19th Annual. Challenges. in Critical Care

Transcription

1 19th Annual Challenges in Critical Care A Multidisciplinary Approach Friday August 22, 2014 The Hotel Hershey 100 Hotel Road Hershey, Pennsylvania A continuing education service of Penn State College of Medicine and Penn State Milton S. Hershey Medical Center in cooperation with: PA Chapter of the Society of Critical Care Medicine (PASCCM) Susquehanna Valley Chapter of the American Association of Critical Care Nurses (SVAACN) PA Society for Respiratory Care (PSRC) Educational content of this program has been endorsed by PSRC

2 Purpose: To determine whether incorporating family members on rounds in the ICU improves patient and family knowledge and comfort, and whether doing so improves team time management and satisfaction with the process. Methods: A single quaternary center s surgical ICU deployed a trial of family members on rounds for 6 months. This period (POST) was compared to the prior 6 months (PRE) assessing patient and family member knowledge and comfort, team time utilization, and physician and nurse satisfaction. Patient demographics, ICU utilization, proportion of mechanically ventilated patients, and proportion undergoing comfort care were determined and compared between time frames using Student s t-test and Chi-square as appropriate. Results: ICU demographics and utilization was similar between time frames. PRE (n=412 patient/family; 49 nurse) and POST (n=427 patient/family; 47 nurse) surveys were coupled with PRE (n=5) and POST (n=6) physician informal feedback. Patient/family knowledge of the clinical course and plans increased from 146/412; 35.4% to 374/427; 87.6% (P< ). Nurses were nearly uniformly satisfied with planned family interaction on rounds (PRE: 9/49; 18.4% vs POST: 46/47; 97.9%; P< ). Family meetings outside of rounds substantially decreased from a mean of to ; p< 0.001). Goals of therapy including end of life care became an element frequently discussed on rounds with families (PRE: % vs POST: %; P< ). One intensivist was dissatisfied with the process. Conclusions: Incorporating family members on rounds in the ICU improves communication, satisfaction, and shifts the focus of the team s time away from

3 events outside of rounds, condensing the majority of activities within the rounding structure. Critical care nurses and intensivists were nearly uniformly satisfied with the process.

4 Gastric v. post-pyloric feeding in the ICU Rosemary Montani, Cody Moore, & Leonard Shamus Early initiation of enteral feeding in adult ICU patients has proven beneficial in providing adequate caloric intake, maintaining gastrointestinal motility, and reducing the risk of infection. However, there are varying provider preferences regarding gastric versus post-pyloric feeding. Thus, we examined the literature to explore the question as to which method of enteral feeding results in better outcomes for critically ill patients. Using PubMed and CINAHL, we searched a combination of the following keywords: gastric feeding, post-pyloric, nasojejunal tube feeding, and enteral feeding. The search yielded 297 results, and we selected 10 articles for full review. Findings from four of the articles were included in meta-analyses, and two of the articles were literature reviews. Therefore, these six articles were excluded from our review. The literature indicates no significant difference between gastric and post-pyloric feeding in regards to length of stay, aspiration, or pneumonia in critically ill patients with normal gastric motility. Post-pyloric feeding does decrease residual volumes in patients with poor gastric motility; however, post-pyloric feeding is associated with more placement and obstruction issues. There is no general preference for post-pyloric over gastric feeding in patients with normal gastrointestinal motility. Post-pyloric feeding may be warranted in patients with poor motility as evidenced by high residual volumes and those who are severely critically ill. Finally, delayed nutrition due to gastric placement of feeding tubes is generally contraindicated. The authors completed this Evidence Based Practice Project under the guidance of Mary Lou Kanaskie, PhD, RN, ACON as part of the Penn State Hershey Nurse Residency Program. Correspondences may be sent to Cody Moore at cmoore6@hmc.psu.edu.

5 Stop the NOISE: Changing the Alarm Overload Environment JoAnne Konick-McMahan, MSN, RN, PCCN and Alicia Urich, MSN(c) RN Pinnacle Health System, Harrisburg, PA Description: This poster will present the process utilized by a health system to decrease alarms based on the American Association of Critical Care Nurses (AACN) Practice Alert on Alarm Management. Steps in the system change process from the information gathering phase through implementation and evaluation will be provided. Quality outcome data pre and post changes will be provided with implications for future work. Key steps and supporting evidence from AACN s Practice Alert on Alarm Management will provide the basis for the nursing work presented in this poster The two phases of the Joint Commission s National Patient Safety Goal of Clinical Alarm Safety are a driving force for health systems to support clinicians efforts to decrease alarms and will be included in the information. The process of data-driven change in alarm management on a step-down unit within the health system will be presented with before and after change numbers. System change through a Nurse Practice Council initiative to develop a telemetry discontinuation order set based on American Heart Association guidelines will be included in the poster. Steps in the process including education initiatives, multidisciplinary team members, and the use of champions will be presented. Evaluating the results and planning for next steps will complete the poster presentation of managing alarms to avoid alarm fatigue. References: American Association of Critical Care Nurses (2013). Alarm Management Practice Alert Joint Commission (2013). New NPSG on clinical alarm safety: phased implementation in 2014 and Accessed September 14, 2013.

6 Title: Don t Stress, Clean Up the Mess: Maintaining a Healthy Work Environment While Decreasing Foley Catheter Utilization Authors: Tara Ostinowsky and Amy Fisher Background and Methods: As a result of the current changes in our Healthcare System, the nurses in the Medical Intensive Care Unit (MICU), specifically the MICU Practice Council, devised and implemented a plan to decrease Catheter Associated Urinary Tract Infections (CAUTIs) and indwelling urinary catheter (Foley catheter) utilization. This initiative was an organizational goal set forth by the academic medical center. Despite initial resistance from the staff nurses, the MICU Practice Council developed and implemented strategies to tackle this dramatic culture change in nursing practice within the unit. The Practice Council identified communication and education as key components to successful implementation of this initiative. The Practice Council goals included decreasing the number of Foley catheter days, re education on Foley catheter insertion/maintenance, and reeducation of urine culture collection. The Council utilized three volunteer staff nurses to perform the role of CAUTI Champion to help disseminate this information and be positive change agents on the unit. The MICU nurses were accustomed to the utilization of Foley catheters for containment of urine in sedated and/or ventilated patients, accurate intake and output balance, and assessment of renal function. Due to the increased workload created by incontinent patients, the staff became more stressed and passionate about the need for Foleys in the MICU patients. The staff initially resisted feedback from the CAUTI Champions and expressed multiple concerns about decreased Foley utilization and how it was detrimental in regard to skin breakdown, patient s dignity, and accurate output measurements. In response to this, the MICU Practice Council discussed different ways to deal with each of the staff s concerns at a monthly meeting. One of these ways was an inter professional approach involving the MICU physicians, a wound/ostomy nurse, a Clinical Nurse Specialist, the MICU skin resource nurses and the CAUTI Champions. Stoma and the MICU skin resource nurses offered several recommendations for skin care and prevention of skin related issues. Different urine containment devices, such as new condom catheters and a female urine collection device were also trialed and evaluated to help assist with the patient s dignity, accurate urine measurements and assist with the nurses stress due to frequent patient hygiene. The hospital also provided two tools that were helpful with determining catheter necessity and catheter utilization days (QI tool/m page). Initially, Practice Council encouraged the Charge nurse and the MICU fellow to use the QI tool daily in patient rounds. At the monthly Practice Council meetings, staff nurses who began to support and advocate for this initiative were recognized for their exemplary nursing practice and received a letter commending their efforts in this difficult culture change. These staff recognitions, along with statistical data updates highlighting both positive progression and areas for improvement, were added to monthly Practice Council s to aid in staff s awareness of achieving the organizational goal. Results: The device utilization average prior to this initiative from January 2013 to June 2013 was From the start of the initiative in July 2013 to December 2013, the device utilization average was The overall device utilization continues to decrease. From January to May 2014, the utilization average was The MICU outperformed NDNQI benchmark for CAUTI 2 out of 3 quarters. It is now commonplace to hear frequent discussions on necessity of Foleys between staff nurses. Nurses now advocate to the physicians to prevent Foley placement for unnecessary reasons. Nurses no longer believe every patient needs a Foley in the ICU just because they are intubated or critically ill. Conclusion: Several months into this initiative, Practice Council began to see a shift in attitudes and staff began embracing these practices as evidenced by a decrease in our device utilization days. The staff is no longer resistant to these practices, but actually encourages each other to remove Foley catheters when appropriate. Not only are Foleys removed earlier, but they are also put in less frequently.

7 Title of abstract - Evidenced-based Guidelines and Scripting to Support Acute Care Nurses in Sepsis Recognition, Reporting and Treatment INTRODUCTION Severe sepsis is a significant problem; with an incidence ranging from 300 to greater than 1000 cases per 100,000 US population annually with associated mortality associated from 30% to 60%. The Institute for Healthcare Improvement (IHI) care bundles and the Surviving Sepsis Campaign (SSC): International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 advocates use of evidence-based practice as a means to improve patient outcomes and decrease mortality. A review of MMC medical records over a nine-month period (July 2012-March 2013) at the project site revealed that sepsis was one of the top 10 diagnoses (N=492) in the hospital (Diagnosis-Related Groups [DRG] 870, 871, & 872). A chart audit also revealed that nurses were not consistently completing the sepsis screen in the electronic medical record (once per day recommended) and compliance with IHI s three and six hour bundles was inconsistent. METHODS Nurses (N=681) received an educational intervention on the IHI bundles and SSC guidelines during annual competency updates. An EHR tool was reintroduced which provided a platform for sepsis screening. Introduction, Situation, Background, Assessment, and Recommendation scripting was implemented to support nurses report of positive findings. RESULTS Nurses rated themselves (Table 1) as significantly more knowledgeable about sepsis after the education, significantly more sure that the hospital has a consistent definition and treatment for sepsis, increased their belief that their peers were aware of the differences in sepsis states, and were more comfortable about their ability to recognize sepsis and report it to a provider (all p < ). Nurses knowledge of sepsis demonstrated a statistically significant difference between the pre and post test (all p < 0.001). For 9 out of 10 questions, there was a statistically significant improvement (Table 2) in the percentage of nurses who answered the item correctly in the post test (the improvement ranges for scores increased by 7.28 to 63.5%). The number of patients who never received the recommended screening decreased from 40.6% pre to only 8.9% post, while the number who received at least some screening increased from 59% to 91%. Statistical significance was demonstrated (Graph) in improved incidence of sepsis screening post educational intervention (p<.0001). CONCLUSION Having nurses at the point of care to implement the sepsis bundles is likely to result in less variability in the screening process and missed opportunities for early diagnosis and treatment. A nursing education intervention coupled with the use of an EHR sepsis screening tool promotes improved sepsis screening, recognition and report, and increased nurse knowledge and compliance with IHI bundle and SCC guideline adoption.

8 Early Progressive Mobilization in the ICU: An Evidence Based Practice Project Purpose: To develop and implement an early progressive mobility pilot protocol in a tenbed medical surgical intensive care unit (MSICU) at a 572 bed community teaching hospital. Evidence suggests that immobility has been linked to mortality, morbidity, complications, and increased patient length of stay (LOS). ICU acquired weakness impairs ventilator weaning and functional mobility. According to the literature, use of a protocol that promotes early and progressive exercise is associated with a decrease in ICU days and hospital LOS. Development of a mobility protocol streamlines the process, increases the patients out of bed activities, and decreases the hazards of immobility. It has been shown to be both feasible and safe and has yielded improved patient outcomes. Methods: Pre/Post data were collected for three months on patient demographics, ventilator days, and ICU and hospital LOS in days. Following implementation of the protocol the number and percentage of patient adverse events during mobility sessions were documented. Data were analyzed to determine whether early mobility resulted in a decrease in ventilator days and hospital and ICU LOS. Establishing a process to increase patient activity may decrease the cost of care and improve patient outcomes. Results: Pre intervention N=180 patients, post intervention N=167 patients. Demographics were very similar between groups. In the pre intervention period more patients were discharged to other facilities for ventilator weaning. In the post intervention group more patients were discharged to a rehabilitation or skilled nursing facility. Hospital LOS decreased by 0.10 days and ICU LOS decreased by 0.42 days. Neither were statistically significant. Ventilator days decreased by 1.77 days, which was statistically significant. Decreased ICU LOS and ventilator days resulted in a three month cost avoidance of $147, One adverse event, removal of an NG tube, occurred during a mobility session. Implications: A protocol will streamline the process for enhancing progressive mobility to all patients in the ICU. Patient care outcomes can be improved with significant cost avoidance in both ICU and ventilator days. Early rehabilitation therapy and ICU mobilization is feasible and safe and can be implemented successfully in the ICU.