotic program continues to expand with nursing as active participants and leaders. In November 2012, PSFHS sent 5 nurses and 2 surgeons to the Texas Institute for Robotic Surgery "OR Efficiency Boot Camp" in Austin, Texas. This day long training focused on strategies to reduce turnover time and improve the consistency and quality of patient care in the robotic operating room. In addition the interactive approach provided an opportunity to expand the collaborative professional relationships.
Following the Boot Camp experience, Bollinger returned to PSFHS and initiated changes based on the new knowledge. Bollinger states "when we were in training, I was able to briefly look at the surgeon who quickly agreed with changes based on best practices." The following overview provides a look at some of the immediate changes we are making in December 2012 and January 2013.
• Instrument Tray set up was an immediate change. Seven different trays were reduced to four trays with basic equipment for robotic urology and gynecology surgeries. This decreases labor and equipment waste. ( NK9-18 )
• Built in cabinets in one room were replaced with mobile cabinets. The modular option improves flexibility in OR room use. ( NK9-19 see picture )
• Both robot and surgeon location in the room are now standardized vs. changing for each surgery. This improved turnover time.
• Supplies have been reorganized and a road map developed to show number of supplies stocked and location. This is being piloted in one room, with plans to evaluate and transition across the OR.
• Documentation revisions have been presented for review and decision. Boot camp provided a sample patient flow sheet which reduced nurse paperwork and improved communication.
• A reduction was accomplished from the need to open nine items presurgery to two or three items presurgery. This improves efficiency and effectiveness with patient safety.
Within the next six months, PSFHS will obtain the newest robotic technology. Bollinger reports "Boot camp prepared me to be clear with what I will need from the vendors for training and competency demonstrations as we implement the new technology." In addition, PSFHS is collaborating with our sister facility in Pueblo as we provide them with our "old" robotics which will be an upgrade for their OR.
Nursing Involvement to Improve Telemetry Technology and Processes At Penrose, 80% of the patients admitted through the ED are placed on telemetry or teleoximetry. Patients traveling from PACU to nursing units are required to be monitored. Up to 128 patients can be monitored at one time. There were limited areas in the hospital where telemetry signals were not received, causing a safety issue during transport. The current equipment was from 7-10 years old, and the server memory was reaching capacity. Frequently there was a waiting list for teleoximetry units due to sheer numbers in use and/or broken units out for repair. ( NK9-20 )
Recognizing that the technology needed to be upgraded, a Telemetry Task Force was formed to discuss several issues including equipment and non-compliance issues with the telemetry policy. Nursing representatives from each nursing unit including PACU were invited. Issues discussed included inadequate numbers of tele-oximetry units and the larger telemetry system. Nursing staff met with two contracted vendors to view the different systems. Selected staff then visited St. Anthony Hospital to evaluate their Phillips system. After viewing the system, nurses decided the GE system was the better choice. ( NK9-21 , NK9-22 , NK9-23 )
Money was budgeted; the system ordered and is currently being installed. Cabling is installed where there were gaps for receiving telemetry signals. Monies are budgeted annually for tele-oximetry replacements due to frequent equipment breakage. The upgrade will now allow monitoring of 165 patients. In the near future, remote viewing of rhythms via personal devices for physicians will be available. ( NK9-24 , NK9-25 )
Penrose Community Urgent Care - Technology:
Penrose Community Urgent Care (PCUC) opened on August 18, 2008. Supplies and equipment left behind when Penrose Community Hospital moved to its new building were used for the Urgent Care, including a very old Trex Computerized Radiography (CR) machine. This piece of equipment was relatively slow by today's standards due to required processing. Over the last few years the machine began having increasingly frequent break downs, resulting in patient care delays and even lack of service at times.
Nurses, physicians and radiology technicians were all frustrated and began lobbying for new equipment. The issue was discussed at the Urgent Care Leadership committee, which includes urgent care RNs and management, Urgent Care medical director, CNO, CMO, and directors of imaging, lab, pharmacy, and supply chain. With this group's support and ongoing collaboration between nursing and imaging leaders, a formal capital equipment request was submitted and approved by our CFO.
The Purchase Order was approved 5/11/12 for a Phillips Direct Radiography (DR) machine, commonly known as a digital system. The new equipment was installed and has been in operation at PCUC with notably improved quality of images and turnaround times. The overall improvement in patient care has been satisfying to patients, radiation techs, nurses, and physicians alike. ( NK9-26 )
Centura Health acquired access to a clinical research tool, Hayes Inc. program, which provides independent, unbiased, and evidence based analysis of emerging technologies. Access to their database allows volumes of information about a wide array of medical technologies to be retrieved from a single source. The safety and efficacy of these technologies are evaluated and a ranking score is provided based on substantiated clinical outcomes. This tool is particularly helpful to our OR services, where many new technologies emerge. Access to the Hayes Inc. program is available via My Virtual Workplace. ( NK9-27 )
The Director of Value Analysis researched inhaled nitrous oxide (iNO) because the contract was about to expire with the vendor. After using Hayes, Inc to research the evidence for its use, she discovered that it had an evidence rating of "D", meaning that there is currently insufficient evidence to suggest a health benefit. She then asked the Nursing EBP Council to review the literature on iNO for premature infants and adults. This product is very expensive and it is not used often.
The council invited the respiratory therapists from each site, along with the NICU manager, and the SFMC VP Nursing to discuss. The guests provided anecdotal evidence of the need for this product.
The guests pointed out that iNO is only used within specific timeframes. The literature cautioned not to use it longer than 4 days. Our longest use was 120 hours. If the patient receives no benefit in 20 minutes, it is discontinued. This product is used as a stop-gap measure to assist the patient to get over a critical period when other methods can be beneficial. A focus of concern in the literature was renal failure in adults. It was pointed out that the meta-analyses reviews discussed the use in critically ill patients, who might have multiple reasons for renal failure, so iNO could not be proven to be the cause.
The EBP Council recommended that iNO continue to be available because of the safeguards that are currently in place. A recommendation was made by the EBP Council to Administration to develop a subcommittee to review clinical indications for high priced technology. This should include physicians who use the equipment. ( NK9-28 )
Multidisciplinary Care Conferences at Penrose Cancer Center:
Penrose Cancer Center has the following multidisciplinary care conferences (MDC) in which newly diagnosed patients with cancer are presented to the team members for the purpose of making treatment recommendations: Weekly Breast and Thoracic, twice a month Gastrointestinal, Once a month Head and Neck, Malignant Hematology and GYN, and quarterly Melanoma and Central Nervous System.
These conferences are attended by medical oncology, radiation oncology, pathologists, radiologists, surgeons, nurse navigators, clinical trial staff, and other support staff (dietician, social worker, dental hygienist, etc). Palliative Care NPs attend the thoracic, GI and malignant hematology MDCs. Participation by these health care providers has been very strong as the providers know this is "the right thing to do" for the patient as well as to improve patient care outcomes. During 2012, 821 non-physicians and 423 physicians participated. ( NK9-29 )
A recent upgrade of equipment in the Penrose Cancer Center conference rooms has given Penrose Cancer Center the capability to teleconference the MDC's to offsite health care providers/hospitals. The offsite participants are able to view imaging results, pathology slides, and other data pertinent data to the case being presented. During 2012, 17 physicians and 16 non-physicians from offsite participated in these conferences.
The ability to have webinars along with remote connection with other sites for presentations is also possible with the equipment upgrades. The weekly Grand Rounds presentations are attended by physicians and nonphysicians. (NK9-30 )
Nurse Participation in Architecture and Space Design:
The opening of the St. Francis Medical Center in late 2008 required frequent nursing collaboration with designers to support nursing practice. This nursing involvement continues as nurses are now helping to plan the new Orthopedic Center of Excellence unit on the sixth floor at SFMC. Continuing at the forefront of the design are safety issues, workflow design for maximum efficiency, and the design of healing environment. ( NK9-31 )
PSFHS' nurses are very active in the evaluation of hospital efficiency. They are particularly active in the shaping of systems (both physical and virtual) that positively affect their practice. These changes are supported by our commitment to shared decision making which expects nurses to participate in decisions on technology, IT and space that impact effectiveness and efficiency of clinical practice.
New Knowledge, Innovations, and Improvements - NK09EO
NK 9 EO Describe and demonstrate an improvement in practice due to nurse involvement in technology and information system decision-making or due to nurses' participation in architecture and space design.
From Outpatient Medical Unit to the Infusion Center
Background and Purpose:
In the fall of 2010, the Outpatient Medical Unit provided infusion services through a small space located in the Outpatient Surgery Unit. This six bed service operated Monday-Friday. When additional space or time was needed for patients, inpatient units with bed space provided the service. As the volume of inpatients and infusion patients increased, direct care nurses, managers, and finance identified the need to examine space, nursing time, and expertise and patient satisfaction. The goal was to serve infusion patients in one primary space (reducing outpatient infusion on units) with satisfied infusion nurses.
Methods and Approaches:
October 2010 An interdisciplinary team convened to analyze the existing situation, identify immediate opportunities for improvement, and plan for future growth of the service. The team identified their goals including feedback from all current infusion nurses. These goals were:
The clinical manager met with representatives from pharmacy, environmental services, maintenance, information technology, Patient Access/Central Scheduling, finance, and the staffing office to seek any additional input or questions not identified in the team meeting. She drafted the plan agreed upon by the team including discussing changes and options with all infusion center nurses. A request for additional nursing staff and unit secretary support was approved by the Director of the Workforce Center and the interdisciplinary team charged with decision making regarding expanding positions. Collaborating with human resources, additional staff was hired and oriented. The PSFHS Space Committee approved using Penrose 10th floor for expanded infusion services. Finance established a unique cost center for the new Infusion Service. Revenue Integrity, Pharmacy, Finance, and the Cancer Center designed a structure and an accompanying process for billing, accessing free drugs, and serving indigent patients. (NK9EO-1, NK9EO-2, NK9EO-3)
Information Technology provided equipment and set up documentation access. (NK9EO-4)
Nursing associates set unit hours and work schedule to provide coverage and developed a protocol for weekend on-call. Staffing standards for the infusion center were discussed. An article in Oncology Issues (Hawley, 2009) provided a staffing model for the unit.
Options for extended space remodeling were limited since the service was scheduled for another move within two to three years. The nurses requested rooms with beds and recliner chairs to provide patients a choice. To reduce the need to search for supplies for certain procedures, buckets were purchased and supplies were placed at each patient bed or chair.
Requests for furniture and painting were approved. (NK9EO-5)
In December 2010, the Infusion Center moved to Penrose 10. Nurses organized and moved the unit with the assistance of the environmental services team. Nursing staff determined the patient flow for the unit, and worked with our Pharmacy to plan and problem-solve medication delivery. Nursing staff drafted a patient satisfaction survey for informal feedback.
Infusion hours of operation were extended to 0700 - 1800 and weekend hours were added. Staff were scheduled accordingly to stagger shifts in order to provide coverage. (NK9EO-6)
The Oncology Nursing Society standards are followed for administering chemotherapy. All new nurses must attend the Chemotherapy biotherapy 2 day class and then demonstrate competency on the unit. New nurses are instructed in the administration of other drugs and demonstrate competency on blood administration. (NK9EO-7)
Shari Mitchell, RN, Infusion Services
Diane DeMasters, BSN, RN, CGRN, Clinical Manager, Infusion Services
Kathy Guy, BSN, MHSA, RN, NE-BC, Clinical Manager Oncology
Rose Ann Moore, BSN, RN, Director of Patient Care Services, Penrose Hospital
Kate McCord, MSN, RN, NEA-BC, Chief Nursing Officer
Manuela Metzler, Manager, Staffing Office
Mike Force, Director of Pharmacy
Bill Lowes, Penrose Pharmacy Manager
Patrick Ballard, VP Finance
Aaron Bohannon, Rocky Mountain Cancer Center
Shannon Howery, Pharmacist
Gail Decker, Director Revenue Integrity
1. Serve infusion patients in the Infusion Center; reduce the number of infusion patients being served on an inpatient unit The graph below depicts the significant improvement made following the opening of the new Infusion Center and expanding hours of service. The goal has been met reflecting patient care delivery in the best service area. Since opening the Infusion Center, the decrease in outpatient infusion patients served on inpatient units is significant.
2. Patient Satisfaction The nurses designed a form based on the questions in the HCAHPS survey to obtain feedback from patients. The feedback is generally 95-100% positive. The results are collated informally and reviewed by the team. (NK9EO-8)
3. Nursing Satisfaction In 2012, all PSFHS associates completed the Press Ganey Partnership Survey. 100% of the Infusion Nurses completed this survey. The following table represents their feedback and assessment of these three Press Ganey categories:
Additionally, specific questions asked in the Press Ganey relative to this project reflect positive feedback.
Quality of care is excellence
Opportunity to be creative and innovative
Makes good use of my skills
Physical conditions are good
This survey shows that the infusion nursing team is satisfied with their job and team work. They are involved in committees within the hospital and engaged in decisions on the unit. Infusion Nurses rated their staffing and quality of care highly. During and following the move, the infusion nurses have continued to make minor changes in their environment to improve care and rate "opportunities to be creative and innovative" at the 85th percentile.
The lowest score related to environment has to do with the physical layout of the unit. The use of individual rooms down a long hall is not the nurse's preference and they look forward to moving to a wide open room with bays to improve access and ongoing surveillance of patients. While they have arranged equipment and resources to do their work, they are sharing a floor with an inpatient unit and this has created challenges in the nursing station and equipment rooms.
Our goal is to serve patients in comfortable areas with easy access and places for visitors. Our Infusion Nurses demonstrate competent nursing practice and are certified in oncology nurses since over 50% of the patients treated are oncology patients. By creating a specific unit, the nurses were able to set up equipment for easy access, collaborate with our Pharmacy to ensure timely medication administration and provide places for patients to receive their infusion in a chair or bed. In addition, unit nurses do not have to care for both inpatients and outpatient infusion patients. The infusion nurses have made PH 10 space effective and efficient, however, they are looking forward to another move in 2013. As they anticipate this change, staff is already planning for their new space. They have determined they do not want to use the work stations on wheels other than for bar code medication scanning and the need for both beds and chairs to meet patient preferences during treatment.
Nurses from all levels participated in designing use of space, obtaining needed equipment including specific chairs, allocation of computers, workstations on the unit, and the location of supplies to improve nursing practice.
Hawley, E. & Carter, N. (2009). An acuity rating system for infusion center nursing staffing. Oncology Issues, 11/12, 34-37\
- Obtaining adequate space
- Create an Infusion Center with generally accepted name vs. Outpatient Medical
- Provide extended hours to meet patient needs in one centralized location
- Private rooms
- Centralized viewing or monitoring