Magnet Recognition Program® Request for Additional Documentation
Homestead Hospital
Homestead, FL
MGN20140102
EP14 Resources, such as professional literature, are readily available to support decision-making in autonomous nursing practice.
EP14a: Provide two examples, with supporting evidence, of how resources are used to support evidence-based clinical decision-making in autonomous nursing practice.
Provide an example, with supporting evidence, of how resources are used to support evidence-based clinical decision-making in autonomous nursing practice.
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A new example is presented below.
NAME OF INITIATIVE
ICU Enteral Feeding Nurse-Driven Protocol
BACKGROUND AND PURPOSE
Intensive Care Unit (ICU) Clinical Nurse Mariluz Lorenzo, RN, had a particular interest in the nutrition of the critically ill patients. While working at the bedside, she identified opportunity areas regarding enteral feeding in the ICU. Specifically, these areas included: 1. delay in initiating dietitian’s recommendations for enteral nutrition; 2. patients not getting the recommended amount of nutrition; and 3. feeding tube management. ICU Clinical Nurse Specialist Rosemary Lee, ARNP collected data to validate Lorenzo’s observation. It showed that the mean amount of enteral nutrition received by ICU patients was only 65% of the recommended amount.
Consequently, in November 2013, when Lorenzo got the endorsement from ICU and Progressive Care Unit (PCU) Patient Care Manager Leslie Everett, RN, to be promoted from “Proficient” to “Advanced” nurse through the Professional Nursing Advancement Program (PNAP), she chose “Improving Nutrition in the Critically Ill Patient” as a topic for the clinical problem appraisal. The critical appraisal of a clinical problem was one of the requirements to move up to the “Advanced” level. During this same time, an Enteral Feeding PI Team, consisting of nursing, dietary and pharmacy, first met.
How Resources Were Used for Evidence-Based Clinical Decision-Making
The Enteral Feeding PI Team met monthly. Lorenzo and Lee performed extensive literature review. They utilized the electronic medical library and accessed, CINAHL, Medline and Mosby Suite. For articles that did not have full text copies available online, they requested article reprints from the onsite medical library, which was staffed by either a medical librarian or a library coordinator. As all nurses have access to the internet, they were able to obtain guidelines from the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN). They also evaluated protocols developed by other acute care hospitals to guide them in developing their own. The literature review helped the team in standardizing definition of terms; developing a list of medications; and formulating a bowel management protocol (EP14 01a Enteral Feeding PI Team Meeting Minutes 02/19/14). It also assisted them in formulating the initial draft of the enteral feeding order set and protocol in April 2014 based on the best available evidence.
Concurrently, Lorenzo pursued her PNAP application. In the process of completing her PNAP portfolio, she sought the assistance of Nurse Scientist Maria Ojeda, ARNP, in developing her critical appraisal of a clinical problem. Her Problem/Population-Intervention-Comparison-Outcome (PICO) question was: “Would the use of an enteral feeding protocol improve the goals of nutrition in critically ill patients?” (EP14 02a Lorenzo’s PNAP portfolio, pp. 25-43).
Autonomous Nursing Practice
After several revisions, the Homestead Hospital’s Critical Care Committee approved the Enteral Feeding Protocol and Order Set in July 2014. Eventually, the protocol was changed to a standing order and became part of the ICU departmental policy (EP14 03a Critical Care Meeting Minutes 7/22/14; Enteral Nutrition Protocol and Order Set). The protocol enabled ICU nurses to initiate enteral feedings that were recommended by the clinical dietitian for hemodynamically stable patients with a functioning gastrointestinal (GI) tract. To enter the orders, the nurse could select in the “Order Source Modifier” section of Soarian (electronic health record), the “Per Protocol – Signature Required” option in the drop down menu (EP14 04a Screenshot Dietitian’s Recommendation and Enteral Feeding Order in Soarian). The physician could then co-sign the enteral feeding order when they rounded on the patients. Prior to having the protocol, ICU nurses were not advancing the enteral feeding rate promptly. With the use of the protocol, ICU nurses became more apt in advancing the feeding rate per dietitian’s recommendation, thus optimizing the patient’s nutrition. Additionally, ICU nurses were holding the enteral feeding for gastric residual volume (GRV) less than 500 ml when evidence showed that it should be held only for GRV above 500 ml. The protocol clarified this and gave specific guidelines on tube management and length of time to hold the feeding. This minimized unnecessary interruptions of the enteral feeding infusion so patients could receive the recommended amount of nutrition (EP14 05a Screenshot of I&O).
PARTICIPANTS
Summary
The use of the nurse-driven Enteral Feeding Protocol and Order Sheet changed the ICU nursing practice so that feedings were not being held for inappropriate gastric residuals and were being advanced to goal in a timelier manner. The protocol gave the nurses autonomy to initiate or restart enteral feeding based on well-defined parameters in order to optimize the nutrition of the critically ill patients. ICU nurses addressed enteral feeding issues continuously and during the daily interprofessional rounds. Lorenzo also used this project for her PNAP portfolio. Thereafter, she was promoted from a "Proficient" to an "Advanced" nurse in September 2014.
Summary of Attachments/Hyperlinks/Evidences
EP14 01a Enteral Feeding PI Team Meeting Minutes 02/19/14
EP14 02a Lorenzo’s PNAP portfolio, pp. 25-43
EP14 03a Critical Care Meeting Minutes 7/22/14; Enteral Nutrition Protocol and Order Set
EP14 04a Screenshot Dietitian’s Recommendation and Enteral Feeding Order in Soarian
EP14 05a Screenshot of I&O