NK5EO Nurses are involved with the design and implementation of technology to enhance the patient experience and nursing practice.
Provide one example, with supporting evidence, of an improvement that occurred due to a change in nursing practice resulting from clinical nurses’ involvement with design and implementation of technology. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
AND
Provide one example, with supporting evidence, of an improvement in the patient experience that resulted from clinical nurses’ involvement with design and implementation of technology. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example 1 – Change in Nursing Practice
Peripherally Inserted Central Catheter (PICC) 3CG (Cardiogram) TCS (Tip Confirmation System)
BACKGROUND/PROBLEM
The Surgical Services department established the Peripherally Inserted Central Catheter (PICC) team in 2009 to address the need for immediate vascular access among patients that need treatments such as monitoring long-term antibiotics, cardiac infusions, TPN (total parenteral) nutrition and chemotherapy. This service was originally provided by surgeons through the surgical placement of central line catheters, which were associated with increased risks such as pneumothorax and infection. Additionally, quick turn-around time for placement of central lines became a challenge because of the surgeons’ hectic schedule. The creation of the PICC team helped alleviate these issues. The team also served as an important resource to the nurses for evidence-based information on IV (intravenous) care and for establishing IV access among patients with poor peripheral access. Additionally, having the PICC team has enabled Homestead Hospital to decrease the length of stay among patients requiring long term venous access for IV antibiotics or nutrition by facilitating early discharge. Under the leadership of Surgical Services Manager Wanda Vargas-Rosado, RN, the team has grown from 4 per diem nurses to 2 full time FTEs and 3 per diem nurses providing 12/7 and 365 days coverage. The team has upheld the zero tolerance to central line-associated blood stream infection (CLABSI) motto through optimal peripheral catheter site selection; Bio patch (chlorhexedine gluconate-impregnated sponge) application; weekly dressing changes performed by the PICC team members themselves; full barrier PICC insertion kits and evaluating new products such as “scrub the hub” caps.
Clinical Nurses’ Involvement
Vascular Access Coordinators Trudy Young, RN and Angel Rodriguez, RN were dedicated members of the PICC team. They are considered clinical nurses as they spend more than 50% of their time with direct patient care. Young and Vargas-Rosado were members of the Infusion Nurse Society (INS). Young obtained her board certification as Certified Registered Nurse Infusionist (CRNI). Rodriguez and Young were also members of the local INS chapter and the BHSF system-wide PICC committee that met quarterly to share best practices and review forms, policies, and order sheets. Young was the elected secretary of the INS local chapter from 2012-2013. Through their professional organization involvement, Rosado, Rodriguez and Young were up-to-date with the latest information in their specialty area and came across the Sherlock 3CG TCS (formerly referred to as Sapiens TCS or PICC Sapiens).
Historically, Homestead Hospital used chest X-ray to confirm PICC tip placement. In early 2012, the PICC team noted that it took an average of 87 minutes from PICC line insertion to the chest X-Ray interpretation. It took even longer to clear the line, averaging about 120 minutes, after 5 p.m., holidays, and weekends. During these times there was no radiologist onsite and chest x-ray orders for PICC line location confirmation were queued as routine orders. This resulted in a significant delay in initiating the prescribed infusion or treatment. The PICC team was especially concerned with Intensive Care Unit (ICU) patients who needed treatments immediately. Additionally, the process impacted the PICC’s team nursing practice by delaying time to release the catheter. It also exposed the patient to harmful radiation and there were costs associated with the chest x-ray.
It was around early 2012 as well that the PICC team was introduced to the innovative adjunct technology of Sherlock 3CG TCS through the Bard clinical representative. This technology utilized magnetic and adult’s cardiac electrical activity (ECG) wave tracking using 3 leads to provide real time catheter tip information location. The final tip location is confirmed by the PICC RN at the bedside once the procedure is completed by evaluating the P wave. TCS was indicated for use as an alternative method to chest x-ray and fluoroscopy for PICC tip placement confirmation in adult patients. This would enable the nurse to release the line for use immediately after completion of insertion so treatments can be started immediately without the need for a confirmatory chest x-ray. Any alteration in cardiac rhythms that changed the presentation of the P wave would limit the use of this technology such as atrial fibrillation, atrial flutter, severe tachycardia, and pacemaker driven rhythm. In these cases placement would be confirmed by other methods like chest x-ray.
GOAL STATEMENT(S)
The PICC team’s goal was to improve nursing practice by reducing the “time to clear the line” wait time among patients who do not have contraindications to the use of Sherlock 3CG TCS. This was determined by measuring the time when the PICC catheter insertion was completed up to the time it was released for use.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Design and Implementation of Technology
In March 2012, Vargas-Rosado obtained approval from the system Product Review Committee to complete a product evaluation agreement between Bard and Baptist Health South Florida (BHSF), which enabled her to conduct the trial in Homestead Hospital. She moved expeditiously and started the training and certification of the PICC team in the latter half of the month. The PICC team conducted the data collection between February and March 2012 and tracked the time when PICC line insertion was completed to release time. The Sherlock 3CG TCS pilot started in March 19, 2012 and occurred over a 4- week period. The results showed that out of 47 patients enrolled in the trial, 43 (92%) had confirmed 3CG waves and only 4 (8%) with no discernible P waves. Additionally, there was 100% correlation, that is, all patients with confirmed 3CG waves also had positive chest X-ray confirmation for proper catheter placement. Rodriguez, Young and Vargas-Rosado collaborated in designing the contents of the PICC Sapiens tray that would be used in conjunction with the new technology. In September 2012, the BHSF Clinical Product Assessment approved the use of Power PICC Sapiens tray to be used across the system. In January 2013, Vargas-Rosado presented to Radiology Director Ira Braun, MD the results of the trial and obtained his approval to adopt it. In May 2013, Rodriguez and Surgical Services Director Carmen Bouchard, RN made a presentation to the Medical Executive Committee (MEC) and gained their approval as well. The PICC team incorporated the Sherlock 3CG TCS technology into their practice in June 2013. Vargas-Rosado revised the PICC policy accordingly in September 2013 to reflect use of 3CG technology.
Exhibit NK5EOa: Sherlock 3CG TCS Machine
PARTICIPANTS
Clinical Nurses Involvement
Name/Credentials |
Title |
Department |
Role in the Team |
Gertrude Young, RN, CRNI |
Vascular Access Nurse Coordinator |
Surgical Services |
PICC Clinical Nurse; collected data for trial |
Angel Rodriguez, RN |
Vascular Access Nurse Coordinator |
Surgical Services |
PICC Clinical Nurse; collected data for trial; assisted in designing the tray; obtained approval from MEC for use of technology |
Wanda Vargas, BSN, RN, CNOR |
Patient Care Manager |
Surgical Services |
Coordinated trial, data collection and implementation |
Carmen Bouchard, MSN, RN, CNOR |
Director |
Surgical Services |
Obtained approval from MEC for use of technology |
OUTCOME(S)
Improvement Due to Change in Nursing Practice
The main improvement in the PICC's team nursing practice was decreasing “time to release catheter” through immediate confirmation of PICC tip position at the bedside and immediate release of the PICC line. It also increased placement efficiency and reduced catheter malpositions because of the real-time guidance provided by the magnetic and electrocardiographic tracking system. It reduced clinical time wasted by the PICC team waiting for PICC tip confirmation with chest x-rays. It improved patient experience by reducing patient’s wait time for the procedure and reduction in radiation exposure. This change in nursing practice was brought about because of Homestead Hospital clinical nurses’ involvement in trialing the technology; designing the PICC Sapiens tray; and obtaining approval from various system-wide and hospital-based committees to move it forward. This was adopted by 2 other hospitals in the system because of Homestead Hospital’s positive outcomes.
Exhibit NK5EOb: PICC Line “Time to Clear” Wait Time for Use among ICU Patients
Analysis: Above graph show that the “time to clear” wait time of the PICC line for first use has dramatically decreased from an average of 70 minutes to 0.
Summary Attachments/Hyperlinks/Evidences
Exhibit NK5EOa: Sherlock 3CG TCS Machine
Exhibit NK5EOb: PICC Line “Time to Clear” Wait Time for Use among ICU Patients
Example 2 – Improvement in Patient Experience
NAME OF INITIATIVE
Enhancing Surgical Patient’s Comfort
BACKGROUND/PROBLEM
Homestead Hospital adopted Comfort Theory, developed by Katherine Kolcaba, as a framework for its care delivery system. When nurses provide for comfort, they help patients engage in health-seeking behaviors. Health seeking-behaviors are those that not only help patients return to wellness but make them take charge of their healthcare. They can be internal or external. Patients in the perioperative setting, experience hypothermia during their surgical stay. Nurses can address this by applying nursing interventions that provide for comfort and warmth of patients. These interventions could be started preoperatively and continued on through the intraoperative and post operative phases. For example, nurses could hang warmed IV solutions and provide warmed blankets or patient regulated warming devices. Using patient-regulated devices provide for warmth and allow patients to have a sense of control during their care.
The Surgical Services Unit Practice Council (UPC) had initially trialed the 3m Bair Paws® system (forced air warming gowns) in June of 2012 with mixed results. The product was well received by the staff and the patients. However, the anesthesiologists were not convinced. This led to inconsistent use of the product. In November 2012, the UPC and nurse leaders started noticing dips in Ambulatory Services’ patient satisfaction scores, especially on the “nurses concern for comfort” question. Surgical Services nurse leaders conducted rounding among clinical nurses and patients to drill down on the root cause. They found out that patients were complaining about feeling cold during the procedures. Clinical nurses in both the preoperative and surgical areas felt that 3M BairPaws® could increase the patients comfort by providing a device that warms them perioperatively. Furthermore, it would allow patients to control the warming device as they set the temperature themselves. Based on the feedback received, the nurse leaders supported the clinical nurses’ input to reintroduce 3mBair Paws® as a way to improve patient satisfaction scores and ensure perioperative normothermia.
GOAL STATEMENT(S)
The goal of the project was improve patient satisfaction scores on “nurses concern for comfort” by maintaining perioperative normothermia.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
Clinical Nurses Involvement in the Design and Implementation of Technology
The Surgical Services UPC oversaw the design and implementation of the 3m Bair Paws® system. First, the UPC brought BairPaws® in for another trial period. The UPC felt it was important to educate and engage every subspecialty to ensure buy-in during the implementation phase. They asked all staff members and physicians to provide feedback on the gowns. The UPC handed out a paper survey from August to September 2012. They requested the staff to evaluate the product on the following areas using a 1-5 Likert scale: effectiveness in warming patients; ease of use; and if user would recommend use of the system. Clinical Nurse Educator Lamberto Hernandez, RN coordinated the data collection. The Clinical staff in the preoperative area gave the product an overall score 4.20. The OR staff gave it a 4.25 while the PACU staff gave it an overall score of 4.03. The anesthesia group gave it a 3.93. Many staff members reported positive feedback from the patients regarding the use of the gown to keep them warm. Overall, the patients liked it. Some staff members did complain about the bulkiness of the machine and cords.
Surgical Services nursing leadership shared with the anesthesia group the positive feedback received from patients and the PACU nurses’ report that patient temperatures were higher. They also shared their concern regarding patient satisfaction results. Consequently, the anesthesia group decided to support the implementation of BairPaws®. The UPC utilized the feedback obtained during the trial period to make some changes during the implementation phase. For example, during the trial period, the staff used the kit that came with a gown, socks, hat and a patient bag. The UPC decided that during the go live, they would only order the kit with the gown and socks since patients were already provided green surgical services bag for their belongings. Second, during the trial they had inpatients change in their preoperative area. They received feedback from the staff to have patients change in their rooms prior to coming to the preoperative area.
Hernandez provided an in-service to the staff on “Maintaining Normothermia in Surgical Services” in August 2012. The re-education gave staff information on the following: importance of maintaining normothermia during surgery to prevent infections; identifying risk factors; mechanism of heat loss; and preventing heat loss during surgery.
The UPC designed the procedure for using the 3m Bair Paws® system as follows:
- The gowns would be given to outpatients to wear when they arrive.
- The OR Technician Assistants would take the gowns to the inpatient units when picking up patients and help patients change into them before coming to the preoperative area.
- An individual warming unit would be provided for each patient. The nurse as part of her teaching would explain the purpose of the system (provide comfort and prevent hypothermia) and how to use the patient-regulated device.
In February 2013, the Surgical Services department began having each surgical patient wear the 3M BairPaws® gown.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Archelle Quintana, RN |
Clinical Nurse |
Surgical Services |
UPC Chair during the implementation |
Nancy Larramendi BSN, RN, CMSRN |
Clinical Nurse |
Surgical Services |
UPC Chair-Elect |
Shannon Newton, RN |
Clinical Nurse |
Surgical Services |
UPC member |
Brenda Shane, RN |
Clinical Nurse |
Surgical Services |
UPC member |
Lamberto Hernandez, MSN, RN, CNOR |
Clinical Nurse Educator |
Surgical Services |
UPC Facilitator |
Pam Rozas, RN |
Clinical Information System (IS) Coordinator |
Surgical Services |
UPC Chair during the trial period |
OUTCOME(S)
Improvement in Patient Experience
Exhibit NK5EOc: Ambulatory Surgery “Nurses Concern for Comfort” Percentile Rank
Analysis: The ambulatory services staff has achieved their goal of improving patient experience with the design and implementation of technology as evidenced by patient satisfaction scores on the “nurses concern for comfort” question at 99th percentile sustained for 11 consecutive months.
References
Kolcaba, K. (2001). Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook. 49(2). 86-92. Retrieved from http://thecomfortline.com/files/pdfs/2001%20-%20Evolution%20of%20the%20Mid%20Range%20Thoery%20of%20Comfort%20for%20Outcomes%20Research.pdf
Summary Attachments/Hyperlinks/Evidences
Exhibit NK5EOc: Ambulatory Surgery “Nurses Concern for Comfort” Percentile Rank