Madigan Army Medical Center

Transcription

1 Brian Weisgram Susan Raymond Using Evidence-Based Nursing Rounds to Improve Patient Outcomes Madigan Army Medical Center (MAMC) is a 204-bed, level two trauma center responsible for care of soldiers and their beneficiaries. Located near Tacoma, WA, on Fort Lewis, this medical center serves more than 120,000 beneficiaries for primary and tertiary care in the region, and is the largest Army Medical Center on the West Coast of the continental United States. Although military hospitals are not required to have Joint Commission reviews, the facility gladly welcomes surveyors and scores very highly with each periodic review. The ability to compare military services to civilian health care networks by Joint Commission reviews allows the military health care system to demonstrate high standards of patient care and delivery methods. Additionally, such reviews MAJ Brian Weisgram, MSN, RN, CCRN, CNS, is a Major, Army Nurse Corps, and was the Critical Care Clinical Nurse Specialist, Madigan Army Medical Center, Fort Lewis, WA, at the time this article was written. He is currently Head Nurse, Intensive Care Unit, Evans Army Community Hospital, Fort Carson, CO. COL Susan Raymond, MSN, RN, ACNP, is a Colonel Army Nurse Corps, and was the Chief Critical Care Service, Madigan Army Medical Center, Fort Lewis, WA, at the time of this article was written. She is currently Chief Nurse, 86th Combat Support Hospital, Baghdad, Iraq. Disclaimer: The opinions and views expressed in this article are those of the author and do not necessarily represent those of the U.S. Army Nurse Corps, nor those of the U.S. Department of Defense. demonstrate that Army hospitals meet the same standards by which civilian facilities are judged. Within MAMC, this is demonstrated by an intense focus on graduate medical education and registered nurse advanced skills training courses as noted by 19 residency programs, 8 fellowship programs, one of four 16- week Army critical care nursing programs, a clinical site for nurse anesthetist training, and a 16-week operating room nursing course. In continued efforts to maintain high standards of patient care at MAMC, the Joint Commission s 2008 National Patient Safety Goals were reviewed formally. This review was part of the systematic approach to improving health care in the critical care arena and the continued pursuit of an evidence-based health care methodology. Reducing the risk of harm resulting from falls (Goal #9) became the focus of the Critical Care Section for the stepdown telemetry unit. This unit was identified to have greater than 75% patient movement and a high turnover rate of nursing staff. The number of patient falls in the last year was the impetus for selecting this goal. Also, potential implementation of measures to decrease the fall rate were examined. Pilot Project In the first quarter of 2007, an increase in patient falls was noted in this busy unit. A discussion by the critical care supervisor and the clinical nurse specialist led to the development of an evidenced-based approach to reduce falls. A review of the literature was performed, and one study was found that validated the use of frequent nursing rounds as a strategy to decrease falls and call light use (Meade, Bursell, & Ketelsen, 2006). The interventions proposed in this study seemed to provide a feasible solution to the problem of falls. Hourly nurse rounding is an example of a protective strategy to reduce accidental and anticipated falls (Morse, 2002). The Madigan Nursing Research Department was consulted to help design and implement the program. The decision was made to replicate the study interventions from Meade and colleagues (2006) with a pilot project on the telemetry ward. A timeline was created to guide program implementation with goal dates for specific interventions. Data collection of nurse call bell usage was initiated first using a convenient check sheet placed adjacent to the call monitor. The staff annotated the time a call was received and the nature of the call by checking one of six categories, such as assistance getting to the bathroom, need for medication, need for a nurse, and other care issues. This report was tabulated daily and entered into a database to capture the number, type, and time of nurse calls in a 24-hour period to provide a sense of the demand the call bell system placed on the nursing staff. Note: Military nursing offers unique practice opportunities. Share your perspectives on your practice as a nurse in the Armed Forces with the readers of MED- SURG Nursing by submitting a manuscript in consideration for this column. Questions and submissions can be directed to the Editor, Dottie Roberts, at msjrnl@ajj.com. MEDSURG Nursing December 2008 Vol. 17/No

2 The rounding process and the Meade et al. (2006) article were discussed with the staff during multiple sensing sessions prior to implementing the program. Champions of the program were identified to facilitate the implementation process, and to encourage their peers and co-workers to support the program. The Nursing Rounds Program consisted of the nurse or designee performing a 12-step process related to the systematic approach to patient care that is typically taught in nursing education. This emphasis on a patient-centered, organized approach to providing attentive nursing care demonstrated the ability to reduce the potential for harm from falls and enhance patient satisfaction. During these rounds, nurses performed the 12-step patient-nurse interaction (see Table 1), including evaluations of pain, toileting needs, positioning, and access to call light, telephone, tissues, and trash can. The program consisted of hourly rounding between 8:00 a.m. and Table Step Nursing Rounds Chart Q1 Hour 0800 to 2200 & Q2 Hours The following items will be checked and performed for each patient. Upon entering the room, tell the patient you are there to do your rounds. During the evaluation, also assess the patient s mental status including location/orientation. 1 Assess patient pain levels using a pain assessment scale. If needed, contact an RN immediately for pain relief so the patient does not have to use the call light. 2 Put medication as needed on RN s scheduled list of things to do for patients and offer the dose when due. 3 Offer toileting assistance. 4 Ensure patient s ID band is on and verify the patient s identity by name and birthday. Verify the easy ID band is on. 5 Make sure the call light is within the patient s reach. 6 Put the telephone within the patient s reach. 7 Put the bedside table next to the bed. 8 Put the tissue box and water within the patient s reach. 9 Put the garbage can next to the bed. 10 Assess the patient s position and position comfort. Ask if patient needs to be repositioned and is comfortable. 11 Prior to leaving the room, ask, Is there anything I can do for you before I leave? I have time while I am here in your room. 12 Tell the patient that a member of the nursing staff will be back in the room making nursing rounds in an hour (or in 2 hours during the night). Source: Modified from Meade, Bursell, & Ketelsen, :00 p.m., and rounding every 2 hours between 10:00 p.m. and 8:00 a.m. A verbal agreement was made with the patient to have a staff member return every 1-2 hours. Outcomes The outcomes that were being monitored during this program included patient falls, call light use, adherence to the 12-step hourly rounds program, and patient satisfaction. The preliminary results of the program demonstrated 84%- 96% nursing adherence to the 12- step hourly rounds program. Patient call light use decreased from a high of 120 to 20 calls in a 24-hour period. Staff observed that when one RN s adherence to the rounding program decreased by 50%, there was an immediate jump in the call light use from 20 to 69 calls over one 24-hour period. This spontaneously prompted self-policing from the other nursing personnel on the unit. Overall, this evidence-based 12-step hourly rounds program has initially decreased patient call light use by 23%. Although more data need to be gathered, fewer falls also have occurred in the first 30 days of the program. The project team has devised a timeline to continue evaluating this program for its long-term effects on call light use, patient satisfaction, and patient safety. Based on the successful results to date, the 12-step hourly rounds program has been expanded to additional medical-surgical units within the facility. If the program is effective overall, the goal is to propose implementation of this program throughout the facility as an operational systems change in accordance with the Joint Commission s National Patient Safety Goal #9. References Meade, C.M., Bursell, A.L., & Ketelsen, L. (2006). Effects of nursing rounds on patients call light use, satisfaction, and safety. American Journal of Nursing, 106(9), Morse, J.M. (2002). Enhancing the safety of hospitalization by reducing patient falls. American Journal of Infection Control, 30, Visit the AHRQ Patient Safety Network Web Site AHRQ s national Web site the AHRQ Patient Safety Network, or AHRQ PSNet continues to be a valuable gateway to resources for improving patient safety and preventing medical errors and is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety. The Web site includes summaries of tools and findings related to patient safety research, information on upcoming meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site around their unique interests and needs through the Web site s unique My PSNet feature. To visit the AHRQ PSNet Web site, go to MEDSURG Nursing December 2008 Vol. 17/No. 6

3 Karen Fitzgerald Should Families Be Present During Resuscitation? Family presence during patient resuscitation has been discussed and debated since the early 1990s. Health care professionals and family members voice varying opinions on this topic, but research indicates that those who have had the experience found it positive. Should family members be offered the option to witness resuscitation efforts at their loved one s bedside? If family presence (FP) is allowed, does it positively or negatively affect the resuscitation efforts, the family, or the staff? Pros and Cons During a recent informal survey of nursing staff in medical-surgical, progressive, and intensive care units at a Long Island hospital, 50 nurses offered varying responses about allowing FP during patient resuscitation. Comments ranged from, Absolutely not to Absolutely yes. Some of the arguments against FP included, too traumatic for the family; there are too many people in the room already; and the code may continue beyond when it would normally be called. The situational arguments included, If the patient is very young or very old, it would be OK; and If the code is expected, the family would be prepared, so it would be OK. Those with positive responses indicated that FP helped the family see that every- Karen Fitzgerald, RN, is Clinical Educator, Critical Care, Good Samaritan Hospital Medical Center, West Islip, NY. thing was done, and to bring closure to the patient s death. Is it a coincidence the positive responses were primarily from staff who had experienced family presence during resuscitation? MacLean, Guzzetta, White, Fontaine, and Eichorn (2003) noted a significantly greater percentage of respondents who preferred allowing family presence during resuscitation had previous experience with FP. Other researchers found nurses initially opposed to FP will change their attitudes after witnessing the connection between the patient and the patient s family and establishing their own relationship with the patient s family (Mian, Warchal, Whitney, Fitzmaurice, & Tancredi, 2007). The range of responses to the question about FP reflects what researchers have found. For example, Alspach (2006) offered advantages and disadvantages to FP in the critical care setting (see Table 1). Advantages Family members can observe the efforts of the health care team. Family Opinions In 1994, the Emergency Nurses Association (ENA) adopted its first position statement on the issue of FP (ENA, 2005). Since then, the American Heart Association, the American Association of Critical- Care Nurses, the National Association of Social Workers, and the National Association of Emergency Medical Technicians have made recommendations supporting FP. A 1998 study tried to determine if witnessing resuscitation had any adverse psychological effects on bereaved relatives (Robinson, Mackenzie-Ross, Hewson, Egleston, & Prevost, 1998). Even though the sample size was small, researchers found no reported adverse psychological effects among the relatives who witnessed resuscitation; all of them were satisfied with their decision to remain with the patient. The resuscitation was not interrupted, and the decision to discontinue was not delayed because of the presence of a rela- Table 1. Advantages and Disadvantages of Family Presence Disadvantages Family members may disrupt resuscitation efforts. Promotes trust by removing secrecy. Fear of litigation may inhibit the actions of the health care team. Family can provide support to their Patient s privacy may be violated. family members and feel as if they are participating in the healing process. The practice is consistent with a holistic family-centered approach to care that sees the patient and family as the unit of care. Source: Alspach, Additional stress is put on the health care staff. MEDSURG Nursing December 2008 Vol. 17/No

4 tive. Relatives did not comment on any of the technical or procedural difficulties encountered during some resuscitations. A more recent survey of 39 family members and 96 health care providers identified attitudes and experiences following FP (Meyers, Eichorn, Guzzetta, Clark, & Taliaferro, 2004). Researchers found 95% of family members said the visitation helped them comprehend the seriousness of the patient s condition and know every possible intervention had been done, and it allowed them to provide comfort and protection to a loved one. Overall, they viewed the experience as a positive one. Core Concept Dignity and respect Information sharing Participation Collaboration Table 2. Core Concepts of Family-Centered Care Definition Patient and family knowledge, values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care. Patients and families receive timely, complete, and accurate information in order to effectively participate in care and decision-making. Patients and families are encouraged and supported in participating in care and decision-making at the level they choose. Patients and families are also included on an institutionwide basis including the delivery of care. Source: Institute for Family Centered Care, What Is Family? According to the U.S. Census Bureau (2007), family is a group of two or more people who reside together and who are related by birth, marriage, or adoption. A broader definition may be needed to include all individuals a patient in fact may identify as family. The Institute for Family-Centered Care (2006) defined family as two or more persons who are related in any way biologically, legally or emotionally; patients and families define their families. Being Family-Centered Historically, the sick received care from the family at home. Technologic advances led to provision of more health care by nurses in the hospital setting. Families often were excluded from providing for the needs of their loved ones (Nibert, 2005). Restricted visiting hours and limitation of visitors at the bedside further increased the distance between patients and their families. Traditionally, during resuscitation efforts, families were led from a room and away from their loved one, often into a private waiting area where they were left alone and uninformed. Frequently, the needs of the family at that time were not considered (York, 2004). A philosophy of family-centered care gained momentum in pediatric practice in the latter 20th century as research identified the effects of parental/child separation during hospitalization (Committee on Hospital Care, American Academy of Pediatrics [AAP], 2003). The idea of involving the family in aspects of care grew to include the hospital delivery room as husbands and other family members wanted to be present during birth (Dokken & Ahmann, 2006). Open visiting hours now are more common in various settings, and family members have become involved in many aspects of care that historically were reserved for nurses. At times, health care providers have resisted these changes. Viewing the family as a continuation of the patient should put these changes in perspective. Changing the way health care providers think about the patient and the family improves patient and family outcomes, increases patient and family satisfaction, builds on family strengths, increases professional satisfaction, decreases health care costs, and leads to more effective use of health care resources (AAP, 2003; Davidson et al., 2007; Institute for Family Centered Care, 2008). Families today are exercising their right to be present during resuscitation the same way they once did to have fathers present in the delivery room (Davidson et al., 2007). A family-centered philosophy requires that outdated rules and regulations that were imposed for the benefit of the organization or staff rather than patients or patients families should be reexamined (Briguglio, 2007). According to the Institute for Family- Centered Care (2008), the core concepts of family-centered care include dignity and respect, information sharing, participation, and collaboration (see Table 2). Emotional Well-Being Effective implementation of FP includes the use of a liaison to assess the emotional well-being of the relative, explain what the family would witness in the room, and stay with the individual throughout the resuscitation (Henneman & Cardin, 2002). In addition, the liaison prepares the family for the loved one s appearance, the procedures being performed, and situations which might require them to be escorted from the room (Meyers et al., 2004). The liaison can be a member of the pastoral care staff or a nurse provider who is well versed in the resuscitation effort. Sometimes family members may just want to say good-bye or offer reassurance and support to the patient. They want to know that everything possible is being done. Asking them to wait outside may further increase their anxiety and stress. Families indicated their presence during resuscitation or invasive procedures decreased worry, minimized the agony of waiting, helped them face the reality of the situation, lessened helplessness, and facilitated grieving in later months (Meyers et al., 2004). They also believed their presence had an effect on health care providers as a reminder of personhood, helping the providers view the patient as a person and part of a family. 432 MEDSURG Nursing December 2008 Vol. 17/No. 6

5 Communication Researchers identified family members needs during a healthrelated crisis, including honest, consistent, thorough communication with health care providers (Duran, Oman, Abel, Koziel, & Szymanski, 2007). Open, honest communication can alleviate anxiety, provide information to the patient and family for making important decisions, and decrease litigation. Effective communication leads to greater comfort in families expecting the resuscitation, and helps staff determine family wishes in the event resuscitation is needed; it also increases the use of advance directives (Barclay & Lie, 2007). A health care provider may find it helpful to ask a family member contemplating FP, If your loved one were able to speak for herself, what do you think she would want us to do for her? (Davidson et al., 2007). Future Plans Because the majority of patients do not survive the resuscitation efforts, it is difficult to know if they may have wanted their family members present. This indicates the need for public education to discuss a family member s desire for FP in much the same way as advance directives and organ donation (Halm, 2005). As Azoulay and Sprung (2004) noted, There is a need for raising public awareness that end-of-life care is more an everyday-life issue than a medical issue. In addition, the majority of research was performed in hospital emergency departments, critical care units, and pediatric care areas. Further research should be expanded to include medical-surgical units. Conclusion Only about 5% of institutions have written policies on FP, but 45% of the nurses surveyed allow FP (MacLean et al., 2003). Barriers to FP still remain, but a multidisciplinary approach with development of a written policy can address the obstacles and allow staff to reflect on the successes. I was pleasantly surprised by the discussions which ensued among nursing staff after my informal survey about FP. With the nurses more open to FP, staff members will be initiating conversation with patients and families, instead of waiting for the family to ask to remain in the room. More information about family presence during resuscitation can be found on the ENA Web site ( References Alspach, J.G. (2006). Core curriculum for critical care nursing (6th ed.). Philadelphia: Saunders Elsevier. Azoulay, E., & Sprung, J.D. (2004). Familyphysician interactions in the intensive care unit [Electronic verison]. Critical Care Medicine, 32(11), Barclay, L., & Lie, D. (2007). New guidelines issued for family support in patient-centered ICU [Electronic verison]. Medscape Medical News, Retrieved February 8, 2008, from viewarticle/551738?src=mp Briguglio, A. (2007). Should the family stay? RN, 70(5), Committee on Hospital Care. American Academy of Pediatrics [AAP]. (2003). Policy statement. Family-centered care and the pediatrician s role [Electronic verison]. Pediatrics, 112(3), Davidson, J.E., Powers, K., Kamyar, K., Tieszen, M, Kon, A.A., Shepard, E., et al. (2007). Clinical practice guidelines for support of the family in the patientcentered intensive care unit: American College of Critical Care Medicine task force [Electronic verison]. Critical Care Medicine, 35(2), Dokken, D., & Ahmann, E. (2006). The many roles of family members in family-centered care-part 1 [Electronic verison]. Pediatric Nursing, 32(6), Duran, C.R., Oman, K.S., Abel, J.J., Koziel, V.M., & Szymanski, D. (2007). Attitudes toward and beliefs about family presence: A survey of healthcare providers, patients families and patients [Electronic verison]. American Journal of Critical Care, 16(3), Emergency Nurses Association [ENA]. (2005). Position statement. Family presence at the bedside during invasive procedures and cardiopulmonary resuscitation. Retrieved November 20, 2007, from asp Halm, M. (2005). Family presence during resuscitation: A critical review of the literature [Electronic verison]. American Journal of Critical Care, 14(6), Henneman, E.A., & Cardin, S. (2002). Familycentered critical care: A practical approach to making it happen [Electronic verison]. Critical Care Nurse, 22(6), Institute for Family-Centered Care. (2006). Partnering with patients and families to design a patient- and family-centered health care system. Retrieved February 6, 2008, from edcare.org Institute for Family-Centered Care. (2008). Core concepts. Advancing the practice of patient and family-centered care. Retrieved February 6, 2008, from MacLean, S.L., Guzzetta, C.E., White, C.I., Fontaine, D., & Eichorn, D.J. (2003). Family presence during cardiopulmonary resuscitation and invasive procedures: Practices of critical care and emergency nurses [Electronic verison]. American Journal of Critical Care, 12(3), Meyers, T.A., Eichorn, D.J., Guzzetta, C.E., Clark, A.P., & Taliaferro, E. (2004). Family presence during invasive procedures and resuscitation [Electronic verison]. Top Emergency Medicine, 26 (1), Mian, P., Warchal, S., Whitney, S., Fitzmaurice, J., & Tancredi, D. (2007). Impact of a multifaceted intervention on nurses and physicians attitudes and behaviors toward family presence during resuscitation [Electronic verison]. Critical Care Nurse, 27(1), Nibert, A.T. (2005). Teaching clinical ethics using a case study: Family presence during cardiopulmonary resuscitation [Electronic verison]. Critical Care Nurse, 25(1), Robinson, S.M., Mackenzie-Ross, S., Hewson, G.L.C., Egleston, C.V, & Prevost, A.T. (1998). Psychological effect of witnessed resuscitation on bereaved relatives [Electronic verison]. Lancet, 352(9128), United States Census Bureau. (2007). Definitions and explanations: Appendix A. Retrieved February 20, 2008, from York, N.L. (2004). Implementing a family presence protocol option [Electronic verison]. Dimensions of Critical Care Nursing, 23(2), MEDSURG Nursing December 2008 Vol. 17/No