Magnet Recognition Program® Request for Additional Documentation
Homestead Hospital
Homestead, FL
MGN20140102
NK4EO Innovation in nursing is supported and encouraged.
NK4EOa: Provide two examples, with supporting evidence, of an improvement that resulted from an innovation in nursing. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Describe the innovation in nursing (i.e. the novel set of nursing behaviors, nursing routines, and ways of working/nursing) that took place, and when, that resulted in the improvement in the troponin collect-to-result turnaround time (the outcome).
______________________________________________________________________
A new example is presented below.
NAME OF INITIATIVE
The Cue-to-Turn Triad (CTT)
BACKGROUND/PROBLEM
Pressure ulcers are a type of complication that is highly prevalent among hospitalized patients. During the 2-year period of 2006-2007, the estimated incidence of pressure ulcers among hospitalized patients in the United States was 4.5% (Lyder, Wang, Metersky, Curry, Kliman, Verzier & Hunt, 2012). Yet, in July 2011, members of the 3 South (medical-surgical/telemetry/orthopedic unit) Unit Practice Council (UPC) at Homestead Hospital noticed that their monthly unit acquired pressure ulcer (UAPU) rate had fluctuated widely between January and June of the same year, ranging from 0% to 2.52%. Clinical Nurse and Wound Care Committee Member Rosa Filomeno, RN, led a subcommittee to examine the possible reasons for the current UAPU rates.
The team conducted a fishbone analysis in September of 2011 to determine what factors may have contributed to the increase in UAPU incidence in 3 South.
Exhibit NK4EOaa: Fishbone Analysis on Potential Factors Influencing UAPU Rates in 3 South
Three barriers to the effective prevention of pressure ulcers emerged from that analysis:
- Nurses and clinical partners (CPs) were unable to identify which patients were at risk using visual reminders.
- Repositioning methodologies required standardization.
- Staff required more assistance in repositioning patients.
Literature Review
The systematic repositioning of bed-bound patients who are at risk for pressure ulcer development every 2-4 hours is supported in the literature as an effective UAPU prevention strategy and has become a standard component of nursing care (Duncan, 2007; Reddy, Gill & Rochon, 2006; Stechmiller et al., 2008). A study conducted by Gunningberg and Stotts (2008) illustrates the importance of staff compliance with patient repositioning as a pressure ulcer prevention strategy. However, work demands and distractions within busy hospital settings frequently serve as barriers to the performance of patient repositioning. A study of missed nursing care opportunities found that 82% of nurses surveyed reported failure to reposition patients every 2 hours during their shift due to unexpected changes in patient volume or acuity (Kalisch, Landstrom & Williams, 2009).
The use of visual cues to deliver reminders for future performance of tasks such as hand washing compliance has been found effective (Williams & Woodman, 2012; Nevo, Fitzpatrick, Thomas, Gluck, Lenchus, & Arheart et al., 2010). Visual cues, such as signs, logos, stickers, etc., are suggested to remind staff throughout the day of the need to reposition patients who are at risk for the development of pressure ulcers (Duncan, 2007). The use of “turn clocks” in patient rooms depicting the specific times and sides in which to reposition patients is one strategy that is easy to implement and has been successful at improving compliance with patient repositioning among hospital nursing staff (Duncan, 2007).
Despite several studies suggesting the value of repositioning and visual cues in pressure ulcer prevention as separate interventions, there was a dearth of evidence regarding the use of repositioning, visual cues, and buddy system as a triad or “bundle”.
On the advice of Magnet Project Director Julie David, ARNP, Unit Practice Council (UPC) members met with the hospital’s Nurse Scientist Maria Ojeda, ARNP in October 2011. At that meeting, they determined that an intervention to address barriers to pressure ulcer prevention would be implemented as part of a research study. Filomeno, together with a team of clinical nurses and a CP, obtained IRB approval in February of 2012.
GOAL STATEMENT(S)
The goal of the project was to decrease the UAPU rate in 3 South.
The data was collected every Wednesday during the “Wound Care Wednesday” rounds. The prevalence rate was calculated as follows:
Number of patients with UAPUs X 100
Total number of patients
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
At that time, Homestead Hospital clinical nurses were already utilizing a standardized assessment (Braden Scale for Pressure Ulcer Prevention) to determine patients’ risk for the development of pressure ulcers on admission and every shift. Therefore, the team chose to focus their efforts on the improvement of nurses’ adherence to pressure ulcer prevention protocols by developing and instituting the CTT. The CTT includes 3 components implemented as a “bundle” and are based upon recommendations from the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel’s (NPUAP/EPUAP, 2009) practice guidelines. The CTT bundle consists of practice changes and tools designed to eliminate each of the barriers to pressure ulcer prevention in 3 South that the UPC identified in the fishbone analysis. The components of the CTT and the specific barrier to pressure ulcer prevention addressed were as follows:
Component 1: The “U turn” magnet was placed on patients’ doors.
At Homestead Hospital, nurses and CP could access information on patient risk for pressure ulcer development within individual patient records. The UPC originally designed the “U Turn” magnet. Its purpose was to serve as a constant visual reminder to the staff that a specific patient was at risk for pressure ulcer development and would require manual repositioning throughout the shift. The UPC designed it in such a way as to maintain patient privacy while gently refocusing the attention of clinical nurses and CPs to the performance of manual repositioning, a routine yet important aspect of pressure ulcer prevention.
Exhibit NK4EOba: The “U Turn” Magnet
Component 2: The “Cue Turn” tool was placed inside the patient’s room.
The purpose of the tool was to standardize the schedule for the manual repositioning of patients throughout the unit. The tool depicted the expected positioning of patients in 2-hour intervals throughout a 24-hour period. By referencing the tool, nurses and CPs were able to estimate whether a specific patient was due to be repositioned at any particular time throughout the day, eliminating reliance on recall. The UPC redesigned an existing “turn clock” to accommodate meal schedules so that patients were placed in supine positions during meal times.
Exhibit NK4EOca: The “Cue Turn” Tool
Component 3: A "Buddy System" for the manual repositioning of patients during each 12-hour shift was implemented on the unit.
The UPC developed a practice change using a formalized system of partnering staff members for the manual repositioning of bedridden patients during each 12-hour shift. This “Buddy System” assigned responsibilities for patient repositioning. It facilitated compliance by increasing the availability of assistance, as needed. The UPC added a section in the assignment sheet and white board to indicate the names of assigned buddies. When completing the assignment for the oncoming shift, the patient care supervisor assigned a buddy to each nurse and CP. The buddies helped each other in repositioning the patients based on the times in the “Cue Turn” tool.
The UPC also developed a video presentation entitled “It’s Your Cue to Turn” to educate clinical nurses and CPs on the use of CTT. They rolled it out in March 2012 during the monthly 3 South staff meeting. They fully implemented the CTT in April 2012 and closed the research study in December 2012.
Novel Set of Nursing Behaviors and Routines
In the standard process, clinical nurses would reposition patients who were identified as at risk for pressure ulcer development every 2 hours relying on their memory to cue them and their CP (who could be occupied with other patients) to assist them. This carried the potential for missed nursing care opportunities. The innovation in nursing involved:
- developing a new tool (“U turn” Magnet to serve as visual cue);
- redesigning an existing one (“Cue Turn” tool to standardize turning schedule);
- implementing a new process (“Buddy System” to promote adherence); and
- using the 3 interventions as a “bundle” for pressure ulcer prevention.
PARTICIPANTS
Name/Credentials |
Years RN / Years Specialty Experience |
Title |
Department |
Role in the Team |
Rosa Filomeno, MSN, RN, CMSRN |
20 years RN /10 years specialty |
Clinical Nurse |
3 South |
Principal Investigator and project lead |
Gloria Gamboa, RN, CMSRN |
7 years RN |
Clinical Nurse |
3 South |
Co-Investigator |
Adriana Garay, RN |
9 years RN |
Clinical Nurse |
3 South |
Co-Investigator |
Shelly Ann Commock, BSN, RN, CMSRN |
8 years RN |
Clinical Nurse |
3 South |
Co-Investigator |
Maria Ojeda, DNP/PhD(c), MPH, ARNP, NP-C |
16 years experience as RN; 20+ years in research |
Nurse Scientist |
Nursing and Health Sciences Research |
Key Personnel; consultant on study design & IRB application process; data analysis and interpretation. |
Erica Cuthbert |
11 years |
Clinical Partner |
3 South |
Key Personnel |
OUTCOMES
Health Outcomes
Exhibit NK4EOda: Percent of Patients with Unit Acquired Pressure Ulcer in 3 South
*Note: This project was implemented as part of a research study that was IRB approved in February of 2012. The CTT intervention was implemented in April of 2012, and the study was closed in December of 2012.
Analysis: The 3 South UPC has achieved their goal of decreasing UAPU rate as evidenced by 0 UAPU for 5 consecutive months post-intervention.
Since the completion of the research study, the CTT became incorporated into 3 South’s nursing practice. This resulted in 0 UAPU and 0 hospital acquired pressure ulcers (HAPUs) of the last 8 reported quarters (ending January-March 2015) in the National Database of Nursing Quality Indicators (NDNQI). Because of their sustained outcomes, Filomeno obtained endorsement for hospital-wide adoption of CTT from the Nurse Governance Council (NGC) during the February 2015 meeting. CTT went live in all inpatient units on May 2015.
References
Duncan, K. (2007). Preventing pressure ulcers: the goal is zero. Joint Commission Journal of Quality and Patient Safety, 33(10), 605-610.
Gurses, A., Seidl, K., Vaidya, V., Bochicchio, G., Harris, A., Hebden, J., & Xiao, Y. (2008). Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare associated infections. Quality & Safety in Health Care, 17, 351–359. doi:10.1136/qshc.2006.021709
Kalisch, B., Landstrom, G., & Williams, R. (2009). Missed nursing care: errors of omission. Nursing Outlook, 57(1), 3-9.
Lyder, C., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N., & Hunt, D. (2012). Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. Journal of the American Geriatrics Society, 60(9):1603-8. doi: 10.1111/j.1532-5415.2012.04106.x.
NPUAP/EPUAP. (2009). Prevention and treatment of pressure ulcers: clinical practice guidelines. Washington, DC: NPUAP.
Nevo, I., Fitzpatrick, M., Thomas, R., Gluck, P., Lenchus, J., Arheart, K., Birnbach, D. (2010). The efficacy of visual cues to improve hand hygiene compliance. Simulation in Healthcare, 5(6):325-331. doi: 10.1097/SIH.0b013e3181f69482.
Pieper, B. (2013). National Pressure Ulcer Advisory Panel [NPUAP] - Registered nurse competency-based curriculum: pressure ulcer prevention. Retrieved from http://www.npuap.org/wp-content/uploads/2012/03/Updated-NPUAP-RN-5-29-13.pdf
Piscotty, R., & Kalisch, B. (2014). The relationship between electronic nursing care reminders and missed nursing care. CIN: Computers, Informatics, Nursing, 32(10), 475-481.
Reddy, M., Gill, S., & Rochon, P. (2006). Preventing pressure ulcers: a systematic review. JAMA, 296(8), 974-984.
Soban, L., Hempel, S., Munjas, B., Miles, J., & Rubenstein, L. (2011). Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Joint Commission Journal of Quality and Patient Safety, 37(6), 245-252.
Stechmiller, J., Cowan, L., Whitney, J., Phillips, L., Aslam, R., Barbul, A. …& Stotts, N. (2008). Guidelines for the prevention of pressure ulcers. Wound Repair and Regeneration, 16, 151-168.
Strand, T., & Lindgren, M. (2010). Knowledge, attitudes and barriers towards prevention of pressure ulcers in intensive care units: a descriptive cross-sectional study. Intensive and Critical Care Nursing, 26, 335-342.
Welp, A., & Manser, T. (2014). Teamwork in healthcare: relationships with stress and patient safety. European Health Psychologist, 16(S), 648.
Williams, M., & Woodman, G. (2012). Directed forgetting and directed remembering in visual working memory. Journal of Experimental Psychology & Learning in Memory and Cognition, 38(5), 1206-1220.
Summary of Attachments/Hyperlinks/Evidences
Exhibit NK4EOaa: Fishbone Analysis on Potential Factors Influencing UAPU Rates in 3 South
Exhibit NK4EOba: The “U Turn” Magnet
Exhibit NK4EOca: The “Cue Turn” Tool
Exhibit NK4EOda: Percent of Patients with Unit Acquired Pressure Ulcer in 3 South