Be a Champion for Excellence: Improving Outcomes While Empowering Nurses By Glenda Riggs RN, VHA-CM, CNL (C)

Be a Champion for Excellence: Improving Outcomes While Empowering Nurses By Glenda Riggs RN, VHA-CM, CNL (C)

Objectives To discuss projects designed, implemented or managed by the ICU CNL candidate To explore specific outcomes influenced by CNL candidate in ICU Review the steps to empowering the nurses Review the Iowa Model for EBP

Pieces to the Puzzle Nursing Education Empowering the nurses to identify problems and pilot solutions Implement EBP into the culture : easier said than done

ICU/SDU The challenge: Organize chaos RN Vacancy Rate and Impact Bed closures Surgical delays Financial strains Unacceptable infection rates The solution: Implementation of the CNL

Is there one simple answer to the problem No

Education:Developing and initiating a comprehensive education program for new graduates and seasoned nurses to increase nurse s knowledge base and establish standard work. Orientation: Develop and initiate a staged orientation programs that customizes the learning process in order to meet nurse s individual needs and reinforce standard work. Competency: Develop and initiate an annual competency program to standardize and maintain nurse s skills while reinforcing standard work.

Support and Accountability: CNL rounds on all patients to monitor all performance measures and evaluate patient s needs while offering nursing support and accountability. Multidisciplinary teams: CNL initiates multidisciplinary patient/family meetings on all patients in ICU that are complicated or have been in ICU for seven days or longer. Evidence Based Practice: Develop system redesign teams for protocol changes to empower nurses to utilize evidence based practice with the goal of improving patient outcomes such as: hyperglycemia, hypoglycemia and sepsis.

Empowering nurses Comprehensive education program Staged orientation program

Standard Work vs. Autonomy Empower the nurses to use EBP creating Autonomy Implementing the change creating standard work

Improving Outcomes Improved outcomes with sustainability only happens when the nurses are empowered to make changes Administration focuses on a topic and the outcome improves until the focus changes and the outcome declines How do we achieve improved outcomes with sustainability?

CNL Interventions in the ICU Improved Patient Care and Outcomes 5 Million Lives Campaign Central Line Bundle VAP RRT Improved Staff Competency and Morale Staged Orientation Critical Care Course Development 36/40 work week Shared Governance CCRN study group Improved patient safety (visibility with rounding)

ICU Recognition Rate - Inf/1000 ventilator days 7 6 5 4 3 2 1 SAVAHCS Ventilator Associated Pneumonias - ICU UCL 6.6 5.2 4 3.1 2.2 2 1.9 CL 1.7 1.4 0 Q1 08 0 0 0 0 0 0 0 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 08 08 08 09 09 09 09 10 10 10 10 11 11 7 6 Rate - inf/1000 line days 5 4 3 2 1 SAVAHCS ICU Central Line Related Blood Stream Infection Rates UCL 6.2 5.5 3.3 2.7 2.5 2.1 2.1 CL 1.3 1.3 1.25 1.4 1.8 1.1 0 0 0 0 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09 Q2 09 Q3 09 Q4 09 Q1 10 Q2 10 Q3 10Q4 10Q111 Q2 11

Update : off the path VAP:One VAP in November 2011 Central line infection: Three new central line infections: One in October, November, and December ( the ICU made a change to swab caps) An aggressive education program on how to use swab caps was initiated \ Results: we have gone three months with no hospital acquired infections. Back on Path

RRT decreased Codes outside of ICU by 54%

Pain Template Developed Meets requirement of VHA directive, Joint Commission And needs of nurses

Empowering the nurses to achieve excellence Interdisciplinary patient and family meetings CNL rounding on all ICU patients: supporting the staff and patients Initiating standard work for nurses Aim: Improve Patient Outcomes

Results in the ICU RN Vacancy Rate 26% in 2008 Vacancy decreased to zero and maintained through 2010 Currently 2 vacant positions Interdisciplinary Family Meetings resulting in decreased length of stay Hypoglycemic Protocol

Outcome Data Fy10 to Fy11, ICU went 77 weeks no central line infections Fy10 to Fy11. ICU went 88 weeks no VAPs No ICU MRSA transmissions for two years, Fy10 and Fy11 Sepsis mortality rate decreased from 48 % to 16% in Fy10 Prior to implementation of the insulin protocols, incidents of events with blood sugars less than 45mg/dL in 2009 averaged 2.25%. Our Fy10 rate decreased to 0.8% and we have earned recognition by IHI (Institute for Healthcare Improvement) and IPEC (Inpatient Evaluation Center) as best practice.

Aim The aim of the CNL is to improve patient outcomes and empower the nurses. Evidence based heath care must be embedded into the nursing culture to maintain the quality of care patients deserve and expect. It is the combination of Standard Work, Culture of Caring, Evidence Based Care, and Skilled nursing care that improved patient outcomes at SAVAHCS. The CNL responsibility is to inspire the nurses to achieve excellence.

Empower the Nurses by implementing Pilot Studies Nurses identify a problem Empower the nurses to develop a PICOT question Empower nurses to complete an EBP literature search Empower the nurses to implement a Pilot Study following the Iowa Model for change Empower the nurses to make a change according to the evidence

SAVAHCS winners of the 2011 Carey Performance Excellence Award The SAVAHCS was honored with the Robert W. Carey Performance Excellence Award for 2011. There was only seven awards given across the nation. This prestigious award recognized SAVAHCS as a leader in sustaining high levels of performance an service to our veterans.

Example of a Pilot study Pressure ulcer prevention bundle

By Glenda Riggs

Pressure Ulcers Pressure ulcer (PU) A localized area of damage to the skin and underlining tissue caused by pressure, shear, friction, or a combination of these factors Hospital Acquired Pressure Ulcer (HAPU) A pressure ulcer developed during a stay in the hospital

Problem Pressure ulcers are a global concern Pressure ulcers complicate the hospitalization resulting in higher morbidity, mortality and increase cost for the patients Critically ill patients are at higher risk for PUs and prevention can be very challenging

Two and half million Pressure ulcers (PU) are treated annually in acute care facilities across the United States. The cost of a single full thickness PU is approximately $70,000 resulting is a cumulative cost in the range of up to $11 billion (Slowikowski & Funk, 2010)

Problem The Southern AZ VA Health Care System (SAVAHCS) is a 285-bed hospital with a 19 bed Intensive Care Unit (ICU) Hospital acquired pressure ulcers (HAPU) are Hospital acquired pressure ulcers (HAPU) are considered preventable, and have become a liability for hospitals and caregivers (Peterson, Schwab, Van Oostrom, Gravenstein, & Caruso, 2010).

Organizational Culture and Readiness for System-Wide Integration of Evidence Based Practice (EBP) Southern Arizona VA Health Care System (SAVAHCS) is dedicated to EBP SAVAHCS s EBP committee implements all practice changes Iowa Model of Evidence-Based Practice to Promote Quality Care is used for guidance at SAVAHCS EBP is encourage and is embedded into the culture at SAVAHCS SAVAHCS is committed to improving quality of care by using EBP

Proposed PICOT Question In the ICU with acute and chronic critically ill patients at risk for pressure ulcers (P), how does the initiation of an aggressive pressure ulcer prevention action plan bundle consisting of seven interventions (I), compared to the current standards: regular mattress surface, HOB greater than 45 degrees, dressings only over pressure points after diagnosis of PU stage one or greater, cushions on O2 tubing when red or painful, skin protectant after dermatitis, and every two hour turns at 20 to 40 degrees (C), decrease the rate of HAPUs in the SAVAHCS ICU (O), within a three month pilot study (T)?

Review of Evidence and Synthesis of Literature The literature supported the design of the pressure ulcer prevention bundle presented in the proposed PICOT question. Cumulative Index to Nursing and Allied Health Literature (CINAHL): Major heading: pressure ulcer Subheading: prevention and control

PUP Bundle Interventions 1. Risk assessment using the Braden Scale 2. Repositioning 3. Nutrition assessment 4. Skin assessment every shift 5. Skin intervention with appropriate Medline skin product 6. Allevyn dressing 7. Cushion to protect ear from o2 tubing

Pilot study The survey team will implement a pressure ulcer prevention bundle consisting of seven evidence-based intervention Measure the effectiveness of the prevention bundle. Measure the impact of educational interventions on the knowledge base of the nursing staff Initiate further research as indicated using the Iowa Model for change

Solution Education for all nursing staff on pressure ulcer prevention (PUP) and treatment Implement a PUP bundle in the SAVAHCS intensive care unit (ICU) The bundle will be initiated when the Braden Scale (pressure ulcer risk assessment) scores mild risk or higher Survey team will monitor the pilot study by rounding daily on every patient in the ICU

EBP literature search on pressure ulcer prevention (PUP) Evaluation of Pilot study and initiation of further research Goal: Elimination of Pressure Ulcers in SAVAHCS ICU Nursing education on pressure ulcer prevention and treatment Initiation of a PUP Pilot Study

Solution and Expected Outcomes The objective of the proposed evidence based study is for SAVAHCS nursing staff to initiate a HAPU prevention bundle consisting of evidence-based interventions with a goal of eliminating HAPU at SAVAHCS ICU. BY: Increase the knowledge base of the nursing staff for PUP and treatment Implementing an evidence based PUP bundle consisting of seven intervention

Solution and Expected Outcomes The following outline covers the proposed solutions and expected outcomes of the project: A risk assessment using the Braden Scale is imperative in preventing PUs The Braden Scale offers the best sensitivity/specificity balance and the highest prediction rate (Gray-Siracusa & Schrier, 2011).

continued Reposition the patient every two hours using pillows Nurses will be educated on turns using the 30-degree tilt side-lying position with pillows to support the back, knees, and ankles (Gray-Siracusa & Schrier, 2011).

Continued Reposition A dynamic surface compared to a static surface is preferred. The air chambers alternate relieving the pressure points resulting in decreased PUs (Gray- Siracusa & Schrier, 2011). The head of bed will be kept less than 30 degrees and the heels floated with Gaymar boots. A Gaymar seat air mattress will be initiated when out of bed in chair with every one-hour repositioning.

Solution and Expected Outcomes A nutrition consult will be implemented for all patients at risk. The consult will meet the individual needs of the patient s nutritional needs. A detailed skin assessment needs to be performed on admission and every shift in order to document any existing PUs and to determine the needs of the patients.

Solution and Expected Outcomes Proper skin care using Medline skin care products: Remedy Antimicrobial Cleanser, Remedy Skin Repair Cream, Remedy Inzo Barrier Cream, and Remedy Dimethicone Skin Protectant

Solution and Expected Outcomes An Allevyn dressing will be applied on the sacrum, elbows, and heels for prevention and treatment of PUs. A protective cushion will be applied to the oxygen tubing to protect ear from the friction of the tubing.

Evaluation Plan The National Database of Nursing Quality Indicators (NDNQI) defines the HAPU rate as the number of patients who develop a PU after their admission to the hospital divided by the total number of patients in the population studied times 100 (Gray-Siracusa & Schrier, 2011). A quasi-experimental design will be used to assess the difference in HAPU rates before and after initiation of the PUPB using one-way analysis of variance.

Data Collection Evaluate Process and Outcomes: The team will assess and record the process during scheduled rounds. A weekly prevalence study will be completed using structured guidelines for data collection. A Medline pre-test will be given to the nurses before the pilot study. A post-test will be given after the pilot study is completed. The results will be compared to measure the impact of the educational interventions.

Summary The overall internal and external validity of the literature review was high. The different studies focused on many of the same interventions. All the studies supported each other findings and come to the same conclusions further supporting their validity. The literature review revealed many different risk factors and therefore needs multiple interventions to achieve success in preventing HAPUs in the critical ill. HAPUs are considered preventable, and have become a liability for hospitals and caregivers (Peterson, Schwab, Van Oostrom, Gravenstein, & Caruso, 2010). Prevention must be a priority.

Research Chalken, N. (2011). Reduction of hospital acquired pressure ulcers in the intensive care unit. Journal of Wound, Ostomy and Continence Nurses Society, 38(35). Eigsti, J. E. (2011). Beds, baths, and bottoms: A quality improvement initiative to standardize use of beds, bathing techniques, and skin care in general criticalcare unit. Dimensions of Critical Care Nursing, 30(3), 169-176. doi:10.1097/dcc.0b013e31820d25b1 Gray-Siracusa, K., & Schrier, L. (2011). Use of an intervention bundle to eliminate pressure ulcers in critical care. Journal of Nursing Care Quality, 26(3), 216-225. doi:10.1097/ncq.ob013e3182oe1be

Jackson, M., McKenney, T., Drumm, J., Merrick, B., LeMaster, T., & VanGilder, C. (2011). Pressure ulcer prevention in high-risk postoperative cardiovascular patients. Critical Care Nurse, 31(4), 44-53. doi:10.4037/ccn2011830 Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidencebased practice in nursing healthcare (2nd ed.). Philadelphia, PA: Wolters Kluwer / Lippincot Williams& Wilkins. Nanjo, Y., Nakagami, G., Kaitani, T., Naito, A., Takehara, K., Lijuan, J.,...Sanada, H. (2011). Relationship between morphological characteristics and etiology of pressure ulcers in intensive care unit patients. Journal of Wound, Ostomy and Continence Nurses Society, 38(4), 404-412.

Peterson, M. J., Schwab, W., Van Oostrom, J. H., Gravenstein, N., & Caruso, L. J. (2010). Effects of turning on skin-bed interface pressures in healthy adults. Journal of Advanced Nursing, 66(7), 1556-1564. doi:10.1111/j-1365-2648.201005292.x Racco, M., & Phillips, B. (2010). Developing a protocol for intensive care patients at high risk for pressure ulcers. Critical Care Nursing, 30(3), 77-80. doi:10.4037/ccn2010501 Shahin, E. S., Dassen, T., & Halfens, R. J. (2009). Incidence, prevention and treatment of pressure ulcers in intensive care patients: A longitudinal study. International Journal of Nursing Studies, 46, 413-421. doi:10.1016/j-ijnurstu.2008.02.011

Slowikowski, G. C., & Funk, M. (2010). Factors associated with pressure ulcers in patient in a surgical intensive care unit. Journal of Wound, Ostomy and Continence Nurses Society, 37(6), 619-626. Strand, T., & Lindgren, M. (2010). Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: A description cross- sectional study. Intensive and Critical Care Nursing, 26, 335-342. doi:10.1016/j.iccn.2010.08.006 Uzun, O., Aylaz, R., & Karadag, E. (2009). Reducing pressure ulcers in intensive care units at a Turkish medical center. Journal of Wound, Ostomy and Continence Nurses Society, 36(4), 404-411.